Infection Control in the Operating Room - RN CEU - … · INFECTION CONTROL IN THE OPERATING ROOM 2...

A SELF STUDY GUIDE

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INFECTION CONTROL IN THE OPERATING ROOMRegistered Nurses

INFECTION

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OVERVIEWWorking in the Operating Room (OR) requires highly skilled staff members to coordinate and deliver the care necessary to surgically treat a wide variety of patients. The OR staff works in an intense, fast-paced, detail-oriented, technically advanced environment to safely perform surgical procedures. In the perioperative setting, good infection prevention and control is essential to ensure that patients who undergo any surgical procedure receive safe and effective care. Safe working practices are also necessary to ensure the safety of the OR team members as well. Risk of exposure to bloodborne pathogens and toxic chemicals is a major concern among healthcare providers who work in the OR. In response to these risks, there should be a focus on the impact of the surgical procedure on the perioperative team and how to prevent the surgical team from acquiring infections as they administer care to the surgical patient. This continuing education activity examines considerations necessary to prevent staff-related infections.

LEARNER OBJECTIVESAfter completing this continuing nursing education activity, the participant should be able to:

1. Discuss surgical glove failure rates and the benefits of double gloving.

2. Discuss the potential benefits of innovative antimicrobial glove technology.

3. Describe the risks associated with surgical smoke and identify when the use of a surgical N95 respirator is recommended.

4. Discuss the advantages of single-use turnover kits to prevent contamination, infections and injuries.

5. Identify best practice to reduce sharp-related injuries in the operating room.

INTENDED AUDIENCEThe information contained in this self-study guidebook is intended for use by healthcare professionals who are responsible for or involved in the following activities related to this topic:

• Educating healthcare personnel.

• Working in the Operating Room and other surgical environments.

• Establishing institutional or departmental policies and procedures.

• Decision-making responsibilities for safety and infection prevention products.

• Maintaining regulatory compliance.

• Managing employee health and infection prevention services.

INSTRUCTIONSAnsell is a Recognized Provider of continuing education by the California Board of Registered Nursing, provider #CEP 15538 and the Australian College of Perioperative Nurses (ACORN). This course has been accredited for 2 (two) contact hours. Obtaining full credit for this offering depends on completion of the self-study materials on-line as directed below.

Approval refers to recognition of educational activities only and does not imply endorsement of any product or company displayed in any form during the educational activity

To receive contact hours for this program, please go to the “Program Tests” area and complete the post-test. You will receive your certificate via email.

AN 85% PASSING SCORE IS REQUIRED FOR SUCCESSFUL COMPLETION

Any learner who does not successfully complete the post-test will be notified and given an opportunity to resubmit for certification.

Ansell Healthcare Products LLC has an ongoing commitment to the development of quality products and services for the healthcare industry. This self-study is one in a series of continuing educational services provided by Ansell.

For more information about our educational programs or perioperative healthcare safety solution topics, please contact Ansell Healthcare Educational Services by e-mail at [email protected]

Planning Committee Members:Luce Ouellet, RNLatisha Richardson, MSN, BSN, RN Patty Taylor, BA, RN Pamela Werner, MBA, BSN, RN, CNOR

As employees of Ansell Mrs. Ouellet, Mrs. Richardson, Mrs. Taylor and Ms. Werner have declared an affiliation that could be perceived as posing a potential conflict of interest with development of this self-study module. This module will include discussion of commercial products referenced in generic terms only.

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TABLE OF CONTENTS

INTRODUCTION……………………………………………………………………..….…………4

SURGICAL GLOVES……........………………………………....……………………..……………5

SURGICAL SMOKE………………………………………....……………………………………...9

SINGLE USE VS. RE-USABLE BARRIER PRODUCTS………………………………………….12

SHARPS SAFETY………………………...……………………………………………………….14

SUMMARY………………………………………………………………………….……….……16

GLOSSARY………………………………………………………………………….………….…17

REFERENCES………………. ............………………………………………………………….…20

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INTRODUCTIONThe risk of infection from bloodborne pathogens in the operating room (OR) is a constant challenge for the perioperative team due to existing bloodborne pathogen risks, drug-resistant pathogens and newly recognized pathogens as well as the daily safety hazards of the working environment. “Protecting patients and healthcare practitioners from potentially infectious agent transmission continues to be a primary focus of the perioperative registered nurses (RNs).”1 Personal Protective Equipment (PPE) has never been more important than it is in today’s world. PPE is specialized clothing and/or equipment for eyes, face, head, body, and extremities; protective clothing; respiratory devices; and protective shields and barriers that is designed to protect the worker from injury or exposure to a patient’s blood, tissue, or body fluids. PPE is used by perioperative team members, healthcare workers and others any time it is needed to protect themselves from a variety of hazards such as bloodborne pathogens, chemical hazards, or mechanical irritants encountered in a manner capable of causing injury or impairment in the function of any part of the body through absorption, inhalation, or physical contact. There are a multitude of exposure risks in the OR; so the perioperative RN should be familiar with the potential infection control issues in the OR, understand the exposure risks and learn preventative measures. In this learning activity, we will focus on significant areas of infection control: surgical gloves; surgical smoke; single-use vs re-usable barrier products and sharps safety. After completing this activity, the participant should be able to discuss glove failure rates, the benefit of double gloving and the benefits of antimicrobial glove technology. The participant will also be able to describe surgical smoke risks and know when to use the surgical N95 respirator along with discussing the advantages of using the single-use turnover kit to prevent contamination, infection and injuries.

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SURGICAL GLOVESSurgical gloves were first introduced in the 1890’s. According to many sources, William Stewart Halsted of Johns Hopkins Hospital is the surgeon who is credited with the introduction of surgical gloves. “In 1890, he became surgeon-in-chief and married Caroline Hampton, the head operating room nurse at the hospital. Hampton had complained about the dermatitis she experienced due to Halsted’s insistence that she use mercuric bichloride as a surgical antiseptic, resulting in her future husband drafting the Goodyear Rubber Company to produce surgical gloves to protect his staff.”2

The gloves soon became a commonly used item in the operating room. In 1966, single-use powdered gloves became available; these are the standard of care that still exists today. Even though the use of latex gloves in surgery became a routine practice after World War I, gloves were not consistently used in most other patient care areas until the mid-1980’s with the onset of the AIDS epidemic and the spread of hepatitis. The importance of protective gloves, both as a barrier between the surgeon and healthcare worker’s hands and the patient’s wound and, more recently as protection from viruses derived from the patient (HIV, hepatitis) and from environmental hazards is self-evident to the perioperative professional today.

Surgical glove standards are governed by National Government Standards. Quality specifications are written into each Standard for a surgical glove product. They relate to physical requirements like strength, thickness, measurements, performance, and freedom from holes. Specifics include, elasticity, elongation, protein and powder levels, allergenicity or biocompatibility. These specifications require a statistical sample scheme which, if passed, mathematically ensures a maximum potential number of defined faults per 100 units. This is called an AQL (Acceptable Quality Level). Batches of product are rejected by the manufacturer if the number of faults exceeds this number. Each Standard Organization has varying requirements to be met and generally arrange

factory inspections before granting a Certificate of Standards Conformity.

• In Europe, medical gloves are subject to the European Standards EN 455 part 1-2-3, while the enforcement is under the responsibility of each Member State through national standards bodies and healthcare agencies. The European EN 455 standard for surgical gloves was approved by CEN (European Committee Standardization) which the members are the National standards bodies of Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland and United Kingdom.

• The US FDA does not write standards but it does recognize standards that are written by the American Society of Testing and Materials (ASTM). Surgical gloves sold into the US must meet the ASTM standards.

• ISO (International Organization for Standardization) is an independent, non-governmental membership organization and the world’s largest developer of voluntary International Standards. Many countries require surgical gloves entering their country to meet the ISO Standards.

All gloves that meet the above standards must provide barrier protection against bloodborne pathogens such as HIV, HBV and HCV. The strict manufacturing standards also must meld with the customer’s needs for durability, tactile sensitivity, flexibility, resiliency and comfort. Manufacturing high-quality gloves that meet the customer’s needs without failures is very challenging. “Glove failure during use can be caused by punctures, tears by sharp devices, or spontaneous failures.”3 Factors that increase the incidence of glove failures during use include:

• Length of procedure;

• Mechanical stress;

• Type of surgery;

• Number of instruments used in the surgical procedure; and

• The role of the glove wearer in the surgical procedure.

“The intact surgical glove is the most important barrier to protect the patient from microorganisms from the hand of the surgical team and vice versa.”4 The preoperative surgical hand preparation can significantly reduce but not eradicate the resident flora on the surgeon’s hands; this reduces but does not eliminate any risk of transmission of these organisms into the operative site.

Goodyear Surgical Glove

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PERFORATION RISK

Surgical Scrub

Conversely, blood-borne pathogens can be transmitted from the patient to the surgeon and pose a safety risk to the perioperative team members. The rates of glove failures as reported in several different studies during a review of pertinent articles vary from 10% to 61% during various types of procedures. “Perforation rates as high as 61% for thoracic surgeons and 40% for scrub personnel have been reported.”5 In fact, the type of surgery is a delineating factor in failure/perforation of surgical gloves and has been studied frequently. “A study conducted to estimate and compare the perforation risk in different categories of surgery found perforations in 203 out of 655 operations (31%), with frequencies of 44.5% in gastrointestinal surgery, 34.7% in orthopedic surgery, 31.1% in gynecology, 18.6% in vascular surgery and 9.2% in general surgery.”6

Gastrointestinal Surgery

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DOUBLE GLOVING In the 2014 Edition, Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings, Recommendation VI states “Perioperative personnel must wear PPE when exposure to blood or other potentially infectious materials is anticipated.”7 This recommendation goes into great detail regarding the wearing of gloves and the evidence based rationale supporting glove use in the prevention of risks associated with infection control in the perioperative setting. Some specific information related to glove failures includes:

• VI.a.2. Sterile gloves should be visually inspected immediately upon donning and before contact with sterile supplies or the sterile field. Gloves may have perforations or tears that occur in the manufacturing process or as gloves are donned.

• VI.a.3. Sterile gloves should be changed:

• After each patient contact;

• When a visible defect is noted;

• When suspected or actual contamination occurs; and

• When a suspected or actual perforation occurs.

Breaches in the glove barrier pose a risk for transmission of bloodborne pathogens during surgical procedures. Glove perforation also increases the risk of surgical site infection (SSI).

Depending on the duration of wear, surgical gloves can develop micro perforations that are not immediately recognizable to the wearer. These perforations allow bacteria from the surgical site to pass through to the wearer’s hands. One method for preventing this is to mandate regular glove changes in organizational policy. Changing gloves at regular intervals may decrease the incidence of glove perforation and bacterial contamination during surgical procedures.8

In addition to suggesting glove changes to decrease the incidence of glove perforation, AORN recommends that “Perioperative team members should wear two pairs of surgical gloves, one over the other, during surgical and other invasive procedures with the potential for exposure to blood, body fluids, or other potentially infectious materials.”9 This use of double gloving will add extra protection. Double gloving reduces the risk of exposure to patient blood by as much as 87% when the outer glove is punctured. Volume of blood on a solid suture needle is reduced by as much as 95% when passing through two glove layers, thereby reducing viral load in the event of a contaminated percutaneous injury.10

Double gloving has many benefits including:

• Wearing double gloves helps prevent SSI and protect health care providers hands.11

• Effective way to reduce the risk of percutaneous injuries.

• May increase the wearer’s awareness of a perforation which may protect against exposure during surgery.

• Minimizes the amount of blood that is transferred to the healthcare provider’s hands during a needlestick injury.

• Reduces risk of glove perforation with a lengthy procedure.

• Reduces the risk of perforation of the inner-most glove.

• “Perioperative personnel’s risk decreased by 70% when double-gloving in comparison to wearing a single-glove.”12

• May protect the wearer’s skin from needlesticks because breaches will most likely occur to the outer gloves, not the inner gloves.

• “Laine and Aarmio suggested that the rate of contamination with blood was 13 times higher with single gloving as opposed to double gloving.”13

The color coded glove system (two-color glove system) is noted to be an effective strategy for risk reduction when double gloving because it aids in early and accurate detection of a hole in the outer glove. The inner-glove is a brighter color (eg, bright green) and the outer-glove is a neutral color (eg, white).

Donning Surgeon

Double Gloving

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STANDARDS OF PRACTICEDuring surgery, if the glove is breached or fails in any way, the color of the inner glove will be visible. This technique can increase awareness, speed the detection of a failure, and is easy to implement.

Several important professional organizations have taken positions on double gloving as a standard of practice in the perioperative environment. The following organizations have issued recommendations and statements supporting and endorsing the use of double-gloving:

• The Association of periOperative Registered Nurses (AORN);

• The American College of Surgeons (ACS);

• The American Association of Orthopaedic Surgeons (AAOS);

• Centers for Disease Control (CDC);

• The Australian College of Operating Room Nurses (ACORN);

• The International College of Surgeons (ICS);

• The European Center for Disease and Control (ECDC); and

• The World Health Organization (WHO).

There are innovations that continue to improve the ability of surgical gloves to provide protection from bloodborne pathogens and to decrease the risk of surgical site infections (SSI). One very important new technology is the innovative antimicrobial glove technology. Several recent studies have reported evidence that microbial passage across surgical gloves can be reduced significantly using an innovative antimicrobial glove technology. One such study stated “Gloves serve as a mechanical protective barrier between the surgeon’s hand and the surgical site, but we hypothesized that antimicrobial gloves might also reduce the risk of contamination of the surgical site in the event of an intraoperative glove breach by suppressing the re-growth of skin flora during the course of a surgical procedure.”14 After conducting the studies needed to satisfy the hypothesis; the conclusion was: “The use of antimicrobial surgical gloves may prevent bacterial contamination of the surgical site and may therefore indirectly decrease the risk of SSI and thus increase patient safety, particularly when the consequences of an SSI are catastrophic, as in vascular surgery. The present study has shown that a new antimicrobial surgical glove was able to suppress the skin flora of surgeons’ hands during operation by a factor of approximately 1.3 log 10 CFU/mL.”15

Antimicrobial decontamination gloves can be used by members of the OR team to facilitate a safe a rapid turn-over between cases. The antimicrobial decontamination glove protects the healthcare workers hands from contamination and transfer of bacteria within the OR environment. These innovative gloves have the potential to reduce the environmental transfer of bacteria as well as provide increased safety for the perioperative team and patients.

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SURGICAL SMOKESmoke generated from the various energy modalities used in today’s OR is a common occurrence. In fact, surgical personnel are vulnerable to a variety of hazardous substances, including potentially infectious agents present in surgical smoke given their prolonged exposure to surgical smoke over the course of their career.16 Energy in the OR is an area of innovation with many modalities, which include: electrosurgery, lasers, ultrasonic energy, argon enhanced coagulation, plasma technology, vapor sealing technology, combination devices as well as others. Most surgical procedures use some type of energy and the combination of increased modalities and vast usage mean that the hazards of surgical smoke in the OR are receiving increased attention.

The smoke from these energy devices has been found to contain many potentially hazardous particles such as:

• Toxic gases and vapors;

• Bio-aerosols;

• Dead and live cellular material;

• Blood fragments;

• Viruses (HIV, HPV);

• Infectious bacteria;

• Carcinogens;

• Neurotoxins;

• Lung-damaging dust; and

• Allergens.

The composition and exposure hazards associated with surgical smoke depend on a variety of factors such as:

• The type of surgical procedure and device (i.e., laser, electrosurgical, ultrasonic);

• Type and infectious nature of the tissue;

• Extent of tissue ablation;

• The duration of surgery; and

• Worker proximity to the surgical field.

The surgical smoke, in high concentrations poses risks to healthcare workers and others and can cause adverse health conditions such as respiratory tract irritations and spread of viruses and toxins through aerosolization. Some risks and adverse health conditions include:

• Lung disease,

• Inhibition of tissue oxygenation,

• Mutations,

• Transmission of HIV, TB, Rubeola, and

• Respiratory changes such as emphysema, asthma, and chronic bronchitis.

In the OR, smoke can cause decreased vision for the surgeon and perioperative team members as well as offensive or noxious odors. “In addition to respiratory problems, after repeated exposures to surgical smoke, perioperative staff members have reported signs and symptoms that include burning and watery eyes, nausea, and headaches.”17

Electrosurgery

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IMPORTANCE OF PARTICLE SIZEAn important consideration when assessing the respiratory hazards of surgical smoke is the size of the particles in the smoke. The different types of energy used in the OR today produce different size particles. The smallest particles can travel the farthest and affect all perioperative team members even those who are not scrubbed. Some particle sizes, in microns, can be compared:

• Surgical Smoke:

» Electrocautery – 0.07

» Laser Ablation – 0.31

» Ultrasonic Scalpel – 0.35-6.5

• Viruses:

» HPV – 0.045

» HIV – 0.18

» Varicella – 0.1-0.2

• Bacteria:

» Anthrax – 1.0-3.0

» TB – 2.0-4.0

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HIV – CDC Photo

TB – CDC Photo

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EVALUATING SURGICAL MASKSSurgical masks are evaluated by the FDA for bacterial filtration, fluid resistance, differential pressure, and flammability and while they are definitely appropriate for use as PPE and in the perioperative setting, they do not have the filtration rating for viruses and bacteria of extremely small particle sizes. AORN recommends that “Perioperative personnel should wear N95 or higher level respirators during aerosol-generating procedures involving patients who have TB, SARS, or avian or pandemic influenza viruses.”18 The N95 respirator is a type of filtering face-piece respirator that prevents at least 95% of the particles that are not resistant to oil from passing through. Taking it a step further, “NIOSH recommends the use of properly fitted, filtering face-piece respirators rather than surgical and laser masks. Filtering face-piece respirators with an N95 filter class designation prevent all sizes of particles from passing through the filter media and entering the wearer’s breathing zone.

Even taking some face-piece seal leakage around the respirator into account, a properly fitted N95 reduces the wearer’s exposure against a range of very small particles (less than 1 μm) to large droplet sized particles (> 60 μm) by at least 10-fold. Thus, healthcare personnel should wear respiratory protection at least as protective as a fit-tested N95 filtering face-piece respirator when working with known disease transmissible cases (i.e., HPV) and/or during aerosol-generating procedures or with aerosol transmissible diseases (i.e., TB, Varicella, and Rubeola). Furthermore as a precautionary measure, it is recommended that respiratory equipment as protective as a fit-tested N95 be worn in the absence of properly functioning smoke control measures (i.e., OR exchanges, LEV).”19

Both surgical masks and N95 respirators play a role in infection prevention in the perioperative setting. They have some marked similarities as well as differences. We have already discussed the limitations of the surgical mask in protecting the user from small particles. Both types are disposable and provide a barrier to splash, droplets and sprays. The N95 is however; more complex and as a high level respirator, has additional characteristics. In addition to effectively filtering both small and large particles from the air, the N95 is designed to fit tight around the face, creating a seal around the perimeter of the respirator to improve protection. The N95 comes in multiple sizes.

In addition to the information presented above, the N95 respirator is recommended for use in the following situations:

• Perioperative personnel should don a surgical mask, N95 or higher level respirator, depending on disease-specific recommendations, before entering the room of a patient who requires airborne precautions.20 TB is an example of this recommendation.

• Regarding Electrosurgery, AORN Recommends: “Personnel should wear respiratory protection (i.e., fit-tested surgical N95 filtering face piece respirator, high-filtration surgical mask) during procedures that generate surgical smoke as secondary protection against residual plume that has escaped capture by LEV, the primary means of protection.”21

• Laser smoke plume has a similar recommendation. AORN recommends: “Personnel should wear respiratory protection (i.e., fit-tested surgical N95 filtering face piece respirator or high-filtration surgical mask) during procedures that generate surgical smoke as secondary protection against residual plume that has escaped capture by local exhaust ventilation.”22

N95 Mask

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SINGLE USE VS. RE-USABLE BARRIER PRODUCTS Hospital-associated infections (HAIs) affect close to two million patients each year and the perioperative RN must be prepared to look at all angles when striving to prevent infection control issues in the OR. The OR is an aseptic environment; however; it is also an environment that is hectic with a constant flow of patients having a wide variety of procedures every day. These procedures generate continuous exposure to blood, body fluids and tissues either directly or indirectly as well as exposure to airborne hazards, surgical smoke and other hazards. Personal Protective Equipment (PPE) has been introduced to protect the traditional cotton scrubs, surgical gowns, and lab coats that can be found in the operating room when dealing with known hazards such as blood and body fluids. In addition, disposable single-use linens are used for everything from drapes, arm board covers and table covers to surgical gowns in order improve efficiency, safety and effectiveness.

“Surgical gowns, gloves, and drape products used during operative and other invasive procedures must provide a barrier and should be resistant to tears, punctures, and abrasions.”23 “Surgical site infections occur in 2% to of the US patients who undergo surgery in inpatient facilities for a total of approximately 500,000 SSIs each year, at a cost of up to $10 billion annually.”24 Damage to the integrity of surgical gowns, gloves and drapes can lead to surgical site infections and increased healthcare costs. There are many factors that should be considered when selecting the types of linens to be used in the perioperative setting:

Surgical PPE

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Protection: High resistance to blood body fluids and other potentially infectious substances is preferred, ability to resist penetration.

• Performance: Overall quality in terms of liquid penetration, microbial penetration, processing cycles (if reusable), consistency.

• Safety: When considering reusable vs disposable linens, it is usually considered safer for workers to handle disposables only to dispose of them after use than to handle reusable linens multiple times to reprocess them risking disease transmission many times.

• Lint and Airborne Particulates: Since airborne particles may play a role in developing SSIs, disposable linens may be preferable due to the lint that may be present on reusable linens;

• Product-specific Requirements: “Product-specific requirements include contractual agreements, compatibility with existing products, and implementation of new products of differing material or construction.”25

• Procedure-specific Requirements: define what is necessary for the procedure where the surgical gowns, gloves, and drape products will be used.

• End-user Requirements and Preferences: Examples include: the degree of protection from blood, body fluids, and other potentially infectious materials; and preferences, such as comfort.

• Patient-related Requirements: Size or ability to conform to the contours of the patient.

• Environmental Considerations: Potential to be recycled, reprocessed or reduced waste.

• Compliance: Federal, state and local regulatory agencies and compliance with standards-setting bodies including the FDA, CDC, and OSHA, along with other regulatory agencies plus standards-setting bodies like AORN.

Comparing single-use and reusable linens does not end with items that are used during surgical procedures. The infection control risks in the perioperative area are so high that cleaning the environment and the use of single-use versus disposable items must also be considered. There can be significant contamination on many surfaces in the OR environment as well such as: mattresses; surfaces such as keyboard, mayo stands, back tables, counter tops; and single-use medical devices.

Currently, single-use disposable linens are commonly used in the perioperative setting. “The benefits of using single-use disposable linens include the fact that product quality is consistent. In a recent study comparing single-use and textile

products, 56% of the textiles showed serious faults impairing functionality compared to 0% of the single-use products.”26 Other benefits of single-use disposable linens include:

• Consistent quality;

• Reduced need for sterilization;

• Lower risk of SSIs; and

• Reduces work load for central sterile personnel.

Another way to affect infection control in the perioperative setting is to manage the process of OR room turnover in a way that reduces the probability of the transmission of pathogens and infectious disease. AORN Recommended Practices for Environmental Cleaning outlines the steps necessary to maintain a clean environment in the OR. Recommendation III states “A clean environment should be reestablished after the patient is transferred from the area.”27 It is very important for the perioperative team to clean effectively and safely while attempting to efficiently utilize time and resources during the turnover. Turnover time must be sufficient to allow personnel to thoroughly clean and disinfect surfaces that have come in contact with the patient or are visibly soiled (eg, blood, tissue) from the surgical procedure.28 There are many steps that must be completed by the OR team in order to complete the turnover process these steps include, but are not limited to:

• Clean and disinfect surfaces that have come in contact with the patient or are visibly soiled from the surgical procedure;

• Wipe down all mobile and fixed equipment (eg, OR lights, monitors, patient transfer devices);

• Mop floors;

• Replace damaged or single-use equipment;

• Clean OR bed and associated positioning devices; and

• Remove trash, contaminated laundry.29

In an effort to assist with improvement of existing turnover processes, “Manufacturers of OR turnover equipment are assisting in this process by designing packaged kits with disposable linens, trash bags, hamper liners, kick bucket liners, wiping cloths, and mops designed to fit the unique needs of each hospital. These kits provide standardization of the process of room turnover and help ensure the right equipment is accessible to clean and disinfect the room properly so turnover is expedited without compromising infection prevention efforts.”30 Although some facilities choose to package their own turnover kits, single-use kits offer many advantages over reusable kits just as single-use linens have proven to have advantages over reusable linens.

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SHARPS SAFETYThe final infection control risk that will be discussed in this educational module is a very challenging concern for the perioperative RN. “Annually, an estimated 384,325 hospital healthcare workers sustain a percutaneous injury.”31 Sharps injury is one of the primary concerns for the perioperative team. The following perioperative professional associations have developed sharps safety position and guidance statements:

• The Association of periOperative Registered Nurses (AORN);

• The Association of Surgical Technologists (AST);

• The American Academy of Orthopaedic Surgeons (AAOS);

• The American College of Surgeons (ACS);

• The Council on Surgical & Perioperative Safety (CSPS);

• The European Agency for Safety and Health at Work (EU-OSHA);

• The Alliance for Sharps Safety and Needlestick Prevention in Healthcare Australia;

• The Australian College of Nurses; and

• The Australian Healthcare and Hospital Association.

(Note: this is not an all-inclusive list).

“The Centers for Disease Control and Prevention (CDC) estimates that about 385,000 sharps-related injuries occur annually among health care workers in hospitals.”32 This is more than 1000 per day. Even more troublesome, it has been estimated that at least a half or more of sharps injuries are not reported. Most of the reported sharps injuries involve nursing staff, but laboratory staff, physicians, housekeepers, and other health care workers are also injured.

Injury related to needle sticks and other sharps objects are associated with the transmission of a large number of pathogens; however, there are three pathogens that pose the greatest risk for perioperative team members: hepatitis B, hepatitis C and HIV. We have already discussed on of the best ways to reduce the risk of bloodborne pathogen contact with skin during surgery, double gloving. This technique, especially when using a colored underglove, also assists in the reduction of risk from puncture. “The risks of bloodborne pathogen exposure are higher in the OR because of prolonged contact with surgical sites, manipulation of sharps, and exposure to larger quantities of blood.”33 AORN has very specific recommendations to aid in the prevention of infection control risks related to sharps in the OR.

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Recommendation II in the Recommended Practices for Sharps Safety outlines the current best practices for sharps safety in the perioperative setting. The recommendations states: “Perioperative personnel must use work practice controls when handling scalpels, hypodermic needles, suture needles, bone fragments, K-wires, burrs, saw blades, drill bits, trocars, razors, bone cutters, towel clips, scissors, electrosurgical tips, skin hooks, retractors, and other sharp devices.”34 Ways to reduce the risk of a sharps injury in the perioperative setting include:

• Confine and contain sharps in specified areas of the sterile field or within a sharps containment device.

• Scrub person should account for and confine all sharps on the sterile field until the patient has been transported from the room.

• Keep used sharps on the sterile field in a puncture-resistant container.

• Obtain a new container if the needle disposal container on the sterile field is full.

• Close needle containers securely before disposal.

• Members of the surgical team should use a neutral zone or hands free technique for passing sharp instruments, blades, and needles. The use of a neutral zone should include:

» Neutral zone should be identified in the preoperative briefing;

» A basin, instrument mat, magnetic pad, or designated area on the mayo stand as the neutral zone;

» Place one sharp at a time in the neutral zone;

» Orient the sharp for easy retrieval by the surgeon;

» Sharp handled by only one team member at a time; and

» Place sharps in the neutral zone after use.

• Use no-touch technique when handling sharps.

• Suture needled should not be handled or manipulated with gloved hands.

• Use a blunt instrument such as a forcep to manipulate and guide the needle through tissue to avoid injury.

• Use an instrument to pick up sharp items such as knife blades and suture needles.

• Only use sharp instruments when clinically necessary and when there is not a safer method available.

• Use safe scalpel handling techniques and methods.

• Use alternative cutting devices such as innovative energy modalities, when clinically indicated.

• Energy devices may be used as an alternative to scalpels.

• “Perioperative team members should use additional sharps safety practices, including:

» Maintaining situational awareness of all sharps on the sterile field;

» Communicating the location of sharps on the sterile field with other members of the perioperative team during the procedure and at times of personnel change;

» Removing suture needles from the suture before tying (eg. cutting, control release);

» Retracting tissue with instruments (eg. retractors) rather than hands; and

» Handling (eg. applying, passing, using, removing) saw blades, sharp K-wires after they have passed through the patient’s skin.35

• Use safe practices when injecting medications or drawing blood.

• Do not bend, recap or remove contaminated needles unless there is no alternative.

• Use needleless entry devices whenever possible.

• Practice ampule safety to minimize percutaneous risk of injury.

Accidental sharps injuries in the perioperative setting are serious problems and can cause perioperative team members to acquire infectious diseases from bloodborne pathogens or injuries in the course of their work. There is also a cost of injury and exposure that is both emotional and financial on the healthcare worker, their families and the facility.

Unprotected Scalpel Blade

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SUMMARYPreventing surgical site infection in the OR is one of the primary goals of the perioperative team, and the team performs many infection prevention best practices to support this goal. In the perioperative setting, good infection prevention and control is essential to ensure that patients who undergo any surgical procedure receive safe and effective care. Safe working practices are also necessary to ensure the safety of the OR team members. Practices such as double gloving, utilizing antimicrobial technology in surgical and decontamination gloves, properly handling surgical smoke and wearing N95 surgical masks when indicated, utilizing disposable barrier linens and turnover kits and practicing sharps safety will reduce infection risks for both patients and perioperative team members.

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GLOSSARYAEROSOLA liquid or solution dispersed in the air in the form of a fine mist.

ANTIMICROBIAL An agent that kills microorganisms or inhibits their growth.

BLOODBORNE PATHOGENS Pathogenic microorganisms present in human blood that can cause disease in humans. These include: hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

CONTACT PRECAUTIONS Precautions designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact.

DIRECT CONTACT Person-to-person contact resulting in physical transfer of infectious microorganisms between an infected or colonized person and a susceptible host.

EXPOSURE INCIDENT When as a result of the performance of an employee’s duties, there is specific eye, mouth, other mucous membrane non-intact skin, or parenteral contact with blood or potentially infectious materials.

HANDS-FREE TECHNIQUE Work practice that restricts members of the perioperative team at the sterile field from touching the same sharp instrument at the same time, also known as the neutral zone.

HOSPITAL ACQUIRED INFECTION (HAI) An infection whose development is favored by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff. Such infections include fungal and bacterial infections and are aggravated by the reduced resistance of individual patients.

INDIRECT CONTACT Contact of a susceptible host with a contaminated object (eg, instruments, hands).

ISOLATION PRECAUTIONS Special precautionary measures, practices, and procedures used in the care of patients with contagious or communicable diseases.

NEUTRAL ZONE A safe work practice control technique used to ensure that the surgeon and scrubbed person do not touch the same sharp instrument at the same time. The technique is accomplished by establishing a designated neutral zone on the sterile field and placing sharp items within the zone for transfer of the item. Also known as Hands-free technique.

OR TURNOVER TIME The time between one patient’s exit and the next patient’s entry to the same OR on the same day. The time it takes to prepare the OR for the next surgical procedure.

PERSONAL PROTECTIVE EQUIPMENT (PPE) Specialized equipment or clothing for eyes, face, head, body, and extremities; protective clothing; respiratory devices; and protective shields and barriers designed to protect the worker from injury or exposure to a patient’s blood, tissue, or body fluids. Used by health care workers and others whenever necessary to protect themselves from the hazards of processes or environments, chemical hazards, or mechanical irritants encountered in a manner capable of causing injury or impairment in the function of any part of the body through absorption, inhalation, or physical contact.

POTENTIALLY INFECTIOUS MATERIALS Blood; all body fluids, secretions, and excretions (except sweat), regardless of whether they contain visible blood; non-intact skin; mucous membranes; and airborne, droplet, and contact-transmitted epidemiologically important pathogens.

PROCEDURE MASK A mask that covers the nose and mouth and is intended for use in general patient care situations. These masks generally attach to the face with ear loops rather than ties or elastic. Unlike surgical masks, procedure masks are not regulated by the US Food and Drug Administration.

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QUALITATIVE FIT TEST A pass/fail test to assess the adequacy of N95 respirator fit, as determined by an individual’s response to the certain aerosolized test solutions.

RESPIRATOR A personal protective device that is worn on the face and covers at least the nose and mouth; it is worn to reduce the wearer’s risk of inhaling hazardous airborne particles (including infectious agents and dust particles), gases, or vapors. A surgical N95 respirator prevents at least 95% of particles from passing through the filter.

SINGLE-USE MATERIALS Nonwoven materials are the essential component of single-use surgical gowns and drapes. They are based on various forms of natural and synthetic fibers, that is, components such as wood pulp and cotton, or polyester, polyolefin and polypropylene.

STANDARD PRECAUTIONS Primary strategy for successful infection control and reduction of worker exposure. Precautions used for care of all patients regardless of their diagnosis or presumed infectious status.

SURGICAL DRAPE A sterile fabric or fabric-like material used to isolate the surgical site from the rest of the body and other possible sources of contamination. Their role is to improve patient safety but also to minimize the spread of infectious agents such antibiotic resistant bacterial strains, human immunodeficiency virus (HIV), and others, and therefore to decrease the risk for staff as well as other patients to be contaminated by these infectious agents.

SURGICAL GOWN A sterile fabric or fabric-like material that must be worn by a member of the surgical team during a surgical procedure in order to minimize the exposure of healthcare workers to pathogenic organisms. Also gowns reduce the risk of “patient-to-patient” transmission of pathogenic organisms and optimize sterility during operative and invasive procedures.

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SURGICAL MASK A device worn over the mouth and nose by perioperative team members during surgical procedures to protect both the surgical patient and perioperative team members from transfer of microorganisms and body fluids. Surgical masks are also used to protect health care workers from contact with large infectious droplets (>5 mcm in size).

SURGICAL SITE INFECTION (SSI) An infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material.

SURGICAL SMOKE Cellular debris, aerosols, vapors and gases that are created as a byproduct of the pyrolysis of human tissue.

TRANSMISSION BASED PRECAUTIONS Precautions designed to be used with patients known or suspected of being infected or colonized with highly transmissible or epidemiologically important pathogens that need additional precautions to prevent transmission in the practice setting.

TURNOVER KITS Kits designed to help streamline the process of OR turn over time. Either hospital assembled kits or commercially assembled kits can include a variety of supplies to accomplish room turnover. Most kits include the linens needed to remake the bed, patient safety straps, mop heads, replacement waste bags and fluid solidifier.

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REFERENCES1. AORN. Recommended Practices for Prevention of Transmissible Infections in the Perioperative Practice Setting. In: Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO: Association of periOperative Registered Nurses; 2014: 385.

2. William S. Complete Dictionary of Scientific Biography. Encyclopedia.com. http://www.encyclopedia.com/doc/1G2-2830901836.html. Accessed December 29, 2014.

3. AORN. Recommended Practices for Prevention of Transmissible Infections in the Perioperative Practice Setting. In: Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO: Association of periOperative Registered Nurses; 2014: 394.

4. Hubner N, Goerdt A, Stanislawski N. et al. Bacteria migration through punctured surgical gloves under real surgical conditions. BMC Infectious Diseases. 2010: 3.

5. McNeilly L. Double Gloving: Myth Versus Fact. http://www.infectioncontroltoday.com/articles/2011/04/double-gloving-myth-versus-fact.aspx. Accessed January 4, 2015.








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13. Korniewicz D, El-Masri M. Exploring the Benefits of Double Gloving During Surgery. AORN Journal. March 2012 March; 95(3): 333.

14. Assadian, et. al. Suppression of surgeons’ bacterial hand flora during surgical procedures using a new antimicrobial surgical glove. Surg Infect. 2013; October 12. http://www.ncbi.nlm.nih.gov/pubmed/24116857. Accessed January 6, 2015.

15. Assadian, et. al. Suppression of surgeons’ bacterial hand flora during surgical procedures using a new antimicrobial surgical glove. Surg Infect. 2013; October 12. http://www.ncbi.nlm.nih.gov/pubmed/24116857. Accessed January 6, 2015.

16. Benson S, Novak D, Ogg M. Proper Use of Surgical N95 Respirators and Surgical Masks in the OR. AORN Journal. 2013 April; 97(4): 458.

17. Ball K. The hazards of surgical smoke. AANA Journal. 2001; 69(2): 125-132.


19. Beckers ASC Review. Understanding and Controlling the Hazards of Surgical Smoke. http://www.beckersasc.com/asc-accreditation-and-patient-safety/understanding-and-controlling-the-hazards-of-surgical-smoke.html. Accessed January 3, 2015.


21. AORN. Recommended Practices for Electrosurgery. In: Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO: Association of periOperative Registered Nurses; 2014: 133.

22. AORN. Recommended Practices for Laser Safety in Perioperative Practice Settings. In: Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO: Association of periOperative Registered Nurses; 2014: 146.

23. AORN. Recommended Practices for Sterile Technique. In: Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO: Association of periOperative Registered Nurses; 2014: 92.


25. AORN. Recommended Practices for Sterile Technique. In: Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO: Association of periOperative Registered Nurses; 2014: 91.

26. Pyrek K. Barrier-Protection Properties are key to Surgical Gown Performance. Surgi Strategies. 2004 October: 1-3.

27. AORN. Recommended Practices for Environmental Cleaning. In: Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO: Association of periOperative Registered Nurses; 2014: 260.

28. Spencer M, Edmiston C. The Role of the OR Environment in Preventing Surgical Site Infections. AORN Journal. 2014 December; 100(6): 605.

29. Spencer M, Edmiston C. The Role of the OR Environment in Preventing Surgical Site Infections. AORN Journal. 2014 December; 100(6): 605-606.

30. AORN. Recommended Practices for Sharps Safety. In: Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO: Association of periOperative Registered Nurses; 2014: 351.

31. The National Institute for Occupational Safety and Health (NIOSH). STOP STICKS CAMPAIGN. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html. Accessed January 6, 2015.

32. Cicconi L, Claypool M, Stevens W. Prevention of Transmissible Infections in the Perioperative Setting. AORN Journal. 2010 November; 92(5): 521.




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Infection Control in the Operating Room - RN CEU - … · INFECTION CONTROL IN THE OPERATING ROOM 2...

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