Infection Prevention: The Surgical Care Continuum SUE BARNES, BSN, RN, CIC
ABSTRACT Lack of careful attention to the increasing complexity of surgical procedures, instrument cleaning and processing, and the transition of surgical and other invasive procedures from the OR to areas outside the traditional hospital OR can contribute to surgical site infection (SSI) risk. Regardless of the location of an intervention, when basic infection prevention measures are applied reliably, even low infection rates can be reduced. To address infection prevention challenges, infection preventionists (IPs) must be well informed regarding infection risk and prevention during surgical and other invasive procedures and the effect a facility type may have on patients’ infection risk. The IP must have a solid understanding of surgical asepsis, instrument disinfection, and sterilization to educate and support clinical teams in identifying opportunities for improvement relative to infection prevention. AORN J 101 (May 2015) 512-518. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.02.006 Key words: infection prevention, infection preventionists, IP, asepsis, sterilization, disinfection, continuum of care.
http://dx.doi.org/10.1016/j.aorn.2015.02.006 ª AORN, Inc, 2015
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urgical procedures are performed with increasing frequency outside of hospital ORs, in ambulatory surgery centers (ASCs) and in numerous other facilities (eg, physician’s ofﬁces, clinics, other departments in the hospital).1,2 The goal of performing surgery in any of these sites is to provide patient care that is convenient, safe, and costeffective. However, performing surgical or other invasive procedures in less controlled environments than those found in the OR also can lead to less than robust infection prevention precautions.3-5 Developing a strong relationship between the infection preventionist (IP) and the various clinical teams can result in a sharing of knowledge regarding speciﬁcs of the procedures (clinical teams) and infection prevention precautions that can ultimately improve patient outcomes. Direct observation by IPs at the invitation of the clinical team can help identify opportunity areas in prevention practice focused on the primary sources of potential contamination: the patient’s own skin, the health care team, and the environment. Although the type and complexity of the procedures in these environments vary widely, the basic infection prevention goal for invasive procedures is always the same: reducing the risk of bacterial contamination during the procedure via antibiotic prophylaxis when indicated, provider hand hygiene, patient skin preparation, and aseptic technique, including proper barrier precautions. Prevention of environmental contamination is ensured by minimizing trafﬁc and practicing comprehensive environmental cleaning/disinfection.6
AMBULATORY SURGERY CENTERS Ambulatory surgical centers provide an environment similar to an inpatient OR by providing similar design, work ﬂow, and surgical asepsis. Personnel in these centers perform a wide range of procedures (eg, orthopedic, gastrointestinal, ophthalmological, gynecological, dermatological, plastic, spinal), and in general, surgical site infection (SSI) rates in these centers are reported to be low; however, surveillance is not required in all states and currently there are inadequate data to determine the true risk of SSIs in ASCs compared with hospital-based ORs.1 To reduce SSIs, perioperative staff members and surgeons in any areas providing surgical interventions, including inpatient ORs, must execute and maintain complex, specialized skill sets while practicing excellent aseptic technique. A recent study of multiple ASCs identiﬁed signiﬁcant SSI prevention practice improvement opportunities, including changes in patient skin preparation, administration of antibiotics, and staff member removal of watches, jewelry, and artiﬁcial nails. The ﬁnal
Infection Prevention in Surgical Settings
conclusion was that “inadequate staff knowledge of infection control principles”7(p1) contributed to SSIs in the ASCs. The Centers for Medicare & Medicaid Services (CMS) conditions of participation8 require an ASC to have an infection control program, but not a certiﬁed IP. However, an IP could help ensure basic surgical infection prevention practices and help personnel remain current with the constantly evolving evidence regarding practices and products designed to reduce SSI risk.
OUTPATIENT PROCEDURE ROOMS Surgical procedures are performed in multiple venues, including examination and procedure rooms. For example, physicians often perform Mohs procedures for the excision of skin cancers in outpatient procedure rooms or their ofﬁces.9 Typically only the wound closure step is treated as sterile during this procedure, and there are wide variations in patient skin prepping techniques, the use of personal protective equipment (PPE), and re-use of instruments.9 Although low infection rates are reported for this procedure, surveillance in these settings is not mandatory.10 Regardless of the setting, at least one published peer-reviewed study reports that when basic infection prevention measures are applied reliably, even the low infection rates after Mohs procedures can be reduced.11 This would be best achieved with a dedicated certiﬁed IP to consult, observe practice, track infection rates, introduce new products/practices with supporting evidence, and educate personnel about infection prevention measures. Podiatrists also frequently perform surgical procedures in medical ofﬁce examination and procedure rooms. These procedures include hammer toe release or tenotomy (the cutting of a tendon, also called tendon release, tendon lengthening, heel-cord release), osteoclasis (the surgical destruction of bone tissue, performed to reconstruct a bone that is malformed), and matrixectomy (the process of surgically or chemically destroying all or part of the base nail portion called the nail matrix).12,13 Similarly, orthopedic surgeons often perform procedures in outpatient procedure rooms and their ofﬁces, including carpal tunnel release and trigger ﬁnger release. Surgical site infections in any procedure in which bone is exposed (eg, orthopedic, podiatric procedures) is reportedly infrequent, but can be catastrophic when it occurs.14,15 AORN Journal j 513
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SURGICAL SITE INFECTION PREVENTION
Complex Procedures and SSI Risk
Regardless of the facility where a surgical procedure is performed, the same basic surgical infection prevention measures must be reliably implemented (ie, prophylactic antibiotics, aseptic and sterile technique, use of PPE, careful prepping and draping, removal of patient hair outside of the OR if required, full containment of staff member hair). In addition, patients should be instructed to perform a preoperative antiseptic bath or shower. In the OR, team members must prep the patient’s skin with dual-agent solutions (eg, alcohol plus another antiseptic such as chlorhexidine gluconate [CHG] or povidone iodine).16 If involved in surgical case observation, an IP can assess all these areas and may be able to help identify improvement opportunities or areas in which practices vary from prescribed protocol. For example, because hair can harbor bacteria and the head and body shed hair and skin cells, all body hair should be covered (ie, with a surgical cap for both staff and patient, cover jacket for nonscrubbed staff members) to prevent this shedding and remove a possible source of an SSI.17
Surgery and the technologies and equipment needed to perform it continue to increase in complexity. Perioperative personnel are faced with increasingly complex tools to use, clean, decontaminate, and sterilize. Typically, the beneﬁts of these innovations are designed to improve patient care and provide better outcomes; however, this is not always true. The beneﬁts of robotic surgery, for example, include improved mobility, visibility, and ergonomic position for the surgeon and smaller incisions, less-invasive procedures, and less blood loss and transfusion requirements for the patient. Robotic procedures are performed in general, spinal, orthopedic, cardiac, gynecological, and neurological surgical specialties. All these improvements can, of course, lead to better patient outcomes and surgeon health.27 However, this innovation can sometimes be associated with an increased risk of infection. In some cases, this is related to the difﬁculty cleaning the complex instruments and equipment. Robotic-assisted procedures also involve a different work ﬂow than nonrobotic procedures, which can challenge personnel in space-constrained ORs relative to maintaining good aseptic technique.27
Additionally, in departments where zero preventable surgical infections has not been achieved or sustained, IPs must be prepared to share with staff members and surgeons information on “plus measures,” which are practices and/or products for which evidence supporting their efﬁcacy in reducing SSI risk is less than category level 1. The list of “plus measures” is constantly evolving and currently includes repeated preoperative antiseptic (CHG) patient bathing the night before and the morning of surgery, which increases the residual antibacterial effect of CHG.18-20 Another plus measure for which evidence is increasing is nasal decolonization for patients who are colonized with methicillin-resistant Staphylococcus aureus (MRSA) and also sensitive strains. Most studies to date have been performed using mupirocin, an antibiotic ointment.21,22 Concerns regarding antibiotic resistance, patient compliance, and cost have prompted the introduction of alternative products (for nasal decolonization), such as antiseptics (eg, povidone iodine and isopropyl alcohol), which are less expensive than antibiotics and are designed to be applied by perioperative personnel one hour before surgery instead of by the patient for several days before the procedure.23-26 New product introduction is an area in which IPs can assist perioperative personnel by sharing product information and associated evidence for its use. This can facilitate an informed decision by the perioperative team regarding whether or when to expand an existing SSI prevention program to target procedures that prevent SSIs. 514 j AORN Journal
Nonsurgical Invasive Procedures Outside of ORs As with surgical procedures, nonsurgical invasive procedures frequently are performed in a variety of settings. These lesscontrolled environments can lead to less-than-robust infection prevention precautions.
Interventional radiology Interventional radiology (IR) proceduralists (IRPs) perform increasing numbers and types of complex invasive procedures.28 A multisociety guideline published in 2012 is a great resource for IPs and IR departments, describing key infection prevention priorities for these complex procedures.6 Most IRPs perform percutaneous procedures, and many procedures involve an implant. Procedures involving implants are associated with greater risk of infection because of the potential for bioﬁlm formation.29 Implants include IV ports, aortic valves, cardiac stents, thoracic stents, internal automatic deﬁbrillators, and cardiac pacemakers. Infrequent but signiﬁcant morbidity and reoperation is reported when infections occur after placement of these implants.30-32 Many patients undergoing IR procedures are at high risk for infection even before the procedure because of comorbidities or the emergent nature of their treatment. For instance, IRPs often place vascular ports in oncology patients for chemotherapy infusions, and these immunosuppressed patients are at
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high risk for infection. These grafts are used to treat incomplete aortic injuries and carry much lower morbidity and mortality than open surgery; however, there is still infection risk.33 Infection prevention measures for percutaneous procedures are the same as those for central venous vascular access, including the use of a dual-agent skin prep (ie, products that include alcohol combined with another antiseptic), aseptic technique during percutaneous entry, full PPE precautions by the IRP, and aseptic technique during the procedure. A few IR procedures involve a small surgical incision to insert a pacemaker or the performance of a vertebroplasty, kyphoplasty, or osteoplasty.34 Infection prevention measures for these procedures should mirror those for any surgical procedure. To support the surgical team in the drive toward a goal of zero preventable postprocedure infections, in facilities with IR suites, the IP should become familiar with the procedures that are performed.
Infection Prevention in Surgical Settings
approach. In one recent study of approximately 3,000 patients, the postprocedure infection rate was 2.8%, and no deaths were reported. The primary risk factor for infection identiﬁed in the multivariate analysis was noncompliance with antibiotic prophylaxis.39 For this procedure then, compliance with antibiotic prophylaxis guidelines must be adhered to, in addition to rigorous instrument reprocessing between patients, including the probe; comprehensive cleaning and decontamination followed by sterilization of the needle guide between patients; and the use of one disposable sterile needle per patient. As with all other infection prevention measures, the IP’s role is to communicate, educate, and collaborate with the frontline clinical team by sharing information and knowledge. Injecting medication into sterile organ spaces including the eye (intravitreal), spine, and joints is another type of a nonsurgical invasive procedure after which an infection could be catastrophic for the patient.40-42 Infection prevention priorities in these procedures include use of appropriate PPE by the provider, appropriate skin prep (dual agent), and sterile disposable needles and medication vials used for one patient, one time.43
Medical ofﬁces and procedure rooms Other nonsurgical invasive procedures performed in clinics and procedure rooms include percutaneous skin, breast, and prostate biopsies. Infection preventionists should become well versed in these procedures to support teams in identifying infection prevention opportunities. Breast procedures are at especially high risk for infection because of the reduced vascularity of the breast tissue.35 Standard infection prevention practices, including dual-agent skin preps containing alcohol plus CHG or iodine, and rigorous aseptic technique are necessary to minimize this risk. Prostate biopsy procedures generally deviate from what we understand to be critical infection prevention precautions required for tissue biopsy. The surgeon inserts a rectal probe with a sterile needle guide attached only once. During the procedure, he or she inserts an initially sterile needle through the needle guide, into and through the rectal tissue, and into the prostate gland up to 12 times, using a needle gun. Both the needle and guide are of course considered contaminated after the ﬁrst biopsy. Researchers have weighed the beneﬁt of removing the probe for each biopsy, removing the sterile needle guide each time, placing a new sterile needle guide on the probe, and reinserting the rectal probe and guide, with its associated time, invasiveness, and cost, against the standard practice of administering preprocedure antibiotics and using one probe, one needle guide, and one needle for one patient.36-38 The reported postprocedure infection rate is low for this
Instrument Decontamination and Sterilization Complex surgical instruments require the specialized expertise of sterile processing (SP) department staff to competently and reliably disassemble, decontaminate, wrap, sterilize, and deliver or store instruments. This process is guided by professional evidenced-based guidelines and by the instrument manufacturer’s instructions for use.44 Inadequately reprocessed sterile (critical) instruments have been associated with surgical infection.45-47 A strong relationship between SP professionals and IPs can facilitate safe patient care. Infection preventionists can support SP departments as they do in ORs, with departmental site visits focusing on elements affecting surgical infection prevention, in partnership with the SP department manager. These visits can also be helpful in other locations where critical instruments (eg, sterile instruments) may be reprocessed, such as in orthopedics, ophthalmology, and podiatry. In addition, instrument reprocessing is a critical aspect of care that must be included during a root cause analysis (RCA) of surgical infection. Key issues of focus for site visits and RCA include point-of-use instrument decontamination, quality assessment of automated and manual decontamination processes, disassembling of instruments before reprocessing, use of disposable instead of reusable cleaning brushes, and use of the appropriate brush size(s) for cleaning lumens.46
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Similarly, the reprocessing of semicritical instruments (ie, highlevel disinfected instruments) including ﬂexible endoscopes must be rigorous and routinely assessed according to published guidelines. While this is not within the scope of the IP, but rather SP professionals, IPs should be informed and able to assess key steps in the process during an RCA of infections and during visits or rounds of these departments. Key areas of focus might include point-of-use decontamination, disposable versus reusable cleaning brushes, quality assessment of scope cleanliness after reprocessing, alcohol ﬂushing after disinfection/ rinsing, and appropriate storage techniques. Inadequately cleaned and disinfected ﬂexible endoscopes have been implicated in more outbreaks than any other medical device.46
Preventing Device-Associated Infections In addition to prevention of surgical infections, IPs can assist in preventing device-associated infections, including catheter-associated urinary tract infection (CAUTI), central lineeassociated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Regardless of the patient environment, a risk of infection is associated with any indwelling device, including central venous catheters, urinary catheters, and endotracheal tubes. All these devices are used with great frequency in the OR. Urinary catheters may be the most common indwelling device inserted during surgical procedures. Because studies conclude that the duration of catheterization is the most important risk factor for developing infection,48,49 The Joint Commission has added a core measure that requires the removal of the urinary catheter on postoperative day one or day two. Exceptions to this requirement include a physician-documented reason not to remove the catheter; all urological, gynecological, and perineal surgeries; a patient in intensive care; a patient receiving diuretics; and a patient with a documented infection before surgery.50 Key strategies designed to support the prompt removal of urinary catheters include automated physician catheter discontinuation orders and nursing practice, catheter-removal protocols.51,52 The risk of pneumonia increases with the duration of intubation.53 There is some evidence that general anesthesia is associated with a greater risk of pneumonia than neuraxial anesthesia (local and/or regional blocks).54 In addition to reliably implemented ventilator bundles, preoperative oral rinse containing 0.12% CHG has been reported to reduce postoperative pneumonia risk for patients receiving general anesthesia.55,56 Central lineeassociated bloodstream infection (BSI) prevention bundles for insertion and maintenance are generally hard 516 j AORN Journal
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wired in all departments, including the OR. Over time, these bundles have been expanded in some locations to include additional products and practices that peer-reviewed studies suggest. For example, there is evidence that CHG bathing reduces device-associated infections in the intensive care unit.57 It might therefore be reasonable to think that preoperative CHG bathing designed to reduce SSI risk could also reduce the risk of intraoperative BSIs. Additionally there is a rapidly expanding body of evidence supporting the use of port protector/hub disinfectors to reduce the risk of device-associated BSIs, by removing the human factor associated with neglecting to scrub the hub before accessing or injecting medication into an IV line.54,58,59
CONCLUSION The increasing complexity of surgical procedures and instruments and the continuing transition of surgical and other invasive procedures from inpatient to ambulatory venues can increase patient infection risk. In supporting clinical teams in attaining the lowest possible number of postsurgical and postprocedural infections, IPs must be well informed regarding which surgical and nonsurgical invasive procedures are performed in their OR and ambulatory departments. Collaboration between IPs and the perioperative and SP departments, as well as the numerous other departments where surgical and invasive procedures are performed, can support optimized infection prevention practices. Additionally, as evidence evolves, IPs can assist teams in considering expanding infection prevention bundles to include new products and practices.
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Barnes 37. Patient Safety Alert, Veteran’s Health Administration Warning System, April 3, 2006. US Department of Veteran’s Affairs. http:// www.va.gov/ncps/alerts/b-kmedicaltransduceralert06-011.pdf. Accessed January 27, 2015. 38. FDA public health notiﬁcation: reprocessing of reusable ultrasound transducer assemblies used for biopsy procedures. http://www.fda .gov/cdrh/safety/061906-ultrasoundtransducers.html. Accessed January 27, 2015. 39. Bruyere F, Malavaud S, Bertrand P, et al. Prosbiotate: a multicentric, prospective analysis of infectious complications after prostate biopsy. J Urol. 2014;193(1):145-150. 40. Murad-Kejbou S, Kashani AH, Capone A Jr, Ruby A. Staphylococcus lugdunensis endophthalmitis after intravitreal injection: a case series. Retin Cases Brief Rep. 2014;8(1):41-44. 41. Epstein NE. The risks of epidural and transforaminal steroid injections in the spine: commentary and a comprehensive review of the literature. Surg Neurol Int. 2013;4(Suppl 2):S74-S93. 42. Chiller TM, Roy M, Nguyen D, et al. Clinical ﬁndings for fungal infections caused by methylprednisolone injections. N Engl J Med. 2013;369(17):1610-1619. 43. Dolan SA, Felizardo G, Barnes S, et al. APIC position paper: safe injection, infusion, and medication vial practices in health care. Am J Infect Control. 2010;38(3):167-172. 44. Seavey R. High-level disinfection, sterilization, and antisepsis: current issues in reprocessing medical and surgical instruments. Am J Infect Control. 2013;41(5)(Suppl):S111-S117. 45. Alfa MJ. Monitoring and improving the effectiveness of cleaning medical and surgical devices. Am J Infect Control. 2013; 41(5)(Suppl):S56-S59. 46. Rutala WA, Weber DJ. New developments in reprocessing semicritical items. Am J Infect Control. 2013;41(5)(Suppl):S60-S66. 47. Smith GW, Goldie F, Long S, Lappin DF, Ramage G, Smith AJ. Quantitative analysis of residual protein contamination of podiatry instruments reprocessed through local and central decontamination units. J Foot Ankle Res. 2011;4(1):2. 48. Bernard MS, Hunter KF, Moore KN. A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urol Nurs. 2012;32(1):29-37. 49. Meddings J, Rogers MA, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf. 2014;23(4):277-289. 50. Joint Commission on Accreditation of Healthcare Organizations. Approved: new infection-related National Patient Safety Goal for
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2012: catheter-associated urinary tract infections pose high risk. Jt Comm Perspect. 2011;31(7):6-7. Fakih M, Rey JE, Pena ME, et al. Sustained reductions in urinary catheter use over 5 years: bedside nurses view themselves responsible for evaluation of catheter necessity. Am J Infect Control. 2013;41(3):236-239. Oman K, Makic MB, Fink R, et al. Nurse directed interventions to reduce catheter associated urinary tract infections. Am J Infect Control. 2012;40(6):548-553. Guay J, Choi P, Suresh S, Albert N, Kopp S, Pace NL. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2014;1:CD010108. Wright MO, Tropp J, Schora DM, et al. Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. Am J Infect Control. 2013;41(1):33-38. Nicolosi LN, Del Carmen Rubio M, Martinez CD, Gonzalez NN, Cruz ME. Effect of oral hygiene and 0.12% chlorhexidine gluconate oral rinse in preventing ventilator associated pneumonia after cardiovascular surgery. Respir Care. 2014;59(4):504-509. Bergan EH, Tura BR, Lamas CC. Impact of improvement in preoperative oral health on nosocomial pneumonia in a group of cardiac surgery patients: a single arm prospective intervention study. Intensive Care Med. 2014;40(1):23-31. Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013; 368(6):533-542. DeVries M, Mancos PS, Valentine M. Evaluating and choosing devices to reduce bloodstream infections in both central and peripheral lines. Am J Infect Control. 2013;41(6)(Suppl):S25-S145. Stango C, Stern JJ, Runyan D, et al. Use of alcohol impregnated caps to reduce catheter related bloodstream infections. Am J Infect Control. 2013;41(6)(Suppl):S90. http://www.ajicjournal.org/article/ S0196-6553%2813%2900479-3/abstract. Accessed December 31, 2014.
Sue Barnes, BSN, RN, CIC is the national leader for infection prevention and control at Kaiser Permanente Healthcare, Oakland, CA. Ms Barnes has no declared afﬁliation that could be perceived as posing a potential conﬂict of interest in the publication of this article.