Transcript Infection Control in the OR Myths and Misconceptions

Infection Control in the
OR
Myths and Misconceptions
Bruce Gamage
Infection Control Consultant
BCCDC
Outline
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Dressing for the theatre – is it just a fashion statement?
Masks – should we wear them?
Food in the OR!
Cleaning the environment – How clean is clean?
Super Bugs – is hand washing enough?
Surgical Hand Scrubs – Alcohol vs. CHX
Instruments – is flashing good enough?
Cleaning challenging instruments – “acetabular reamers”
Artificial Fingernails – there’s no place for them in HC
I’ve never seen a body piercing there before!
The OR of the future – designed with IC in mind.
Dressing for the Theatre
Evolution of OR Attire
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Origins of Scrub attire
• Paralleled
aseptic and sterile technique in late
th
19 century
• Hunter – advocated a complete change of
costume rather than don a sterilized coat and
trousers
• Mayo (1913) –operating team wore gowns caps
and masks
• 30s and 40s scrub dresses replaced “surgeons
uniforms”
• 60s Pantsuits and scrub dresses replaced full
skirts to reduce risk of clothing contaminating the
sterile field
IC issues
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“Germ theory” evolved in the early 19th
century
Principles of asepsis developed in mid19th century
The garment of the
HCW is part of the environment that can
become contaminated
Microbes (e.g. Staph, Strep,
Pseudomonas) can adhere to fabrics
Survival of Microbes on fabric
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Study done at
Shiners Hospital in
Cincinnati
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Staph and Enterococci
can survive for
extended periods of
time on materials
commonly worn by
HCWs (e.g. 100%
cotton or 60/40 cotton
blend)
Laundering of Scrubs
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“Contaminated” scrubs should be
washed in 160F (71C) water with 50150 ppm chlorine bleach and dried in a
hot dryer
Home laundering?
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University of Florida conducted a 4 year study to
determine the effect on perinatal infection rate of
wearing home laundered scrubs in L&D. Prior to
study rate was 1.7% - after study rate was 1.0%.
Practice was found to  costs without in  SSI
Opinions in flux
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Hospitals see scrub attire as a huge cost.
Experts in IC say “ there is no empiric data
that shows that home laundering leads to
 infections than commercial laundering.
Risk factors for SSI are pre-existing
morbidity, obesity, diabetes and  age.
Expert Opinion?
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APIC/CDC – there is little evidence that scrubs
in the OR setting is a means of infection
control in a health care facility
AORN – Scrub attire is not intended to be
protective in any way: it is simply a uniform. It’s
assurance that people coming into the OR are
wearing freshly laundered attire that hasn’t
been sat upon by the dog” Dorothy Fogg
AORN Position
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“Surgical Attire should be laundered
under controlled conditions where the
laundry facility has specific formulas
and they monitor the concentration of
chemicals”
AORN does not support home
laundering.
WHO/CDC
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All persons entering the surgical theatre
must wear surgical attire restricted to being
worn only within the surgical area.
The design and composition of surgical
attire should minimize bacterial shedding
into the environment
No recommendations on how or where to
launder scrub suits, on restricting use of
scrub suits to the OR or for covering scrub
suits when out of the OR.
Masks – should we wear them?
Masks – should we wear them?
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AORN – all persons entering the restricted area
of the OR suite should wear a mask when open
sterile items and equipment present.
AORN acknowledges that there is a difference of
opinion.
CDC states “a surgical mask that fully covers the
mouth and nose when entering the OR if surgery
is about to begin, is already underway or if sterile
equipment is open.”
What’s the evidence?
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Recent reports in the literature
advocate wearing of masks by nonscrubbed staff with forced
ventilation is not necessary
Studies from Europe show that oral
bacteria expelled during talking by
non-scrubbed personnel not in the
immediate vicinity of the operating
site posed no risk of infection.
What is the risk?
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The risk of contamination
depends on
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Airflow
Traffic
Personal practices.
Best practice would require
wearing of mask,
independent of distance
until research provides
definitive answers.
Personal Protection
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As part of Routine Practice
• Wearing a mask as part of PPE
to reduce the risk of exposure to
potentially infectious material.
Food in the OR?
Food in the OR?
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Eating in the OR is not acceptable!
Eating, drinking, smoking, applying
cosmetics or lip balm and handling contact
lenses in work area where there is
reasonable likelihood of occupational
exposure to infectious materials is
prohibited.
This is an OH&S issue!
How clean is clean?
Cleaning the environment :
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Airborne bacteria must be minimized and
surfaces kept clean.
When visible soiling or contamination with
BBF occurs during an operation, use
disinfectant to clean areas before next
operation.
There is no need to perform special cleaning
or closure of OR after contaminated or dirty
cases.
Recommendations
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Wet vacuum the OR floor after the last
operation of the day with disinfectant.
Tacky mats at the entrance to the OR have no
IC purpose
There is no recommendation on disinfection of
surfaces or equipment in the OR between
operations if there is no visible soiling.
Routine environmental sampling is not
recommended. Perform only as part of an
epidemiologic investigation.
WHO recommends:
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Cleaning of all horizontal surfaces every
morning
Cleaning and disinfection of horizontal
surfaces and surgical items between
procedures
Complete cleaning of the OR at the end of
the day
Complete cleaning of the entire OR annex
once a week.
Super Bugs – is hand washing
enough?
Super bugs
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CDC recommends:
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Exclude from duty surgical personnel who
have draining skin lesions until infection has
been ruled out or personnel have been
treated and infection has resolved.
No need to routinely exclude personnel
colonized unless there is epidemiological
evidence of spread in the health care
setting.
ARO Precautions
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There is no evidence that wearing gloves
when touching colonized patients is
necessary.
There is no evidence to support all staff
wearing a gown to enter the room.
There is no evidence for wearing a mask
when caring for a patient with ARO (may 
likelihood of HCW touching their nose).
There is no evidence that enhanced
cleaning is necessary to  transmission.
ARO Precautions
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There is no evidence that wearing gloves
when touching colonized patients is
necessary.
There is no evidence to support all staff
wearing a gown to enter the room.
There is no evidence for wearing a mask
when caring for a patient with ARO (may 
likelihood of HCW touching their nose).
There is no evidence that enhanced
cleaning is necessary to  transmission.
Current Recommendations
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Wash your hands!
Follow Routine Practices
Use contact precautions if will be
having direct (skin to skin)
contact with the patient or their
BBF.
Use regular cleaning practices.
Antibiotic resistance ≠ disinfectant
resistance.
Hand Scrubs – Alcohol vs. CHX
Hand Scrubs – Alcohol vs. CHX
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A surgical hand disinfection should be
performed by all persons participating in
the operative procedure.
The AORN continues to recommend the
traditional hand scrub with an antimicrobial
hand scrub agent.
AORN acknowledges that alcohol is an
excellent skin antiseptic with a persistent
effect for up to three hours.
Alcohol scrubs
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Care should be exercsed to use these products
if the procedure is <3 hours.
At the present time there is sparse evidence
showing that alcohols are more or less effective
than CHX scrubs
Recommend:
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Alcohol has no cleaning ability
First thoroughly wash hands and forearms with
soap and water
Then apply alcohol based surgical hand scrub
according to manufacturer’s instructions.
Instruments – is flashing good
enough?
Instruments – is flashing good
enough?
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Flash sterilization should only be used
for patient care items that will be used
immediately (e.g. to reprocess an
inadvertently dropped instrument)
Instruments should not be flash
sterilized because it is convenient or
because you don’t have enough sets
or to save time!
Flash Sterilization
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A chemical integrator that confirms temperature,
pressure and steam saturation was achieved.
Instruments must be cleaned before they can be
sterilized.
Cycle 3 minutes at 132C for non-porous, nonlumen
Cycle 10 minutes at 132C for porous or lumened
instruments.
Complex instruments – only at manufacturer's
recommendation.
Implants – not recommended.
Ensure staff are educated, process monitored
and audited.
Cleaning challenging
instruments
Cleaning challenging
instruments
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Reusable endoscopic instruments
that are not (or can’t be) properly
cleaned and sterilized are a major
cause of nosocomial infections
(CDC).
Decontamination and removal of all
possible biomaterial is the most
important step in the sterilization
process
“When in doubt, throw it out”
“The infection control dream”
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“an instrument that is
never reused does not
present and infection risk
to another patient!”
Problems with Endoscopes
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Long narrow shaft are difficult if not
impossible to clean.
The more complicated the device the
harder it is to clean.
Focus is on function, not on cleaning in
the design phase.
Forces sterile processing technicians to
do what they can and hope for the
best…
Other challenges…
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Keeping the instruments free of gross soil.
Minimize time between use and cleaning
process.
Making sure the SPD staff know and use the
correct procedures.
Having the right cleaning equipment and
solutions in the right place
Complex instruments that requires timeconsuming disassembly, cleaning and
reassembly before processing…
Proper Steps
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Begin cleaning as soon as possible (don’t let
blood and tissue dry and cake - covering with a
wet cloth is not enough.
Place the instruments in a basin of solution as
soon as they come off the procedure table.
Wipe down surfaces and flush lumens to
remove gross debris.
Separate general from specialized instruments.
Transport to SPD.
Clean and disinfect or sterilize according to
manufacturer's written instructions.
Manufacturer’s Responsibility
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Manufacturer’s must incorporate
“cleanability” into design.
“Manufacturer’s should provide
documentation from an independent
laboratory that proves the device can
actually be cleaned.” Dennis Maki.
“Acetabular Reamers”
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In January 2004, a technician at a hospital in
Canada discovered that some of these
instruments could be partially disassembled
prior to cleaning. This may have not been
known by some hospitals using this
equipment and the information originally
received from the manufacturer did not
adequately describe the disassembly
procedures.
What about artificial
fingernails?
What about artificial
fingernails?
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Some folks think it’s OK to wear
acrylic nails if they are only
circulating…
Artificial should not be worn in the
perioperative setting
AORN: Artificial nails should not be
worn.
Rationale
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The is not evidence that artificial nails
increase the risk of SSI.
These nail may harbour organisms and
prevent effective handwashing.
High numbers of gram-negative
organisms have been cultured from
personnel wearing artificial nails!
I’ve never seen a body piercing there
before!
Body Piercing!?!
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Removing jewelry means removing jewelry!
There is a risk of burns if an electrosurgical
unit is used.
Risk is less if ESU has an
isolated generator that
eliminates the risk of alternate site burns.
Ask patients to remove body piercing prior
to coming to the hospital.
The OR of the Future
Designing an OR with Infection Control in
mind.
The OR of the Future
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OR designed to be large (600 sq. ft.)
allow greater separation of sterile field
and non-sterile perimeter.
Patients and OR staff have separate
entrances to avoid cross contamination
No floor penetrations and all wall and
ceiling penetrations are sealed.
Designing the OR for IC
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An observation gallery to
minimize people going in
and out.
Hands free or voice
activated surgical
equipment (robotic).
Multiple cameras for
consulting and teaching
purposes.
Hands free telephone
and voice activated
devices.
Touch screen computers
instead of keyboards.
Designing the OR for IC
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Ceiling-hung equipment booms to hold
equipment off the floor.
All utilities and medical gases originate
from ceiling to eliminate hoses and
cables running across the floor and in
and out of the sterile field.
Makes things much easier to clean and
disinfect.
Designing the OR for IC
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Special attention given to surfaces
finishes for ease of cleaning and
durability.
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Epoxy terrazzo floor.
Ceramic tile walls with epoxy-based grout.
Seamless gypsum wallboard for ceiling, sealed
with epoxy paint.
Stainless steel and glass cabinets.
Ventilation
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Laminar flow HVAC system
that delivers air from the ceiling
and exhausts in rooms
corners.
Positive pressure to outside
rooms
All ductwork insulated on the
exterior to minimize surfaces
where moulds and bacteria can
grow.
Lighting
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Voice command adjustable
lighting.
Gaskets and seals on fixtures to
promote dust control and make
cleaning easier.
Goals
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Easier to clean 
faster TAT
Shortened time
frames
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Voice activated 
everything moves
quicker
Patient is open on the
table for a shorter
period
Risk of infection 
Summary
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IC practice should be evidence based.
Sometimes best practice is based on
expert opinion.
It shouldn’t be “we’ve always done it that
way”.
New designs should have IC in mind.
Questions?