Infection Control in the OR Myths and Misconceptions

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Infection Control in the ORMyths and
Misconceptions

• Bruce Gamage
• Infection Control Consultant
• BCCDC

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Outline

• 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 theres no place for
  them in HC
• Ive never seen a body piercing there before!
• The OR of the future designed with IC in mind.

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Dressing for the Theatre
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Evolution of OR Attire

• Origins of Scrub attire
• Paralleled aseptic and sterile technique in late
  19th 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

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IC issues

• Germ theory evolved in the early 19th century
• Principles of asepsis developed in mid-19th
  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

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Survival of Microbes on fabric

• Study done at Shiners Hospital in Cincinnati
• 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)

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Laundering of Scrubs

• Contaminated scrubs should be washed in 160?F
  (71?C) water with 50-150 ppm chlorine bleach and
  dried in a hot dryer

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Home laundering?

• University of Florida conducted a 4 year study to
  determine the effect on perinatal infection rate
  of wearing home laundered scrubs in LD. Prior to
  study rate was 1.7 - after study rate was 1.0.
• Practice was found to ? costs without in ? SSI

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Opinions in flux

• 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.

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Expert Opinion?

• 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.
  Its assurance that people coming into the OR are
  wearing freshly laundered attire that hasnt been
  sat upon by the dog Dorothy Fogg

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AORN Position

• 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.

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WHO/CDC

• 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.

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Masks should we wear them?
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Masks should we wear them?

• 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.

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Whats the evidence?

• Recent reports in the literature advocate wearing
  of masks by non-scrubbed 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.

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What is the risk?

• The risk of contamination depends on
• Airflow
• Traffic
• Personal practices.
• Best practice would require wearing of mask,
  independent of distance until research provides
  definitive answers.

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Personal Protection

• As part of Routine Practice
• Wearing a mask as part of PPE to reduce the risk
  of exposure to potentially infectious material.

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Food in the OR?
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Food in the OR?

• 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 OHS issue!

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How clean is clean?
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Cleaning the environment

• 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.

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Recommendations

• 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.

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WHO recommends

• 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.

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Super Bugs is hand washing enough?
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Super bugs

• CDC recommends
• 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.

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ARO Precautions

• 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.

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ARO Precautions

• 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.

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Current Recommendations

• 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.

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Hand Scrubs Alcohol vs. CHX
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Hand Scrubs Alcohol vs. CHX

• 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.

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Alcohol scrubs

• Care should be exercsed to use these products if
  the procedure is lt3 hours.
• At the present time there is sparse evidence
  showing that alcohols are more or less effective
  than CHX scrubs
• Recommend
• Alcohol has no cleaning ability
• First thoroughly wash hands and forearms with
  soap and water
• Then apply alcohol based surgical hand scrub
  according to manufacturers instructions.

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Instruments is flashing good enough?
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Instruments is flashing good enough?

• 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 dont
  have enough sets or to save time!

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Flash Sterilization

• 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,
  non-lumen
• 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.

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Cleaning challenging instruments
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Cleaning challenging instruments

• Reusable endoscopic instruments that are not (or
  cant 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

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The infection control dream

• an instrument that is never reused does not
  present and infection risk to another patient!

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Problems with Endoscopes

• 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

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Other challenges

• 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 time-consuming
  disassembly, cleaning and reassembly before
  processing

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Proper Steps

• Begin cleaning as soon as possible (dont 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.

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Manufacturers Responsibility

• Manufacturers must incorporate cleanability
  into design.
• Manufacturers should provide documentation from
  an independent laboratory that proves the device
  can actually be cleaned. Dennis Maki.

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Acetabular Reamers

• 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.

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What about artificial fingernails?
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What about artificial fingernails?

• Some folks think its 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.

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Rationale

• 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!

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Ive never seen a body piercing there before!
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Body Piercing!?!

• 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.

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The OR of the FutureDesigning an OR with
Infection Control in mind.
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The OR of the Future

• 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.

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Designing the OR for IC

• 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.

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Designing the OR for IC

• 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.

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Designing the OR for IC

• Special attention given to surfaces finishes for
  ease of cleaning and durability.
• Epoxy terrazzo floor.
• Ceramic tile walls with epoxy-based grout.
• Seamless gypsum wallboard for ceiling, sealed
  with epoxy paint.
• Stainless steel and glass cabinets.

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Ventilation

• 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.

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Lighting

• Voice command adjustable lighting.
• Gaskets and seals on fixtures to promote dust
  control and make cleaning easier.

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Goals

• Easier to clean ? faster TAT
• Shortened time frames
• Voice activated ? everything moves quicker
• Patient is open on the table for a shorter period
• Risk of infection ?

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Summary

• IC practice should be evidence based.
• Sometimes best practice is based on expert
  opinion.
• It shouldnt be weve always done it that way.
• New designs should have IC in mind.

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• Questions?