Infection Control in the ORMyths and

Misconceptions

Bruce Gamage

Infection Control Consultant

BCCDC

Outline Dressing for the theatre – is it just a fashion statement? Masks – should we wear them? Food in the OR! Cleaning the environment – How clean is clean? Super Bugs – is hand washing enough? Surgical Hand Scrubs – Alcohol vs. CHX Instruments – is flashing good enough? Cleaning challenging instruments – “acetabular reamers” Artificial Fingernails – there’s no place for them in HC I’ve never seen a body piercing there before! The OR of the future – designed with IC in mind.

Dressing for the Theatre

Evolution of OR Attire Origins of Scrub attire

• Paralleled aseptic and sterile technique in late 19th century

• Hunter – advocated a complete change of costume rather than don a sterilized coat and trousers

• Mayo (1913) –operating team wore gowns caps and masks

• 30s and 40s scrub dresses replaced “surgeons uniforms”

• 60s Pantsuits and scrub dresses replaced full skirts to reduce risk of clothing contaminating the sterile field

IC issues “Germ theory” evolved in the early 19th

century Principles of asepsis developed in mid-

19th century The garment of the

HCW is part of the environment that can become contaminated

Microbes (e.g. Staph, Strep, Pseudomonas) can adhere to fabrics

Survival of Microbes on fabric

Study done at Shiners Hospital in Cincinnati• Staph and Enterococci

can survive for extended periods of time on materials commonly worn by HCWs (e.g. 100% cotton or 60/40 cotton blend)

Laundering of Scrubs

“Contaminated” scrubs should be washed in 160F (71C) water with 50-150 ppm chlorine bleach and dried in a hot dryer

Home laundering?

• University of Florida conducted a 4 year study to determine the effect on perinatal infection rate of wearing home laundered scrubs in L&D. Prior to study rate was 1.7% - after study rate was 1.0%.

• Practice was found to costs without in SSI

Opinions in flux

Hospitals see scrub attire as a huge cost. Experts in IC say “ there is no empiric data

that shows that home laundering leads to infections than commercial laundering. Risk factors for SSI are pre-existing morbidity, obesity, diabetes and age.

Expert Opinion?

APIC/CDC – there is little evidence that scrubs in the OR setting is a means of infection control in a health care facility

AORN – Scrub attire is not intended to be protective in any way: it is simply a uniform. It’s assurance that people coming into the OR are wearing freshly laundered attire that hasn’t been sat upon by the dog” Dorothy Fogg

AORN Position

“Surgical Attire should be laundered under controlled conditions where the laundry facility has specific formulas and they monitor the concentration of chemicals”

AORN does not support home laundering.

WHO/CDC

All persons entering the surgical theatre must wear surgical attire restricted to being worn only within the surgical area.

The design and composition of surgical attire should minimize bacterial shedding into the environment

No recommendations on how or where to launder scrub suits, on restricting use of scrub suits to the OR or for covering scrub suits when out of the OR.

Masks – should we wear them?

Masks – should we wear them?

AORN – all persons entering the restricted area of the OR suite should wear a mask when open sterile items and equipment present.

AORN acknowledges that there is a difference of opinion.

CDC states “a surgical mask that fully covers the mouth and nose when entering the OR if surgery is about to begin, is already underway or if sterile equipment is open.”

What’s the evidence?

Recent reports in the literature advocate wearing of masks by non-scrubbed staff with forced ventilation is not necessary

Studies from Europe show that oral bacteria expelled during talking by non-scrubbed personnel not in the immediate vicinity of the operating site posed no risk of infection.

What is the risk?

The risk of contamination depends on• Airflow

• Traffic

• Personal practices.

Best practice would require wearing of mask, independent of distance until research provides definitive answers.

Personal Protection

As part of Routine Practice

• Wearing a mask as part of PPE to reduce the risk of exposure to potentially infectious material.

Food in the OR?

Food in the OR?

Eating in the OR is not acceptable! Eating, drinking, smoking, applying

cosmetics or lip balm and handling contact lenses in work area where there is reasonable likelihood of occupational exposure to infectious materials is prohibited.

This is an OH&S issue!

How clean is clean?

Cleaning the environment :

Airborne bacteria must be minimized and surfaces kept clean.

When visible soiling or contamination with BBF occurs during an operation, use disinfectant to clean areas before next operation.

There is no need to perform special cleaning or closure of OR after contaminated or dirty cases.

Recommendations

Wet vacuum the OR floor after the last operation of the day with disinfectant.

Tacky mats at the entrance to the OR have no IC purpose

There is no recommendation on disinfection of surfaces or equipment in the OR between operations if there is no visible soiling.

Routine environmental sampling is not recommended. Perform only as part of an epidemiologic investigation.

WHO recommends:

Cleaning of all horizontal surfaces every morning

Cleaning and disinfection of horizontal surfaces and surgical items between procedures

Complete cleaning of the OR at the end of the day

Complete cleaning of the entire OR annex once a week.

Super Bugs – is hand washing enough?

Super bugs

CDC recommends:• Exclude from duty surgical personnel who

have draining skin lesions until infection has been ruled out or personnel have been treated and infection has resolved.

• No need to routinely exclude personnel colonized unless there is epidemiological evidence of spread in the health care setting.

ARO Precautions

There is no evidence that wearing gloves when touching colonized patients is necessary.

There is no evidence to support all staff wearing a gown to enter the room.

There is no evidence for wearing a mask when caring for a patient with ARO (may likelihood of HCW touching their nose).

There is no evidence that enhanced cleaning is necessary to transmission.

ARO Precautions

There is no evidence that wearing gloves when touching colonized patients is necessary.

There is no evidence to support all staff wearing a gown to enter the room.

There is no evidence for wearing a mask when caring for a patient with ARO (may likelihood of HCW touching their nose).

There is no evidence that enhanced cleaning is necessary to transmission.

Current Recommendations

Wash your hands! Follow Routine Practices Use contact precautions if will be

having direct (skin to skin) contact with the patient or their BBF.

Use regular cleaning practices. Antibiotic resistance ≠ disinfectant

resistance.

Hand Scrubs – Alcohol vs. CHX

Hand Scrubs – Alcohol vs. CHX

A surgical hand disinfection should be performed by all persons participating in the operative procedure.

The AORN continues to recommend the traditional hand scrub with an antimicrobial hand scrub agent.

AORN acknowledges that alcohol is an excellent skin antiseptic with a persistent effect for up to three hours.

Alcohol scrubs

Care should be exercsed to use these products if the procedure is <3 hours.

At the present time there is sparse evidence showing that alcohols are more or less effective than CHX scrubs

Recommend:• Alcohol has no cleaning ability

• First thoroughly wash hands and forearms with soap and water

• Then apply alcohol based surgical hand scrub according to manufacturer’s instructions.

Instruments – is flashing good enough?

Instruments – is flashing good enough?

Flash sterilization should only be used for patient care items that will be used immediately (e.g. to reprocess an inadvertently dropped instrument)

Instruments should not be flash sterilized because it is convenient or because you don’t have enough sets or to save time!

Flash Sterilization A chemical integrator that confirms temperature,

pressure and steam saturation was achieved. Instruments must be cleaned before they can be

sterilized. Cycle 3 minutes at 132C for non-porous, non-

lumen Cycle 10 minutes at 132C for porous or lumened

instruments. Complex instruments – only at manufacturer's

recommendation. Implants – not recommended. Ensure staff are educated, process monitored

and audited.

Cleaning challenging instruments

Cleaning challenging instruments

Reusable endoscopic instruments that are not (or can’t be) properly cleaned and sterilized are a major cause of nosocomial infections (CDC).

Decontamination and removal of all possible biomaterial is the most important step in the sterilization process

“When in doubt, throw it out”

“The infection control dream”

“an instrument that is never reused does not present and infection risk to another patient!”

Problems with Endoscopes Long narrow shaft are difficult if not

impossible to clean. The more complicated the device the

harder it is to clean. Focus is on function, not on cleaning in

the design phase. Forces sterile processing technicians to

do what they can and hope for the best…

Other challenges… Keeping the instruments free of gross soil. Minimize time between use and cleaning process. Making sure the SPD staff know and use the

correct procedures. Having the right cleaning equipment and solutions

in the right place Complex instruments that requires time-

consuming disassembly, cleaning and reassembly before processing…

Proper Steps Begin cleaning as soon as possible (don’t let

blood and tissue dry and cake - covering with a wet cloth is not enough.

Place the instruments in a basin of solution as soon as they come off the procedure table.

Wipe down surfaces and flush lumens to remove gross debris.

Separate general from specialized instruments. Transport to SPD. Clean and disinfect or sterilize according to

manufacturer's written instructions.

Manufacturer’s Responsibility

Manufacturer’s must incorporate “cleanability” into design.

“Manufacturer’s should provide documentation from an independent laboratory that proves the device can actually be cleaned.” Dennis Maki.

“Acetabular Reamers”

In January 2004, a technician at a hospital in Canada discovered that some of these instruments could be partially disassembled prior to cleaning. This may have not been known by some hospitals using this equipment and the information originally received from the manufacturer did not adequately describe the disassembly procedures.

What about artificial fingernails?

What about artificial fingernails?

Some folks think it’s OK to wear acrylic nails if they are only circulating…

Artificial should not be worn in the perioperative setting

AORN: Artificial nails should not be worn.

Rationale

The is not evidence that artificial nails increase the risk of SSI.

These nail may harbour organisms and prevent effective handwashing.

High numbers of gram-negative organisms have been cultured from personnel wearing artificial nails!

I’ve never seen a body piercing there before!

Body Piercing!?! Removing jewelry means removing jewelry! There is a risk of burns if an electrosurgical

unit is used. Risk is less if ESU has an isolated generator that eliminates the risk of alternate site burns. Ask patients to remove body piercing prior

to coming to the hospital.

The OR of the FutureDesigning an OR with Infection Control in mind.

The OR of the Future

OR designed to be large (600 sq. ft.) allow greater separation of sterile field and non-sterile perimeter.

Patients and OR staff have separate entrances to avoid cross contamination

No floor penetrations and all wall and ceiling penetrations are sealed.

Designing the OR for IC An observation gallery to

minimize people going in and out.

Hands free or voice activated surgical equipment (robotic).

Multiple cameras for consulting and teaching purposes.

Hands free telephone and voice activated devices.

Touch screen computers instead of keyboards.

Designing the OR for IC

Ceiling-hung equipment booms to hold equipment off the floor.

All utilities and medical gases originate from ceiling to eliminate hoses and cables running across the floor and in and out of the sterile field.

Makes things much easier to clean and disinfect.

Designing the OR for IC

Special attention given to surfaces finishes for ease of cleaning and durability.• Epoxy terrazzo floor.

• Ceramic tile walls with epoxy-based grout.

• Seamless gypsum wallboard for ceiling, sealed with epoxy paint.

• Stainless steel and glass cabinets.

Ventilation

Laminar flow HVAC system that delivers air from the ceiling and exhausts in rooms corners.

Positive pressure to outside rooms

All ductwork insulated on the exterior to minimize surfaces where moulds and bacteria can grow.

Lighting

Voice command adjustable lighting.

Gaskets and seals on fixtures to promote dust control and make cleaning easier.

Goals

Easier to clean faster TAT

Shortened time frames• Voice activated

everything moves quicker

• Patient is open on the table for a shorter period

• Risk of infection

Summary

IC practice should be evidence based. Sometimes best practice is based on

expert opinion. It shouldn’t be “we’ve always done it that

way”. New designs should have IC in mind.

Questions?