Breaches in the OR: The Perioperative and Infection Prevention Challenge

By Kelly M. Pyrek

Last year, we surveyed professionals working in surgical services and perioperative nursing and infection prevention about how well recommended practices are being implemented in the surgical suites across the U.S. When asked what they believed was the most critical component of infection prevention and control in the OR, 76 percent cited maintaining the sterile field; 57 percent cited proper patient skin prep; 55 percent cited proper surgical scrub/hand antisepsis; 43 percent cited proper barrier protection; and 28 percent cited other concerns.

One year later, the story remains the same, essentially, with a few tiny shifts in perception of priorities. When asked what they thought was the most critical component, 66 percent cited maintaining the sterile field; 61 percent cited surgical scrub/hand antisepsis; 53 percent cited patient skin prep; 30 percent cited proper barrier protection, and 23 percent pointed to other concerns that will be discussed in this article.

A savvy respondent summed it up by saying that a "sterile conscience" was most critical, "because if an individual has that, all things mentioned above will be covered completely," while another respondent emphasized, "I don't feel one of these are more weighted than the next in steps of prevention. They are ALL necessary steps to create an environment of the highest standards to prevent infection."

Hand Hygiene

Lack of or improper hand hygiene was the No. 1 breach reported in the 2011 survey, with 25 percent of respondents consistently reporting a failure by OR personnel to engage in timely, proper hand disinfection, especially after removing gloves.

The importance of proper hand hygiene cannot be overemphasized as this is the single most important measure to reduce the spread of microorganisms," says Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC, a perioperative nursing specialist with the Association of periOperative Registered Nurses (AORN). "Proper hand hygiene protects both patients and health care workers from exposure to blood, body fluids, microorganisms and other hazardous substances."

Van Wicklin reminds practitioners that hand hygiene should be performed:

- upon arrival at the healthcare facility

- before and after every patient contact

- before putting gloves on and after removing gloves or other protective equipment

- any time there is a possibility that there has been contact with blood or other surfaces

- before and after eating

- before and after using the restroom

- before leaving the healthcare facility

- when hands are visibly soiled

"According to AORNs Recommended Practices for Hand Hygiene, a surgical hand scrub should be performed by all members of the surgical team before donning sterile gown and gloves," Van Wicklin says. "Although the skin can never be rendered sterile, it can be made surgically clean by reducing the number of microorganisms. The surgical hand scrub should be accomplished according to the manufacturers written directions for use using either an antimicrobial surgical scrub agent intended for this purpose, or an alcohol-based antiseptic surgical hand rub with persistent and cumulative activity that has met the FDA requirements for surgical hand antisepsis. Surgical hand antisepsis/handscrubs are effective only if all surfaces are exposed to the mechanical cleaning and chemical antisepsis process. Surgical hand hygiene products should be selected, evaluated and approved by the organizations infection prevention personnel."

Surgical Attire

Eighteen percent of survey respondents cited problems relating to surgical attire as the most common breach seen in the OR, and it was the second most-cited issue by survey respondents. Specifically, respondents noted these situations:

- Wearing inappropriate attire

- Improper use of surgical attire

- Bringing personal items into the OR such as handbags, briefcases and laptops

- Wearing home-laundered surgical attire, especially caps

- Staff coming and going with shoe and head covers without replacing them before returning to the OR

- Lack of proper head coverings

- Hair not covered or contained

- Staff wearing long sleeves underneath scrubs

- Surgeons not changing into hospital-laundered scrubs

- Improper wearing of masks

- Improper fit of masks and head gear

- Lack of protective eyewear

- Staff wearing jewelry

- Reps walking into the OR without donning OR attire

Although it has always recommended institution laundering of surgical attire, the Association of periOperative Registered Nurses (AORN) is unequivocal on this position in its newly revised Recommended Practices for Surgical Attire, released in December. In this recommended practice, AORN is underscoring the science-based rationale for quality assurance monitoring of laundering practices, as well as taking a stand on other attire-related issues that compromise patient safety. AORN recommends that surgical attire should be laundered in a healthcare-accredited laundry facility, according to Recommendation V within the recommended practice, and all recommendations for home laundering of surgical attire have been removed. This is the most significant change since 2005, when the Recommended Practices for Surgical Attire was first released. Like other recommendations in this updated recommended practice, Recommendation V includes an expanded rationale section that cites literature and guidelines published since the previous version.

In addition to the new recommendation on quality assurance monitoring of laundering processes, the updated recommended practice on surgical attire includes:

- New information on characteristics of safe surgical attire fabrics, including recommendations that fabrics should be tightly woven, stain resistant and durable, and that 100 percent cotton fleece should not be worn

- Recommendations for safe footwear

- More information on wearing of jewelry, including how, where and when jewelry can be worn

- New information on regular and appropriate cleaning of stethoscopes and ID badges

- A new recommendation that fanny packs, brief cases and backpacks should not be taken into semi-restricted or restricted areas

- Updated information on disposable and reusable head coverings

Breach of the Sterile Field

The third most cited issue in the OR was breach of the sterile field, with 17 percent of respondents saying they had witnessed actions taken by OR personnel that compromised the integrity of this highly restrictive area. Specifically, respondents noted these situations:

- Non-scrubbed personnel reaching across the sterile field

- Inadvertent contamination of the OR table

- Personnel turning their backs to the sterile field

- Hands below the OR table level

Of note, several respondents acknowledged the presence of technology-driven equipment that further challenged the constant protection of the sterile field.

"Adherence to aseptic practices by all individuals involved in surgical and invasive procedures helps to fulfill the responsibility of perioperative team members to reduce the risk for surgical site infection and to protect the patient from injury," Van Wicklin says. "Healthcare-acquired surgical infections are a leading cause of patient morbidity and mortality in the United States. According to AORNs Recommended Practices for Maintaining a Sterile Field, rigorous adherence to the principles of asepsis is the foundation of surgical site infection prevention and should never be circumvented to save time or money. The surgical team should utilize proper aseptic technique for all surgical patients and all invasive surgical procedures should be performed using sterile instruments and supplies. When a break in sterile technique occurs, corrective action should be taken immediately unless the patients safety is at risk. If the patients safety is at risk, the break in technique should be corrected as soon as it is safe to do so."

Van Wicklin continues, "Personnel should be knowledgeable about the procedures involved in developing and maintaining a sterile field. An introduction and review of policies and procedures for maintaining the sterile field should be included in orientation to the perioperative setting for all personnel. Continuing education should be provided when new technologies are introduced. Ongoing education of perioperative personnel facilitates the development of knowledge, skills, and attitudes that affect aseptic practices and surgical patient outcomes.

Traffic Control

In both the 2010 and 2011 ICT surveys, traffic in the OR has been a consistent concern, as one survey respondent noted, "I would like to see more investigation on the limitation of the number of people in the OR suite. With the increased number of students, residents, etc, this is creating an unsafe environment with a high number of people in the OR. The number of reps in OR suites needs to be reduced." This fourth most common breach was identified by 13 percent of respondents who reported they too had a high volume of traffic going in and out of the ORs, and that appropriate traffic control was sorely lacking. Many respondents complained about personnel leaving the OR doors open, or leaving the OR open while unattended.

"According to AORNs Recommended Practices for Traffic Patterns, movement of personnel should be kept to a minimum while invasive and noninvasive procedures are in progress," says Van Wicklin. "In order to maintain critical environmental parameters such as a minimum of 15 total room air exchanges per hour, doors to the operating or procedure rooms should be closed except during necessary movement of patients, personnel, supplies, and equipment. Air is a potential source of microorganisms that can contaminate surgical wounds. Microbial shedding increases with activity and greater amounts of airborne contamination can be expected with increased numbers and movement of surgical team members. As well, operating rooms must be secure. Patient privacy must be maintained, patient, personnel and visitor safety should be ensured, and supplies and equipment should be protected from tampering and theft."

Break in Sterile Technique

Coming in as the fifth most common breach in the OR is a lack of or break in sterile technique, with 8 percent of respondents saying they noticed improper practices that could lead to infection or post-surgical complications.

Environmental Hygiene in the OR

Six percent of respondents felt strongly that timely and proper cleaning and disinfection of the surgical suite was not occurring, whether it was between cases or terminal cleaning at the end of the day. One respondent cited a "deplorable lack of adequate cleaning of high-touch areas between cases as well as the lack of cleaning of equipment," while another respondent said "the OR team is pressured for a quick OR turnover and are not waiting an appropriate time before opening the next case."

"Environmental cleaning is a team effort involving surgical personnel and environmental services personnel," Van Wicklin emphasizes. "All areas and equipment in the surgical practice setting should be cleaned according to an established schedule. Routine cleaning and disinfection reduces the amount of dust, organic debris, and microbial load in the environment. Following scientifically based recommendations for cleaning and disinfection practices in healthcare organizations helps to reduce infections associated with contaminated items."

Van Wicklin points to AORNs Recommended Practices for Environmental Cleaning in the Perioperative Setting that says all horizontal surfaces in the OR (e.g., furniture, surgical lights, booms, equipment) should be damp-dusted before the first scheduled surgical procedure of the day. "Cleaning and disinfection methods that produce mist, aerosols, or dust (e.g., spray bottles containing disinfectant) should not be used," she says. "Manufacturers cleaning recommendations should be consulted before cleaning computer keyboards, monitor screens, telephones, and other electronic devices. Equipment from areas outside the restricted area of the OR should be cleaned before being brought into an OR. Surgical and invasive procedure rooms and scrub/utility areas should be terminally cleaned daily. Terminal cleaning and disinfection of the perioperative environment decreases the number of pathogens, dust, and debris that is created during the day. Terminal cleaning and disinfection of operating and invasive procedure rooms should be done when the scheduled procedures are completed for the day, and each 24-hour period during the regular work week. Unused rooms should be cleaned once during each 24-hour period during the regularly scheduled work week. All personnel must comply with OSHAs bloodborne pathogen standards when performing cleaning and disinfection procedures involving contact with blood and other potentially infectious materials."

Patient Skin Prep

Six percent of survey respondents said they had seen poor skin prep in the OR, or had noticed that the patient skin-prep solution had not been allowed to dry properly following application. Also, when it comes to the pre-surgical scrub issue, several respondents said they wanted to see a stronger stance on making products such as CHG-impregnated sponges available to OR staff.

"According to AORNs Recommended Practices for Preoperative Patient Skin Antisepsis, only preoperative skin antiseptics that have been FDA-approved or cleared and approved by the healthcare organizations infection prevention personnel should be used for preoperative skin preparation," Van Wicklin emphasizes. "The patient should be assessed for contraindications to specific skin preparation agents. Likewise, the patients skin condition should be assessed for the presence of lesions or other tissue conditions at the surgical site before skin preparation begins. The efficacy of antiseptic agents is dependent on the cleanliness of the skin. Preoperative washing removes gross contaminants and oils that may block penetration of the antiseptic agent and also removes spores and other organisms that are not killed by the antiseptic agent. Removal of superficial soil, debris, and transient microbes before applying antiseptic agents reduces the risk of wound contamination. Hand hygiene should be performed before initiating the prep. Sterile gloves should be worn unless the antiseptic prep applicator is of sufficient length to prevent the antiseptic and patients skin from contact with the non-sterile glove. The antiseptic agent should be applied to the skin over the surgical site and surrounding area progressing from the incision site to the periphery in a manner that minimizes contamination, preserves skin integrity, and prevents tissue damage. The prepared area should be large enough to accommodate potential shifting of the drape fenestration, extension of the incision, the potential for additional incisions, and all potential drain sites. Protective measures (e.g., occlusive drapes) should be implemented to prevent skin and tissue injury due to prolonged contact with skin prep agents. Solutions should not be allowed to drip or pool beneath or around the patient. The antiseptic agent should remain in place for the full time suggested by the manufacturers written recommendations. If a flammable solution is used, the agent should be allowed to dry and vapors to dissipate before application of drapes. The use of a flammable agent should be discussed during the time-out."

Gloves

Holes in gloves and the improper use of gloves in general is still a vexing issue in the OR, with 5 percent of respondents reporting that personnel's gloves were somehow compromised -- whether through a puncture, hole or rip -- and healthcare workers were not changing their gloves when they should. Other respondents noted that OR staff members were wearing gloves for patient care and not removing them before touching items such as monitors, other equipment or phones in the room.

"According to AORNs Recommended Practices for Prevention of Transmissible Infections, all members of the surgical team should double-glove during invasive procedures as this will minimize the risk of exposure to blood and the number of perforations to the innermost glove," Van Wicklin says. "Punctured or torn gloves should be changed immediately if a visible defect is noted or if contamination of the glove is suspected or has occurred. Likewise, appropriate actions should be taken to remove any instrument(s) or remedy any area of the sterile field that may have been compromised by contact with the unsterile glove. Gloves should be changed after contact with uncured methyl methacrylate because the wearer is at risk for direct contact and skin absorption of the chemical via penetration of the glove material. Gloves should also be changed when an unintentional electric shock from an ESU is received to the hands of the user; and, when gloves begin to swell, expand, and become loose on the wearers hands as a result of the materials absorption of fluid and fats."

Surgeons and Anesthesiologists

Five percent of respondents were ready to point fingers at OR team members, especially surgeons and anesthesiologists, for breaches in practice in the OR. Many said that these physicians have a blatant disregard for the guidelines and ignore evidence-based practices relating to infection prevention and control. One respondent said she was growing weary of "surgeons who want try to short-change the proper protocol," while others said many surgeons and anesthesiologists were not wearing face masks or other items of PPE properly.

Surgical Instruments

More than 4 percent of respondents took issue with the lack of what they perceived to be proper cleaning, disinfection and processing of surgical instrumentation, both by the sterile processing department before the case opens, as well as instrument handling perioperatively. Respondents also noted a considerable lack of knowledge by some members of the OR team when it came time to use sterilizers properly, citing inconsistent sterile processing efforts.

Van Wicklin suggests that perioperative personnel consider that, "The term bioburden is frequently misused in the surgical setting because many consider this to be organic material on surgical instruments and equipment. According to AORNs Recommended Practices for Sterilization in the Perioperative Practice Setting, the accurate definition of bioburden is, 'The degree of microbial load; the number of viable organisms contaminating an object."' A contaminated instrument may contain both organic material (e.g., blood, tissue, mucous, body fluids) and viable infectious organisms. Effective sterilization cannot take place without effective cleaning. The process of sterilization is negatively affected by the amount of bioburden and the number, type, and inherent resistance of microorganisms, on the items to be sterilized. Soils, oils, and other materials may shield microorganisms on items from contact with the sterilant, or combine with, and inactivate the sterilant. Therefore, if blood, bone or other suspicious material is found on an instrument, the entire tray should be considered contaminated with corrective measures taken immediately."

Flash Sterilization

With the aforementioned lack of knowledge about instrument decontamination and sterilization, it's no surprise that about 2 percent of respondents reported problems with autoclaving in the OR, whether it was done too frequently or at all.

Van Wicklin encourages perioperative personnel to use the correct verbiage to describe two distinct processes relating to sterilization int he OR. "The term 'flash sterilization' does not fully describe the shorter sterilization cycles currently in use to process instruments," Van Wicklin explains. "Likewise, it does not encompass the critical steps of cleaning, decontamination, and aseptic transport that must accompany any sterilization cycle. These processes in total are more accurately reflected and described by the words 'immediate-use steam sterilization.' Immediate-use steam sterilization should be kept to a minimum, performed in a controlled manner, and used only in selected clinical situations (eg, when there is insufficient time to process by the preferred wrapped or container method). All items should be subjected to the same decontamination processes as described in AORNs "Recommended practices for cleaning and care of surgical instruments and powered equipment."

According to Van Wicklin, sterilization of items for immediate-use should be performed only if all of the following requirements are met:

- The device manufacturers written instructions on cycle type, exposure times, temperature settings, and drying times (if recommended) are available and adhered to.

- Items are disassembled, thoroughly cleaned with detergent and water to remove soil, blood, body fats, and other substances.

- Lumens are brushed and flushed under water with a cleaning solution and rinsed thoroughly.

- Items are placed in a closed sterilization container or tray, validated for immediate-use sterilization, in a manner that allows steam to contact all instrument surfaces.

- Measures are taken to prevent contamination during transfer to the sterile field.

- Sterilized items are used immediately and not stored for use at a later time.

"Immediate-use steam sterilization cycles should be monitored to verify that the parameters required for sterilization have been met," Van Wicklin adds. "Documentation of cycle information and monitoring results should be maintained in a log (electronic or manual) to provide tracking of the immediate-use sterilized item(s) to the individual patient."

Other Issues

There were a handful of other issues cited, with each issue representing about 1 percent of responses:

- Timely prophylactic antibiotic administration

- Compliance with SCIP measures

- Maintaining patient normothermia

- Holes in tray wrappers

- Moisture in instrument sets

- No sterility assurance of instruments

- Poor draping technique

- Proper barrier protection

- Proper handling of clean and sterile supplies

- Issues relating to humidity and temperature levels in the OR

- Safe injection practices, plus proper use of syringes and multi-dose vials

- Newspapers and magazines in the OR

- The condition and health of the patient coming into the OR

- Too much talking in the OR/inattention to the patient

- Staff not containing contaminated instruments while transporting to decontamination area

- OR personnel working when ill

OR Infections

With the many breaches seemingly occuring in the OR, respondents were not reporting sky-high infection rates. When asked if their OR has been associated with an infection or outbreak in the last six months, just 24 percent of respondents said yes, while 77 percent of respondents said no. But things got murkier when asked if respondents could identify the cause of an infection or outbreak. A few cavalier individuals attributed infection to the presence of "bugs" in the OR, while some said they were not provided with infection rate data. Eight-five percent of respondents said the cause was "unknown" or they were "unsure" about an infection's origins. About 5 percent of respondents blamed surgeons' practices for the infection, while another 5 percent identified improper skin antisepsis, inadequate patient prep, and improper draping. About 1 percent placed the blame on patients for their lack of compliance with pre-operative bathing or other measures, and another 1 percent pointed to patient co-morbidities. And about 3 percent of respondents blamed an infection on the "presence of staph bacteria."

Education, Education, Education

One critical area that needs improvement, survey respondents said, is the education of perioperative personnel. Not only must the level of education and training be elevated, it must be a continual process, they said. As one respondent put it, there must be a continuous effort on the part of perioperative and infection prevention educators to teach the concept of a "sterile conscience" to not only newbies, but to remind veterans of this obligation as well. One respondent advised, "Ensure proper initial instruction on all procedures and constant reiteration," while another advocated "frequent education of all staff and contracted personnel on infection prevention and control." The continual education process is necessary, said one respondent, due to "turnover that increases the likelihood for forgotten or ignored protocols among staff."

Collaboration Between IPs and Perioperative Personnel

Collaboration between perioperative professionals and infection preventionists seems to be a given among survey respondents; 79 percent of perioperative personnel indicated they worked closely with their institution's infection prevention department to help control and eliminate potential for infections. Eleven percent admitted that they "sometimes" work with infection prevention, while 5 percent said they "never" worked with this department. Noted one respondent, "I am the IP, and the OR director and I have a very strong working relationship with mutual respect for each other's knowledge base." But not everyone had this kind of relationship; one respondent noted, "I am the IP, and the OR nurse manager undermines input from infection prevention, including policies." A few other respondents reported that not only did they collaborate with the infection prevention department, but they also included the sterile processing department in their conversations.