Nursing Role

December 1, 2000

Microsurgery Team's Role in Surgical Site Infection Prevention
Team strategies for assessing and preparing the patient and the OR

By Cynthia Halvorson, RN, MSN, CNOR

Approximately 27million surgical procedures are performed each year. As the third most-reported nosocomialinfection, surgical site infections (SSIs) account for 14-16% of nosocomial infections.1A 1992 study estimates that SSIs increase the hospital length of stay by seven additionaladmission days and add an extra $3,100 in charges per admission (for tissue debridement,antibiotic therapy, and other treatments). 1

Implications

Put into the context of today's healthcare reality of managed care, case management,and clinical pathways, this is neither an acceptable clinical or financial outcome forsurgical patients. The objective of case management is to provide "a continuum ofcare that allows consistent delivery of quality treatment and services across all carecontinuums."3 Case management focuses on patient populations that arecomplex (but not necessarily acute) with multiple interacting issues in addition to beinghigh risk, high volume, or requiring high utilization of services. Within case managementclinical care, paths are used as "guidelines that outline the ideal course oftreatment during the episode of care"4 and are designed to decrease costs,improve outcomes, and increase patient satisfaction.5 Today's healthcare ismeasured in outcomes of cost and satisfaction. Surgical site infection rates are animportant indicator of these parameters.

Microsurgery Patient Population

Patients undergoing microsurgical procedures are appropriate for case managementpathways. Microsurgical procedures are performed in several surgical subspecialties. Theseare complex, technically precise, and challenging procedures. The length of stay rangesfrom a three-hour outpatient admission for the cataract patient to an AM admission and afive-day postoperative length of stay for the acoustic neuroma patient. Cataract patientvolume is high (an average of 10+ patients/surgeon/day) while the acoustic neuroma patienthas high risk and requires multidisciplinary services. In addition, Centers for DiseaseControl and Prevention (CDC) lists the likely SSI pathogens for several microsurgeryprocedures as well as site-specific organ/space SSI (disc space, mastoid space,endophthalmitis).6

Nursing Role

The nursing profession describes its primary role as patient advocacy. Central to thisadvocacy role is the goal of ensuring patient safety. This is especially true forperioperative nursing and the surgical patient. During the perioperative surgicalexperience, the patient receives a rapid sequence of care from a multidisciplinary teamwithin a shortened length of stay.

The patient's most vulnerable phase of care is in the operating room. The patient has adependent trust on his providers because of positioning requirements, anesthesia (general,monitored anesthesia care or conscious sedation), and inherent to surgery, the compromiseof the first line of defense against infection. The two most frequent critical judgmentsand clinical decisions of perioperative patient care are protecting the patient from harmand injury (from surgical positioning requirements, use of electrosurgical, and laserunits, etc.) and preventing surgical site infections.7

Infection Control Practices

The prevention of surgical site infections is not a result of isolated actions taken byone provider. Rather, it is the objective and desired outcome of an integrated teamprocess. The process of infection control includes a variety of strategies and techniquesacross the continuum of perioperative care, including the pre-operative, intra-operative,and post-operative phases. Many advances have been made in infection control practices,addressing aseptic and surgical techniques as well as antimicrobial prophylaxis. Inparticular, the Association of periOperative Nurses (AORN) Recommended Practices serve asguidelines for clinical practice for the microsurgical team. These guidelines are based onmicrobiology, research, review of evidence-based literature, and opinions ofmultidisciplinary experts.8 The Recommended Practices with infection preventionapplication can be grouped into the sterilization process; patient preparation; theenvironment, and the sterile field (Table 1).

Microsurgery Technique

Several surgical specialties include microsurgical procedures. The knowledge and skillsbasic to general operating room care are applied to these microsurgical procedures, takinginto account the specific considerations and needs of the subspecialty. Ophthalmology,orthopedics, ENT (including otology and laryngology), neurosurgery, and reconstructiveplastics are specialties with microsurgery procedures (Table 2).

Microsurgery requires optical magnification, using an operating microscope to visualizeanatomical structures not adequately visible to the unaided eye.9 As theoptical magnification increases, the scope of field and depth of focus decreases,increasing the illumination requirements. As compared to major abdominal procedures (suchas organ transplant or colon rectal procedures) the operative field area is justmillimeters to centimeters in size. In addition, the room is darkened to enhance the highintensity illumination of the microscope's light source. The surgeon does not take hiseyes from the microscope to receive instruments -- the scrub person hands the instrumentsto the surgeon in the position of use. By taking his eyes from the microscopes, thesurgeon's concentration is broken, requiring refocusing on the surgical field through themicroscope and can increase the length of surgery.

Surgical Instrumentation

To perform these delicate, precise procedures, special instruments are used. Thesesinclude a variety of instruments in the same categories as general instrumentation, i.e.,sharps and cutting items (scissors, scalpels, knives), graspers (clamps, forceps), andretractors (self-retaining, hand-held) that are designed to fit the specific technicalneeds of the procedure and micro-anatomy. The instruments are made of either non-corrosivestainless steel or titanium. All microsurgery instruments are delicate and expensive butwith proper care and handling, can withstand multiple processing for several years.

The decontamination and processing of these instruments is dictated by their design.Delicate instruments must be separated from heavier general instruments. Hand washing isnecessary for instruments that cannot tolerate the powerful cycle of thewasher-decontamination unit or items that cannot be immersed (such as air-powered drills,hand-held lens, ultrasonic irrigation, and aspiration handpieces).

Technology

Optimal surgical exposure is key to any procedure. Many microsurgical proceduresrequire exposure through bony structures (vertebral discs, temporal, or mastoid bone)using high-speed air powered drills. Components of these drill systems include a motorcord, motor handpiece, attachments, and drill bits. Further soft tissue dissection orevacuation is accomplished with lasers, using either a free beam (such as CO2laser for microlaryngoscopy) or a laser fiber (such as argon laser for otology, acousticneuromas, vitreo-retinal procedures, or brain tumors), or an ultrasonicsuction-irrigation-aspirator (phacoemulsification unit for cataract extraction or the CUSAunit for neurosurgery).

Implants and Grafts

Many microsurgery procedures involve the placement of an implant or a graft. CDCidentifies such procedures as at risk for SSI, requiring preoperative prophylacticantibiotics. Implant material varies from metals (stainless steel, MRI-compatibletitanium), metal-plastic combinations, plastics, silicones (as formed implants or asinjectable oil), and acrylics. Graft material can be autologous (patient's own tissue) ordonor tissue (corneal transplants or processed donor tissue such as bone). These implantsare supplied sterile and do not require sterilization within the institution.Documentation of implants and grafts on the operative record identifies the implant,manufacturer, lot and serial number, implant size, location and expiration date. Animplant documentation record identifying the implant, patient, implanting surgeon,institution, and date of implant is returned to the manufacturer. The surgeon and patientcan then be notified in the event of a product alert or recall.

Length and Phases of Cases

The length of surgery, complexity, and phases of microsurgery procedures and the numberof team members involved vary greatly. Operative times for myringotomies and cataracts are5 and 10 minutes respectively, while an acoustic neuroma is 6 to12 hours in length. Lesscomplex procedures require only four personnel (anesthesia, scrub, circulator, andsurgeon) while multi-specialty procedures can involve as many as 12 personnel. Manyprocedures require 30 to 60 minutes of setup time to prepare the sterile field, set up andtest equipment, and safely position the patient for extended procedure time. More complexprocedures involve two or more specialties with several surgeons, residents, and fellows.Crossed-trained OR teams work together throughout the procedure. Additional non-scrubbedmembers include anesthesia providers and neuro-diagnostic personnel for intraoperativemonitoring.

During these longer procedures, the OR nurses "stage" activities to theprogressive phases of the procedure. This is necessary to ensure smooth flow of theprocedure with multiple team members (scrubbed and not scrubbed) and availability ofrequired instruments, equipment, and supplies. Equipment needed later into the procedureis set-up and opened closer to point-of-use to keep the sterile field and operating roomless cluttered and to decrease the likelihood of contamination from an extended exposuretime.

Team Strategies for Infection Prevention in Microsurgery

The perioperative nurse is in an excellent position as the primary patient advocate toguide the patient's surgical experience and ensure appropriate infection preventionpractices are implemented. When preparing for new procedures, the RN specialty managermeets with the surgeon to discuss key aspects of the procedure. A detailedpreference/procedure card (i.e., standing orders for specific procedure) is writtento include instrumentation, equipment, supplies, and medications. The entire OR team meetswith the surgeon, anesthesia-providers, and other team members for an oral review of theprocedure and conducts "dry labs" to prepare before a "live" case.

Assessment of Risk Factors

The perioperative nurse must be knowledgeable of the SSI risk factors, create andmaintain a safe, effective environment, and classify the surgical wound. A completeassessment of the patient and surgical procedure is necessary. Table 3 lists the patient(intrinsic) and operative (extrinsic) risk factors. The patient's medical status isexpressed as the American Society of Anesthesiologists physical classification system (ASAphysical status). The anesthesia provider scores the patient as a preoperative predictorof the patient's risk for surgery. This status is also considered predictive for SSI.Healthier patients scored one or two (healthy or mild systemic disease) and are at lowerrisk than sicker patients with chronic and/or poorly managed diseases (scored 3 or 4). Thesurgical wound is classified in the OR at the conclusion of the procedure according to CDCcriteria (clean, clean-contaminated, contaminated, and dirty-infected). Most microsurgicalprocedures are Class I, clean. The surgeon and circulating RN base this on the type ofsurgery, condition of the wound, and maintenance of aseptic technique throughout theprocedure.

A. Sterilization Process

B. Patient Preparation

C. Environment

D. Sterile Field

From Standards, Recommended Practices, and Guidelines. Association of Operating Room Nurses; Denver, CO: 2000.

Patient Preparation

Microsurgery exaggerates several risk factors. Patients undergoing complex procedures(neurosurgery) are admitted the day of surgery (DOS) in the morning to reduce preoperativelength of stay. Many microsurgery procedures are long (over two hours) and involve theplacement of an implant or graft. CDC includes these two factors in a higher risk groupand ranks prophylactic preoperative antibiotics (PPA) as Category 1A.10

Preoperative Prophylactic Antibiotics (PPA)

PPA is an accepted standard of care for SSI prevention. Antibiotics are administered toreduce the microorganism burden to a level that does not exceed the patient's naturaldefenses. To be effective, administration is timed to ensure adequate serum and tissueconcentration before the incision is made and to maintain the level throughout theprocedure.11 Typically, the antibiotic is administered intravenously in theholding area 30 minutes prior to the patient entering the operating room. Often thesecases are longer than the agent's three-to-four hour effective concentration level,necessitating intraoperative redosing (such as nafcillin at 6 hours for acousticneuromas). Antibiotics are also given intra-operatively on the sterile field in anirrigation solution (such as cefazolin or bacitracin in normal saline for orthopedic,neuro/neurotology, plastics procedures), topical ointments or drops (for otologic andophthalmic procedures) or injection (gentamycin or cefazolin subconjunctival injection forvitreo retinal and trabeculectomies, respectively). The perioperative nurse must know thelikely SSI source pathogen risks for the various microsurgery procedures, the patient'sallergies, and ensure the antibiotic of choice is available and administeredappropriately. Lewis and Porazzi apply the Five R's of medication administration to PPA (Table4).12

ENT

Otology:

Ossicular chain procedures * (stapedectomy, ossiculoplasty)
Chronic ear procedures (tympano-mastoidectomy)
Myringotomy w/ventilation tube insertion *
Sensorineural hearing loss procedures * (Cochlear implant)

Laryngology:

Microlaryngoscopy

Neurotology:

Acoustic Neuroma
Vestibular neurectomy

OPHTHALMOLOGY  Anterior Procedures:

Cataract extraction w/IOL *
Corneal transplant *
Glaucoma procedures * (trabeculectomy, valve placement)
Vitreo-retinal Procedures:
Vitrectomies *

ORTHOPEDICS  Ortho Spine:

Micro discectomy

NEUROSURGERY

Craniotomy

RECONSTRUCTIVE PLASTICS

Micro re-vascularization of tissue flaps

Patient Attire

Preparation of the patient also includes patient attire and the shave-and-skin prep.Just as the surgical team wears surgical attire (scrubs, hats, masks), the patient wears ahospital gown and hair covering. The exception to this rule is outpatient procedures, suchas cataract extraction. Many centers require at most disrobing to the waist only and mayrequire simply a patient gown over the patient's street clothes. Pathway data supportsthis protocol. The total admission time for the patient is shortened, and post-operativecomplications (i.e. endophthalmitis) have not increased.

Skin Preparation

Hair removal is the first step in skin preparation. The shave prep is done as close tothe time of surgery as possible. Considering the body areas of microsurgery (spine andhead), this is done in the OR after induction and positioning. Endophthalmitis isattributed to endogenous sources, particularly from the eyelashes, which harbormicroorganisms. The eyelashes are clipped for vitreo retinal procedures using a curvediris scissors with blades coated with an ophthalmic antibiotic ointment to catch thelashes. Vitreoretinal procedures are similar to endoscopy procedures (such asarthroscopy), involving infusion and aspiration lines and portals for operativeinstruments. These lines could potentially drag pathogens into the vitreous chamber.

The scrub prep follows general skin preps. Neurosurgical preps add an alcohol step fordegreasing. Eye preps include irrigating the eye with sterile saline, cleansing the baseof the eyelashes and the periorbital area with a betadine solution.

The Environment

Preparing the surgical environment involves many steps, several of which are completedthe day prior to the patient's scheduled procedure. Equipment, such as microscopes, arecovered during storage to prevent dust accumulation on its surfaces. Terminal cleaning isdone at the end of the day's schedule on all horizontal surfaces, surgical lights,furniture, equipment, ventilation plates, anesthesia equipment, and contact surfaces(handles, switch plates, etc). Prior to the first case of the day, damp dusting is done onhorizontal surfaces and overhead surgical lights. The perioperative nurse does a quickvisual check of the room before set up and opening of sterile supplies.

Extraneous traffic through the room by personnel not involved in the case isdiscouraged. Since the microsurgery room is often crowded with multiple pieces ofequipment and the team is busy with tasks, contamination may not be observed. During thecase, strict adherence to aseptic technique is critical. Contamination is event relatedand with longer cases, there is more opportunity for an event to occur. This can bechallenging because many microsurgical procedures are performed in a darkened room toenhance the illumination of the surgical anatomy by the microscope's light source. Manyteams "map" out the procedure room set-up for optimal placement of equipment,furniture, anesthesia, and team members. This allows the scrub team easy access toinstruments and equipment, the anesthesia providers' patient access for monitoring, andthe non-scrubbed team to circulate in the room without compromising the sterile field.

Traffic patterns and zones are established to reduce cross contamination, controlaccess to the areas, and to facilitate efficiency.13 These divisions separatethe department by activity and required attire. In the unrestricted area, there isinterfacing with other departments (such as the scheduling department and holding area)and street clothes are allowed. The semi-restricted area includes sterile storage,instrument processing, and access corridors, which require scrub attire to be worn (scrubsand hats). In restricted areas of sterile cores, autoclave usage, and ORs with opensterile supplies or a case in progress, masks must be worn. All members of themicrosurgical team, scrubbed and non-scrubbed, must observe these requirements.

Three parameters of the OR environment are controlled to inhibit the growth ofmicroorganisms. Humidity is maintained at 30-60%, the rooms are kept cooler at 68-73ºF,and the room is ventilated through high-efficiency filters at a rate of 20-25 total roomair exchanges per hour.

Instrumentation must be delivered to the OR sterile and in proper working condition.When creating instrument sets and single items, the service specialty manager works withthe CS team to select the best packaging system (rigid container, peel pac, protectivetray and tips) as well as decontamination and sterilization methods (steam, gas, orplasma) using the manufacturers' guidelines. Some items required special detail inprocessing. Drills and irrigation/aspiration handpieces have components that must beseparated for cleaning and safety seals that are replaced. Inservice training and initialsupport by the vendor for both the OR and CS team is important. The CS team providessupport intra-operatively when a contaminated item or additional items are needed as wellas processing the instrumentation during the turnover between cases.

The sterile field is defined by the surgical draping of the patient, equipment, andfurniture. Patient draping isolates the surgical incision area. Equipment used in thesterile field or brought into proximity must be draped. Microscopes are brought in closeto the field with the ocular arm extended directly over the field. Draping allows thescrubbed personnel to adjust the microscope, protects the field from contaminants on thesurface of the microscope and provides a sterile backsplash during drilling. Drapes areselected according to the particular needs of the case. Towels and/or adhesive drapes areused to "square off" or outline the prepped incisional area and to confine hair.Adhesive incise drapes are used for ophthalmology procedures that do not require eyelashclipping (cataracts) to confine the eyelashes. Disposable drape technology providesextended barrier properties against moist bacterial "strike through" and controlof blood and body fluids and irrigation during the procedure.

A. Patient Factors (Intrinsic)

B. Surgical Factors (Extrinsic)

*Adapted from Guidelines for Prevention of Surgical Site Infection, 1999 CDC: Atlanta, GA.

Conclusion

The perioperative nurse can use optimal aseptic technique for case set up andthroughout the procedure. However, providing a safe and effective microsurgical experiencefor the patient begins before the day of surgery. SSI prevention is a collaborative andintegrated process involving many departments as well as professional, technical, andsupport personnel. The multi-skilled support staff prepares a surgically clean environmentand provides sterile instrumentation. The pharmacist and holding-area RN ensureadministration of the preoperative prophylactic antibiotic. Equipment vendors provideinservice training and processing technical support to the CS and OR team. All personnelinvolved directly in the case observe traffic and attire protocols as well as correct anysterile field compromises.

The perioperative nurse is in an excellent position to ensure an effective pathway. Thenurse combines knowledge of the procedure, potential pathogen contaminates, andappropriate prophylactic antibiotic agents with a complete patient assessment to preparefor the case. Intraoperatively, additional instruments and equipment are available andreadied for point-of-use. The sterile field and OR environment are monitored throughoutthe procedure. With assistance from the housekeeping and CS staff, compromises(contaminated instruments, blood and body fluid spills) are corrected. As patientadvocate, the perioperative nurse ensures the critical steps of the pathway are met toprevent a surgical site infection.

Cynthia K. Halvorson, RN, MSN, CNOR, has 24 years of perioperative experience inclinical, educational, and managerial positions in rural, urban, and academic centers ofexcellence. She has been a generalist staff nurse, clinical specialist, specialty servicemanager, and a perioperative/outcomes case manger.

For a list of references, access the ICT Web site.

Right Patient: CDC wound class 1 and 2

Implant or graft placement

Right Route:

Intravenously -- pre-op and intra-operative redosing
Irrigation -- in normal saline for wound irrigation prior to closure
Topical -- otologic and ophthalmic procedures (ointment or drops)
Injection -- subconjunctival for ophthalmic procedures

Right Antibiotic:

Agent per likely SSI pathogen source

Right Time:

30 minutes prior to patient entering OR (one hour if Vancomycin)

Right Dose:

Intraoperatively when agent reaches 1/2 life to maintain serum/tissue effective concentration levels

Adapted from Lewis and Porazzi. Quality Improvement of the Prophylactic Antibiotic Function in Seminars in Perioperative Nursing. Vol. 2 No 2. 210-215.