This Way to the OR, Infection Preventionists

In fall 2016, I was on my way to work at 8 AM on a Monday when my cell phone rang. It was the surgical department of a 350-bed acute care hospital in Texas where I served as an infection prevention (IP) consultant. They wanted to report that some instruments were used on a patient over the weekend even though the biological indicator failed.

To be of help in an operating room (OR) an IP must grasp 4 key concepts about biological indicators: what a biological indicator is (an indicator that goes into each pack of surgical instruments to determine that each instrument gets sterilized), where it is placed in the instrument pack (in the middle), how it is documented (in a freestanding notebook in the OR), and what to do with a patient who had surgery with potentially nonsterile instruments (notify the infection control department).

Linda Spaulding RN, BC, CIC, CHEC, CHOP

Luckily, I knew all these things because I have the experience of being a consultant and working for many hospitals. I reviewed the case, then set up a protocol to monitor the patient for possible infection.

Although that was resolved quickly, what happens if the scenario is more complicated, as it was for me in summer 2019? At 5 pm on a Friday, I received a call moments after I turned off my computer eager to start the weekend.

The surgery department of a 250-bed acute care hospital in Washington needed my help because they had experienced problems during the week with wet packs (packages or containers that hold surgical instruments that become moist after sterilization is completed). They were frustrated because they couldn’t figure out why.

I was told they had already reviewed all documentation showing that staff members followed policies and procedures. Because there was a record of staff who had signed off indicating that the sterilizer trap was cleaned twice a day, they didn’t suspect that was the problem. Meanwhile, they called the sterilizer company to come troubleshoot the issue. However, the staff wondered if there was something else they should do.

I thought about factors that could lead to wet packs and asked:

• “Has the trap of the sterilizer been cleaned?” Their response: “Yes. We have staff documenting that it is cleaned and checked every morning.”
• “Were the packs overloaded?” Their response: “No.”
• “Is there a problem with the function of the sterilizer?” Their response: “The vendor is coming to check this.”
• “Is there a problem with how packs are stored post sterilization?” Their response: “We don’t think so.”

I decided to go to the OR to verify and validate everything I had been told. I reviewed the department’s practices to see if I could determine the problem and work with the department to develop an action plan. I did a quick walk-through of the area to look for anything that might be causing the problem but found nothing. So I decided to look at the documentation for each sterilizer, paying close attention to the sterilizer for which the problem packs were processed.

The staff had documented that all Bowie-Dick, biological, and chemical indicators had passed inspection.

I thought, “What should I do next? Do I know what I’m looking for? Do I know the sterilizer in question needs to be put out of service until the issue is identified and corrected?” I felt pressure because having 1 sterilizer down might mean canceling some surgical procedures.

The Checklist

I scanned the checklist to ensure that the trap had been emptied at the beginning of the shift each day and that someone had signed the form verifying that the sterilizer trap had been cleaned every day per hospital policy. I asked the sterilizer technician to remove the trap. Inside I found a sticker that had a date of a week and a half earlier, which caused the wet packs.

Essentially, personnel were falsely documenting that they had cleaned the trap when it had not been cleaned appropriately for a few days. I told the staff that they must not only run their fingers through the trap to clean it but also look inside because a sticker that is stuck in the trap will not come out with a finger swipe. Management of the department took disciplinary action. (I do not know what that included.)

These 2 scenarios are examples of why IPs must verify and validate everything they are told. Many IPs have a misconception that the surgical suite is the cleanest and most sterile area in the hospital. Because of this, many IPs trust that everyone working in the OR knows what they are doing and often shy away from going into the OR because they do not have a comfort level in their knowledge of OR practices.

Many IPs spend most of their time on the computer developing policies and procedures, submitting data to the National Healthcare Safety Network, reviewing charts for patient infections, developing education programs, attending meetings, and putting out fires. This leaves little time to learn about infection prevention in the OR.

Yet there may be many issues related to infection prevention in the OR that staff in the area do not see. They have worked in the area for so long that their ability to identify incorrect practices decreases because what they see every day appears normal to them. For this reason, it is crucial that IPs make regular rounds in the surgical suite as well as perform direct observation of cases and observation of the cleaning, disinfection, and sterilization processing areas.

These actions can help IPs identify any practices or shortcuts staff are taking that may contribute to decreased patient safety.

For instance, a vendor for a particular instrument might accompany the surgeons in the OR to teach them about the instrument during the procedure. But earlier in the day, the IP saw the vendor walking in the hallway in the same scrubs now being worn in the OR. In addition, the IP can tell the scrubs aren’t hospital scrubs because they are a different color. Although the OR staff should have noticed, in the rush to get the case under way, they missed it. A fresh set of eyes can help identify issues that others may overlook.

Where to Start

Because IPs are familiar with areas such as biological and chemical indicator documentation, they should begin there. Ask staff to show how they document the indicators and where the records are kept. From there, see if there is documentation for every pack.

Next, expand upon that knowledge by studying what it means if there is a failed indicator. What is the proper action staff should take? As IPs make rounds, they should strike up a conversation with OR staff and have them explain what they would do if there is an indicator failure and then compare that response to the hospital policy. If there are discrepancies, talk with the manager and determine if there was a misunderstanding. This may also alert the manager that the staff could use a policy refresher. Working side by side with OR staff and learning the ropes will benefit the IP, putting another level of patient safety in place.

Another way for IPs to learn more about surgical cases and decontamination processes is to review the DNV Accreditation Standards and/or the Joint Commission accreditation standards.^1,2

The IP’s role is to be the verifier and validator of the OR and decontamination policies and procedures. Therefore, IPs need to observe practices in these areas to ensure all policies, procedures, standards, and guidelines are being followed. This can be accomplished through collaboration with OR managers and staff. The IP should also be a member of the surgical committee.

IPs should be notified of the following: failure of a Bowie-Dick test, problems with wet packs as indicated by biological or chemical indicators, or concern about unsterile instruments in the surgical suite and whether they were used on a patient. If any of these incidents occur, an IP can properly monitor a patient or group of patients for a surgical site infection.

The IP and surgical department need to catch near misses and put corrective action plans in place.

Infection prevention cannot be entirely learned in the OR, but continuing education will help IPs become experts in the surgical suite.

The many references that IPs should obtain include the following:

1. Association of periOperative Registered Nurses standards³
2. Association for the Advancement of Medical Instrumentation standards⁴
3. Disinfection & Sterilization, a website maintained by William A. Rutala, PhD, MPH⁵
4. Central Service Technical Manual, published by the International Association of Healthcare Central Service Materiel Management⁶
5. Centers for Disease Control and Prevention standards for prevention of surgical site infections⁷

These references will provide IPs with a strong knowledge base, allowing a complete review of surgical suites and decontamination/sterilization areas to assist in preventing poor practices and increasing patient safety.

By understanding the information in these references, the IP will be able to verify and validate proper practices in these areas. IPs must remember that practices are as good as people are taught. Proper training is the responsibility of the facility and the IP, who should take advantage of all opportunities to improve their knowledge.

LINDA SPAULDING, RN, CIC, BC, CHEC, CHOP, is an infection prevention consultant and founder of InCo and Associates International, Inc.

References:

1. National Center for Immunization and Respiratory Diseases (NCIRD). CDC. Updated July 6, 2020. Accessed August 23,2021. https://www.cdc.gov/ncird/index.html
2. 1918 pandemic (H1N1 virus). CDC. Updated March 20, 2019. Accessed August 24, 2021. https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html
3. Past pandemics. CDC August 10, 2018. Accessed August 20, 2021, https://www.cdc.gov/flu/pandemic-resources/basics/past-pandemics.html
4. 2020-2021 flu season summary. CDC. Updated July 22, 2021. Accessed August 19, 2021. https://www.cdc.gov/flu/season/faq-flu-season-2020-2021.htm
5. How the flu virus can change: “drift” and “shift.” CDC. Updated October 15, 2019. Accessed August 20, 2021. https://www.cdc.gov/flu/about/viruses/change.htm
6. Influenza vaccine for the 2021-2022 season. United States Food and Drug Administration. Updated September 2, 2021. Accessed August 19, 2021, https://www.fda.gov/vaccines-blood-biologics/lot-release/influenza-vaccine-2021-2022-season
7. Frequently asked influenza (flu) questions: 2021-2022 season. CDC. Updated September 1, 2021. Accessed August 23, 2021. https://cdc.gov/flu/season/faq-flu-season-2021-2022.htm