How Infection Preventionists, OR Nurses Work Better Together

Infection Control Today® (ICT®) interviewed Linda K. Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and executive director of the Association of periOperative Registered Nurses (AORN), last November. The wide-ranging discussion touched on many areas of concern, including the need for operating room nurses and infection preventionists (IPs) to work more closely together. Groah admitted that there had been some tension between the two groups in the past. Now Linda Spaulding, RN, BC, CIC, CHEC, CHOP, an infection prevention consultant, gives her view of this sometimes—and in some circumstances, but not all or even most—uneasy alliance. Spaulding, a member of ICT®’s Editorial Advisory Board, agrees with Groah that OR nurses and IPs need to form a stronger alliance, but that IPs need to finesse it. “You don’t have to be in OR’s face all the time,” Spaulding says. “But it’s good to take a walk through and let the OR staff teach you why they do what they do.” Ask questions but be aware that some OR directors don’t “always like to be questioned. So there does have to become a friendship between the OR and the IPs in order to be successful.”

Infection Control Today®: Where has your research taken you so far?

Linda Spaulding RN, BC, CIC, CHEC, CHOP: Well, as I’m going through and researching for the article, I’ve been looking at the relationship between IPs and the OR. And many places have a good relationship between IPs and the OR staff. Other areas that I found, it’s kind of a tense situation. The fact that OR managers take their job really serious, which is a good thing. People that do the sterilization and disinfection, again, take it very seriously. But one of the things that IPs can add to that, if the IP is properly trained in infection prevention, in the OR, in the areas of cleaning disinfection and sterilization is that they can go in and they can see things that people in the OR see every single day. Get used to seeing it. And don’t notice that it’s wrong. Such as floors in the OR. If you have any cracks in the floors that can harbor microorganisms. OR people are used to working with the instruments and setting up tables in the OR and making sure everything stays sterile before, during an

Linda Spaulding RN, BC, CIC, CHEC, CHOP

d properly cleaned after the cases. It’s good to have fresh eyes from the IPs making rounds in the OR sometimes just to pick those things up that people see every day, but now they don't really see them, if you know what I mean. Because the fresh eyes are looking at something for the first time and questing it. OR doesn’t always like to be questioned. So there does have to become a friendship between the OR and the IPs in order to be successful. When I was an IP in a hospital, I always assumed that OR is the most sterile, the cleanest place in the hospital. And I trusted the OR people to do what they needed to do. Until one day when I found out they were having … some of their indicators, either their Bowie-Dick test; we didn’t test or their chemical indicators or biological indicators weren’t passing inspection. That’s when I started to get more involved in the OR and learning what do those things mean? And that’s what IPs need to do. You don’t have to be in OR’s face all the time. But it’s good to take a walk through and let the OR staff teach you why they do what they do. That helps a lot.

ICT®: Can this turn into a turf war?

Spaulding: In my career I haven’t had a problem related to that. And I think majority of IPs don’t. Occasionally you’ll get people’s personal attitudes can rub with each other the wrong direction. Or if you have an OR manager that’s been there 25 or 30 years, who is absolutely positive that everybody’s doing everything correct. And doesn’t like things to be pointed out. But you have the same problem with the IPs. If the OR director’s trying to tell the IP that the IP is incorrect, then you can get some kind of friction that way. It’s important that everybody knows exactly what they’re supposed to be doing.

ICT®: Is knowledge of what goes on in an OR part of IP training?

Spaulding: A lot of IPs get the job because it’s posted in the hospital as a position that’s open. Someone is very interested in infection prevention and feels that they can just walk in and do the job. Some hospitals encourage that. People that go into IP had no experience whatsoever. They may not have taken either the APIC [Association for Professionals in Infection Control and Epidemiology] training course or someone else’s training course because it wasn’t offered to them. And they learn as they go, and they do the best job they can without a formal training program. And that is something that hospitals really need to look at. You can’t put somebody into that position, and assume they know everything you need to know about infection control. One of the things that I’ve learned, and I’ve cautioned people with, is sometimes you’re looking at a situation and it seems correct. OK. But then when you learn the infection prevention side of it, you find out “Oh, even though that seemed common sense, it doesn’t work in the infection prevention world.” And that’s where you have to be able to identify those things and let people know. I can give you an example. I was working with a young guy that used to be a surgical tech. He started working with another company and decided that because he was a surgical tech, he knew everything there was about infection prevention. He started working. He would be telling people incorrect information. And then when I pointed it out to him, he felt I was the one that was wrong, and he was still right. Young guy probably in his late 20s. You get IPs who think they know it all. And then you get IPs that no, they know nothing about the OR. And the majority of IPs, unless they’ve concentrated on learning the AORN [Association of periOperative Registered Nurses] standards, or the information from APIC related to surgery, site infections, and cleaning and sterilization, they don’t know. You think you know, but you don’t really know what you’re doing. And some people can talk really good. And they’re really friendly with everybody. People take you for your word. It’s very important that IPs concentrate on what's going on in the OR and build a relationship that both the OR and the IP can learn from. Because OR can teach infection preventionists a lot. It’s the infection prevention stuff in the OR is … it’s just astronomical. There’s just so much to learn. You can’t learn that by reading an article about how to prevent surgical site infections, or reading an article about cleaning disinfection, sterilization. You learn information, but you don’t learn hands-on eyes-on what’s going on. And that’s where the IP can come in and be helpful. And the IP that concentrates on learning everything there is about the OR will benefit the OR in the long run. That betters the hospital. That improves patient care.

ICT®: How are gaps in cleaning and disinfection ORs most likely to happen?

Spaulding: Take a look at cleaning the rooms in between each patient. A lot of times people are using the PDI wipes or some other wipe to clean the rooms after each case; in between each case. Well staff usually have just a few minutes between each case in order to turn that room over and get it ready for the next [operation]. Because the schedules are so tight. So, you go in and you observe them and the IP, if they’re standing there and observing, they’re noticing when the staff is just using like one or two wipes and they're going from, say, on top of an anesthesia machine and cleaning it down to the floor. OK, we all know you clean from clean to dirty, dispose of the wipes, get another wipe, go to the next item: clean to dirty. A lot of times what I observed is that the staff uses one or two wipes, and they clean from clean to dirty, but then use the same wipe and go to the next piece of equipment. Well, that wipe has already been close to the floor, you can’t take it and use it on the next item. So, an IP standing there watching that can point out, “You need to use more wipes.” And a lot of times what you get is: “Well it costs too much money.” That doesn't matter. The more wipes you use, the cleaner that OR room is when it’s turned over.

ICT®: Where does environmental services fit when it comes to keeping ORs clean and disinfected?

Spaulding: Environmental services usually cleans the entire OR suite at the end of the day. Or they might clean the common areas during the day, but they don’t always clean the rooms during turnover. The OR staff does that. And that’s why it’s important that there’s an extra set of eyes on them. Because you want … IPs’ responsibility in that situation would be to make sure that there were competencies in the OR on how the room was supposed to be cleaned between cases. Since the OR staff does it. They verify and validate that the OR staff has been trained properly. And they should be trained exactly the same as a facility that might have enough environmental services staff to do that. You look at does the OR staff have the same training for turning over a room as environmental services? And many times we find, “I’ve done this for years. Don’t worry about it. I know how to do it.” And then that’s when you can point out, “I know, but you know that you clean from clean to dirty, yet you just cleaned the EKG cables from the top of them to the bottom of them and they’ve been sitting on the floor. Then you’ve taken the same wipe, and you clean the OR table with it after you just clean cables that have been touching the floor.” And then the light turns on. You have to be able to approach it as “let’s work together” and not going in and just pointing out everything they do wrong. Because it has to be a good working relationship between the two.

ICT®: What kind of welcome do IPs get in ORs?

Spaulding: In my experience as long as you go in and you say, “Hey, I’m Linda, I’m the new IP here. I don’t know much about the OR. I’d like to come spend some time with you. Check out what to do. Have you teach me some things.” But at the same time, Linda is also going through the AORN standards, and then verifying and validating what she’s being told is the correct way to do something.

ICT®: I’m assuming that you’ve heard about the tension between ORs and IPs. Is that more myth than reality?

Spaulding: I think it’s probably a 50/50. It depends on the attitudes of both the OR directors and the IP department. Sometimes people get along well, and other times people butt heads. But I would say there are some very strong feelings within the OR staff. And then there are some very strong IPs, who may or may not have really taken time to learn the OR. There might be a new manager in the OR who has never worked in the OR before but feels threatened because now somebody is coming in to tell me what I'm supposed to do. It’s just human nature. But I’d say a majority of the time it works out well. It’s the IP’s responsibility not to just determine when to go to the OR to kind of say, “Hey, I'm going to be in the OR on X, Y, and Z [days]. Is there anything you want me to look at?” Or “I’m trying to learn more about the OR. I want to come to the OR at this time.” Don’t just be a surprise because that kind of throws people off their game. And if they’re really busy, then you might get a bad reaction because they just don’t have time for you because they’re trying to get through the cases of the day. The OR is a very, very busy, rapid turnaround place.

ICT®: I guess at this early point it might be anecdotal. But do you see that the COVID-19 pandemic possibly helped foster stronger ties between IPs and operating room nurses?

Spaulding: In my opinion, I don’t think it has. Now somebody else might have more information because there are so many hospitals in the U.S. Because OR cases were decreased during the time of COVID. And so not that much was going on. And so, if a lot of the cases were cancelled, except for emergency cancellations, there really wasn’t an opportunity for IPs to be more involved in the OR. My concern is—and I was thinking about this last night—is a lot of the orders have been closed for almost a year. They’ve only done a few cases on those occasions. Some of them are starting to open back up to do more now. The OR staff has to gear back up. They have to get back in the swing of things of getting into the speed and the pace of the OR again. I think you have a better opportunity during that kind of time to possibly make mistakes. This is a good time for IPs and the OR to work together. If OR staff or decontamination staff were let go during the pandemic, and now they’re trying to hire people back. They may be bringing in inexperienced people. It’s important that IPs have eyes on. Right now is going to be a very stressful time between the OR and the IPs. And with COVID, a lot of new IPs are being hired all over the place now. Problem is they’re new IPs They’ve never done the job before. They can’t go into the OR and start telling the OR what to do. Because they don’t know what to do yet. It’s important that the IPs are trained well or taking the initiative on their own to learn what they need to learn. And sitting down and reading all the guidelines, reading all the standards, reading your facility policies, and making sure you understand them. If you don’t understand them, ask the manager to help you out with it. That’ll build a better relationship.

ICT®: Hospitals are hiring a lot of new IPs?

Spaulding: Yes.

ICT®: From what you can tell.

Spaulding: Yes. There are a lot of IP positions that are open right now. There are not always experienced IPs out there to hire. A lot of the places are going to start hiring from within, or somebody from outside who’s a good talker, and they think they know infection prevention. And in reality, it’s up to the hospital to provide training for those people.

ICT®: Is this just filling holes when people retire or quit? Or are hospitals, in your opinion, building up their infection prevention and control departments and hiring more IPs than they have historically done?

Spaulding: I think a lot of them are hiring more IPs than they’ve historically done.

ICT®: There’s no real data yet about this. But as far as you can tell, right?

Spaulding: No, well, I’m sure we can find out someplace that talks about that. There has always been a shortage of IPs, even before COVID. There has always been a shortage of trained, knowledgeable IPs prior to COVID. Now, it’s a little more important that people understand IPs really do have to have a good base of knowledge. But it depends on … there are some areas where people are … that they don’t have access to experienced IPs, and have to train from within.

ICT®: Is there anything that I neglected to ask you that you want to tell your fellow infection preventionists or other health care professionals?

Spaulding: I just say right now be patient. Learn about the OR before you walk in the OR and start addressing issues. You know that you’re identifying something that’s incorrect. It only takes you saying something a couple times that the OR knows is absolutely absurd and incorrect, and it’s going to ruin the relationship for a long time. Infection preventionists really need to take the responsibility of learning.

This interview has been edited for clarity and length.