Breaks in Aseptic Technique Require Review of OR Basics

As an infection preventionist, do you know what’s happening in your hospital’s operating rooms (ORs) related to infection prevention and control practices? To get an idea of how well recommended practices are being implemented in the surgical suites across the U.S., ICT conducted an opinion poll of OR nurses to gather their opinions on a number of issues related to infection prevention and control.

When asked what they believe are the most critical components 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; and 43 percent cited proper barrier protection. Thirty-three respondents (28 percent) cited other main concerns that will be addressed in this article.

Skin Prep, Aseptic Technique and the Sterile Field

The best safeguard against surgical site infections (SSIs) and other infections acquired in the OR is maintaining aseptic technique — a set of specific practices and procedures performed under carefully controlled conditions with the goal of minimizing contamination by infectious pathogens — at all times. Aseptic technique refers to the practices performed immediately before and during a clinical procedure to reduce post-operative infection; these include patient skin prep, handwashing, surgical scrub, using barrier protection for the patient (draping) and for the surgical team (surgical attire), maintaining the sterile field, using safe operative technique and maintaining a safe and sterile environment in the surgical arena.

The Centers for Disease Control and Prevention (CDC)’s Guideline for Prevention of Surgical Site Infections notes, “Rigorous adherence to the principles of asepsis by all scrubbed personnel is the foundation of surgical site infection prevention. Others who work in close proximity to the sterile surgical field, such as anesthesia personnel who are separated from the field only by a drape barrier, also must abide by these principles.”

According to the AST, the three basic principles of asepsis, as stated in the Core Curriculum for Surgical Technology to be applied to all patients are: Principle I: A sterile field is created for each surgical procedure; Principle II: Sterile team members must be appropriately attired prior to entering the sterile field; Principle III: Movement in and around the sterile field must not compromise the field. These principles form the basis for the development of surgical conscience as applied to the surgical treatment of patients.

Some issues crop up before the first incision is made. Because the most common source of pathogenic bacteria is the patient’s endogenous flora, it is essential to prep the patient’s skin by clipping hair from the surgical site, cleansing the skin with an antiseptic product and applying sterile drapes around the surgical site. Survey respondents said they regularly observed improper pre-surgical patient skin prep, including the taboo shaving of patients with razors or not performing a proper cleansing method

Equally important to the pre-operative antisepsis process is the surgical skin prep by the surgeon and members of the OR team. A surgical scrub is performed by surgical team members who will interact with the sterile field or with sterile instruments. The pre-op scrub requires use of an efficacious, persistent antimicrobial soap on the hands and forearms for a longer period of time than used for typical hand antisepsis. Institutional policy usually designates an acceptable minimum length of time required; the CDC recommends at least 2 to 5 minutes of mechanical scrubbing, followed by thorough drying. Alarmingly, many survey respondents reported seeing surgeons severely curtail their scrub time.

When asked what infection control-related breach they see occurring in the OR regularly, ICT survey respondents agreed on a number of issues, including a general break in aseptic technique or contamination of the sterile field precipitated by a number of occurrences such as unscrubbed personnel getting too close to or reaching over the sterile field. Many survey respondents cited hands and instruments being allowed to drop below the level of the sterile field, as well as gowned personnel turning their backs to the sterile field. Some nurses said they saw holes or tears in the sterile packaging of instruments or gloves, while others reported seeing cases set up in the sterile field and then left unattended. One survey respondent noted, “There is a serious lack of understanding about what is sterile, what is clean and how a person’s actions in the OR affect these things.”

“I think the concept of hospitals reviewing ‘periop 101’ issues is so important,” says Sharon McNamara, RN, BSN, MSN, CNOR, director of surgical services at WakeMed Health and Hospitals in Raleigh, N.C. “Due to personnel shortages and other time constraints, people are being rushed through orientation and I don’t think they are necessarily getting a good didactic background on perioperative issues. That may be why when they get into the clinical setting they don’t have the information they need to critically think through situations in the OR. Many institutions like ours conduct an annual back-to-basics course; people may complain that they’ve heard it every year, but each time we try to tackle it differently, such as in a grand-rounds format, for example. The other thing we do is use a root cause analysis (RCA) when we have an issue in the OR, such as a break in aseptic technique. We never used to talk about a lot of what went wrong, but now it’s immensely valuable to have teams talk about what happened so it doesn’t happen again. We share information without pointing fingers.” McNamara continues, “I think the concept of maintaining a ‘just culture’ plays into this – instead of blaming people, you examine whether or not institutional policies and procedures did not support the individual. We also need to address the near-misses, as these are as important as actual breaches. I guarantee you that if it happened to one person on the surgical team, there are probably other people who almost experienced the same near-miss too and could have avoided it, so sharing these experiences and learning from them is critical.”

Surgical Attire

One of the most critical elements of aseptic technique is wearing the appropriate kind of surgical attire that provides impervious barrier protection against exposure to potentially infectious body fluids and tissue during invasive surgical procedures. Such attire – called personal protective equipment (PPE) — consists of caps, face shields and surgical masks, surgical gowns and gloves and sturdy, closed footwear. To protect the patient from microbial contamination, sterile drapes are applied to the incision site.

“One of the most important practices related to PPE use in the OR is the implementation of Association for the Advancement of Medical Instrumentation (AAMI) guidelines,” says Wava Truscott, PhD, MBA, director of scientific affairs and clinical education for Kimberly-Clark Health Care. “Ultimately, these guidelines help users understand the level of protection needed when selecting PPE for both isolation and surgical gowns as well as surgical drapes for various procedures. There are five designated levels of performance: AAMI Levels 1-4 represent increasing protection against greater fluid volumes subjected to higher pressure challenges; and non-protective designation, for gowns that fail to meet the Level 1 category requirements.” Truscott adds, “It is important to work closely with the gown selection committees and materials managers to ensure that selections are made in full knowledge of the exposure risk and gown performance requirements needed. Use AAMI PB70 to enable credible comparisons of gown fluid resistance performance. Acquire data on aerosol and dry spore barrier performance. After appropriate levels of protection are procured, facilitate compliance by storing gowns such that they are readily accessible in/near areas where need for that level of protection is anticipated. Reduce healthcare worker and environmental contamination by posting proper PPE removal techniques, providing convenient disposal bins and appropriately placed hand sanitation stations. Address both concern categories: noncompliance and assumed protection. Enable staff and patient protection.”

ICT survey respondents said they observed many instances of improper barrier protection, with specific problems including the movement of drapes after application, contamination when draping, barrier breakthrough, glove punctures and gown strike-through. “I see constant glove tears, rips and punctures,” said one survey respondent, who added, “What bothers me is the poor re-gloving technique.” Another survey respondent noted, “Improper wearing of face masks is a big problem” while others cited hair hanging outside of hats and shedding into wounds from errant hair or improper attire. One respondent observed, “Lack of compliance to the facility’s dress code for the OR is a big problem,” while another person said, “I see disposable masks being used all day and left hanging around the neck when not in use.” Yet another person commented, “Surgeons wear the same scrubs they were in when they came from another hospital.”

Many members of the surgical team may experience a breach of their gloves intraoperatively. “Breach of surgical gloves occurs frequently,” says Carolyn L. Twomey, RN, BSN, global head of clinical services for Molnlycke Health Care US, LLC. “Incidences from the literature are often as high as 11 percent to 51 percent, depending on the complexity of the case, the prevalence of bone fragments, the instrumentation and use of and management of sharps in the field, and certainly the expertise and technique of the practitioner. For medical students needlesticks occur frequently, as high as 59 percent of the time. And these are only the reported needlesticks. Another study reports only 17 percent of the practitioners in the U.S. report needlesticks. Often practitioners do not know the have a breach until they finish the case and remove their gloves to find blood on their hands.” Twomey continues, “Double-gloving is now recommended as a risk reduction strategy by many organizations, including AORN in its Recommended Practices, the American College of Surgeons, The American Association of Orthopaedic Surgeons and others. Double-gloving exponentially reduces that risk. The use of a colored puncture indication system provides a visual alert to the wearer that they have a glove compromise and allows them to change their glove(s). Best practice recommends changing of both inner and outer glove in the event of a needlestick.”

Perhaps one of the biggest issues today focuses on scrubs – both the wearing of scrubs in and out of the OR, and the debate over proper laundering of this kind of attire. “I constantly see the wearing of surgical scrubs outside of restricted areas and coming back into the OR,” one ICT survey respondent noted, echoing a vast majority of respondents’ experiences. And as one person noted, “The issue of hospital-laundered versus home-laundered scrubs has got to be resolved.”

“We have our scrubs laundered in-house,” says McNamara. “There are a few exceptions for people with allergy issues and they have specific instructions to follow, including containing their scrubs when carried in or out of the facility, as well as washing instructions for home laundering. But overall, our personnel are not allowed to wear their scrubs in or out of the facility, and we police this very carefully. If staff are caught breaking this policy, we address it, and so far we had very good luck with compliance. We had to explain to people about the ‘germiness’ of their scrubs and the studies that have shown the persistence of microorganisms on cloth. I also tell people, besides what you might bring into the facility on your scrubs, think about what is on your scrubs at the end of the day that you are taking home to your family. Education is key and you have to follow up on issues like these. If you have someone not doing what they should, you have to find out if they are simply not educated about it – is our process not in place where we can support them in doing the right thing? Or are they just blatantly not following policy?”

ICT survey respondents also noted that OR personnel are bringing into the surgical suites numerous items from the outside world, including newspapers, purses, tote bags and laptops. Bringing food and drink into the OR was also noted by many survey respondents, including one nurse who said the anesthesiologist was “always hiding food in drawers.”

Traffic in the OR

Besides the issue of scrubs and non-sterile items being brought into the OR, many survey respondents noticed the chaos that seems to rule surgical arenas these days. As one survey respondent noted, “Traffic control is almost nonexistent, with people leaving doors open and staff constantly going in and out of rooms.” Another survey respondent observed that silence is golden, remarking, “There is excessive talking during cases and definitely way too much chatter among team members during sterile procedures.”

“I agree that there are numerous distractions in the ORs today.” McNamara says. “WakeMed is a teaching facility, so we have many types of students coming through. It’s important to control the traffic and we may turn students or observers away. You must find ways to limit traffic when it poses a potential hazard for infection control or patient confidentiality. We made one day a week off limits to students, because our staff needs a day without all of that extra attention to teaching. We also have a policy with restrictions for vendor representatives. There are many distracters evidenced in the literature such as pagers going off, the music blaring, vendors or observers present -- those are the things that are going on in ORs and if not controlled they can become distractions that could potentially contribute to errors.”

Some respondents also noted that the increased traffic in ORs cause greater build-ups of grime and said cleaning needed to be more thorough. “Cleaning protocol should be more standardized at our hospital,” noted one respondent, while another remarked, “There needs to be better communication between the OR and environmental services about the need for extensive cleaning after heavy-soil cases.”

Instrumentation Issues

A number of ICT survey respondents indicated problems with surgical instruments not being properly cleaned and disinfected before they reached the OR. Many said they observed obvious bioburden that had not been removed from surgical instrument, as well as saw their own colleagues dump instruments into piles after use without any kind of pre-cleaning efforts (For a related article on reprocessing, see page 18). Other survey respondents said they were concerned about too many dropped instruments and too much use of flash sterilization. Said one survey respondent, “If you even have the slightest doubt about an item and its sterility don’t use it. Flash it, or get another one. Think of each patient as your loved one.”

Hand Hygiene

Numerous ICT survey respondents complained about the blatant lack of hand hygiene in their surgical suites as well as elsewhere in their healthcare institutions. The grievances related to everything from missing critical hand hygiene opportunities, to a lack of hand hygiene when changing gloves, to improper use of alcohol-based handrubs.

A number of ICT survey respondents said they were worried about people not speaking up about this pervasive lack of hand hygiene. McNamara says her facility has had great success with their hand hygiene education program known as the FROG program, whose acronym stood for “friction rubs out germs.” As McNamara explains, “This was a hospital-wide project in which we had frogs everywhere to remind people to engage in appropriate and correct hand hygiene. The really ingenious part of the program is that we used the word ‘ribbit’ as a subtle way to remind people that they were observed not washing their hands when they should. Many times people don’t want to confront others, especially physicians. So with the FROG program they could simply say ‘ribbit’ to someone and that would make them stop and think about a missed handwashing opportunity. The staff found it to be very non-threatening and enabled them to approach someone when they saw someone not performing good technique. It doesn’t embarrass anyone, and it seemed to work for us. We were also conducting audits, and the good news is that when the Joint Commission was here, they only found two instances where people were not performing proper hand hygiene.”

Surgical Site Infections

To subvert a popular saying about Las Vegas, what happens in the OR doesn’t stay in the OR; everything that occurs in the OR can have a profound impact on a patient’s post-op recovery and the likelihood that he or she will develop an infection. When asked if their OR has been associated with an infection or outbreak in the last six months, 77 percent of ICT survey respondents said no, but 23 percent said yes. Of those respondents in this anonymous survey who decided to come clean about infections, some attributed the SSIs to MRSA transmission from one patient to another due to the same surgeon, the OR and the same surgical team being present for both cases. One respondent chalked it up to “incorrect technique when assisting surgeon into sterile gown” while others attributed them to an improper sternal closure, a Foley catheter insertion or general breaks in technique. One respondent cited improper sterilization process of instrumentation while others said the cause of the infection was undetermined or that the SSI was still under investigation. One person blamed it on the patient due to “poor compliance.”

Educating patients about SSI prevention is not emphasized enough, says McNamara. “It’s something we don’t always do, but it’s important to explain to patients what they can do to prevents SSIs and be better prepared for their surgeries. I don’t think we do as good a job of that as we probably could. We tend to think they come in and they go to sleep and that’s it. But they can bathe with antimicrobial soap. They can ensure that people are washing their hands. They can make sure they are getting their antibiotics in a timely fashion. Educating patients about this is a good thing and we need to do more of that.”

Sacred Cows Die Hard

While several survey respondents had to ask what a sacred cow was, there were still plenty of OR-related bovine roaming the ORs, it would seem. One of the biggest sacred cows cited by respondents was overkill — the wearing of shoe covers or doubling of masks and gloves, as well as use of sterile sheets in addition to the impervious drapes.

“The biggest sacred cow that we have had to deal with is skin preparation,” McNamara says. “Some docs still want to shave and we finally took away all the razors. I confiscated every razor and let everyone know we will not tolerate razors. They showed up again, as people were taking them out of their lockers where they had hidden them, and so finally, we had the chief of surgery and our infection control specialist speak to every physician one-on-one and that finally turned the situation around. There are no more razors, but it took a lot of gnashing of teeth to accomplish that.”

One survey respondent admonished, “We don’t use ‘sacred cow’ practices; practices need to be evidence based,” while another declared, “I think the ‘sacred cow’ has died!” Putting the sacred cows to pasture requires diligence and persistence. When asked how they accomplished this, respondents overwhelmingly attributed change in habits and practices to education of healthcare workers. Many respondents said they countered sacred-cow practices by presenting perpetrators with research material and recommended practices from organizations such as AORN during in-services. Several respondents said they planned to have meetings specifically to review and discuss evidence-based practices, while others said they resorted to police power – reporting to a “higher authority” if necessary or bringing the deficiency to leadership’s attention. A few folks may be resigned to living with these sacred cows; one person commented, “We’ve already eliminated most of them. There are still some around but if they’re not hurting anyone, why change?” while another person said nothing could be done about sacred cows. Another said it was necessary to consistently “teach and re-teach” on this subject and one person emphasized the importance of reinforcing positive practice, counseling on better practices, and applying peer pressure. Several respondents advised OR personnel to work with the infection prevention and control department to standardize practice and monitor for compliance.

Cutting Corners and Other Areas for Improvement

When asked what infection prevention-related practice needs the most improvement in the perioperative setting, we received numerous comments, with several main themes emerging. Several ICT survey respondents expressed difficulty with “buy-in of literature regarding infection prevention.” And as we have seen, speaking up when a breach has been observed continues to be a problem. Noted one respondent, “All members of the surgical team must function as a cohesive and respective team and all have an equal voice; there must be recognition when there is a break in sterile technique and there must be a way for how to address them.” Another respondent wrote, “OR staff members have to feel like they have the power to speak up when they see standards being bent or broken for the sake of time and there has to be less conflict with doctors.”

A significant number of ICT survey respondents said they had seen their OR colleagues skimp on things like surgical scrub times because they were rushed, possibly compromising sterile technique. “There is a real push for decreased OR turnaround times and that means a lot of corners are being cut,” said one respondent. Another respondent emphasized that it was critical to have “an environment where speaking up about a breach is safe.”

Words of Wisdom

We asked ICT survey respondents to impart their best pearls of wisdom for the edification of their counterparts, and it was encouraging to see the importance placed on addressing breaches when they happen, for starters. “Staff needs to be more aware of the environment around them for the sake of their patients,” one person noted, adding, “Be more observant of others behaviors and point them out when they are wrong.” Speaking up seems to be an easier thing to do these days, as one person noted, “Be a patient advocate and if you feel something might be contaminated, speak up and take corrective action.” Another respondent emphasized, “Don’t be afraid of telling the doctors to wash their hands!” One person said, “Manage the case, do not let the case (or doctors) manage you. Take time to see that your patient and all associated sterility mechanisms are maintained.” Other advice from respondents included “Pay attention to what you are doing,” and “Do not take shortcuts.”

Recommendations from respondents included standardization, as one person noted, “Standardize best practices for all surgical patients. Too many ‘if this, then that’ causes confusion.” Another person advised, “Create standard work processes for surgical hand scrubs, aseptic technique, count process, etc. and conduct random audits to assess compliance.” Yet another person confirmed, “Everyone involved needs to be on the same page.”

Knowing the recommended practices was critical to survey respondents. As one person noted, “All OR personnel and physicians should adhere meticulously to the principles of aseptic technique. Get back to the basics spelled out in the AORN standards.” Another respondent added, “All practitioners need to review the AORN recommendations and standards and follow them. They speak to infection prevention throughout.” Another noted that an annual review of sterile technique with surgeons and staff members was helpful.

Designating one person who is the champion of aseptic technique can be valuable, as one respondent noted, “Have a knowledgeable educator/clinical specialist who can show the staff and physicians why they must practice according to AORN standards.” That doesn’t mean everyone else can coast, as one respondent put it, “Everyone is responsible for preventing infections in the OR.” Another person noted that “only educated, well-trained personnel involved in all aspects of patient care” should be allowed in the OR.

Respondents felt strongly about the need to uphold best practices because it is the right thing to do for the patient. “Don’t forget that the patient on the table is someone’s loved one, so do what’s right,” commented one respondent. Other comments were “Treat the patient as if it was you” and “We need to be very conscientious about what we do and consider each patient as to how we would want to be treated or have our family members treated.”

Several respondents mentioned the importance of maintain a “surgical conscience” as they worked: “Follow best practices for infection prevention, have a good surgical conscience, and put the patient first at all times,” and “Having a surgical conscience is my best piece of advice. Without having a conscience, the surgical patient is at risk 100 percent of the time."

In terms of practice, respondents expressed the following sentiments:

On hand hygiene:

• “Make hand hygiene a hardwired process.”

• “Always engage in proper and appropriate use of surgical skin prep agents and technique.”

• “Wash your hands and speak up when someone else hasn’t washed theirs.”

• “If nothing else, strict compliance to hand hygiene is the best practice to preventing any kind of infections.”

• “I think just remembering back to the statement that bacteria and organisms do not fly. They need to be carried by something.”

On maintaining sterility and proper technique:

• “Sterility is a code of honor. You have to know what asepsis is and practice it every day, no questions asked.”

• “Have a culture of ‘always!’ Everyone should be educated on aseptic technique, with constant reminders and updates from the infection control department.”

On evidence-based practices:

• “Base infection control behavior on evidenced-based information rather than on historical approach. Prove what increases and decreases infection rates.”

On limiting opportunities for cross-contamination:

• “Limiting the number of people in an OR during a case can provide a safer environment for a patient undergoing a surgical procedure.”

•“Begin each patient in ultra clean environment do not cross-contaminate.”

Reference:

Mangram AJ, et al. Guideline for Prevention of Surgical Site Infection, 1999. Vol. 20, No. 4. Infect Control Hosp Epidem. April 1999.