Operating Room and Burn Unit

INFECTION

CONTROL IN THE

OPERATING AND

DELIVERY ROOMSMa. Laarni D. Canceran, R.N.

Department Manager, St. Luke’s Medical Center- Global City

Basic Principles

Operating Room

Characteristic features:

• Patients are at risk due to exposed wound

• Natural body defenses are depressed

• Most patients are compromised

• Our goal is to decrease Surgical Site Infection

(SSI)

Operating Room

• Room needs to be as

clean as possible

• Houses special

equipments that can

be source of infection

• Set up should take

infection control

principles into account

Operating Room Environment

Operating Room Divisions

Design and Traffic Pattern – 3 zone concept Unrestricted Area which includes the patient reception

area, locker rooms, lounges and offices.

Semi-restricted Areas which include the storage areas for clean and sterile supplies, work areas for storage and processing of instruments and corridors to restricted areas of the suite. Traffic is limited to authorized personnel and patients. Personnel are required to wear gown and hair covering.

Restricted Area includes all areas where personnel are required to wear surgical masks and scrub attire at all times. It includes operating suites, clean core and scrub areas.

Relative humidity should be approximately

30%-60% in most ORs and in the PACU

Air-change rate in OR of 20 to 25 air

changes per hour (ACH)

Recommended temperatures for ORs are

between 68°F and 73°F (20-23°C) during

surgery , and recommendations for the post-

anesthesia care unit (PACU) are between 70°F

and 75°F (21-24°C)

American Society of Heating, Refrigerating and Air-Conditioning

Engineers, Inc. ASHRAE Journal Ventilation

New Ventilation Guidelines

For Health-Care Facilities

The IC Team should be notified

whenever the air delivery system

for the OT has been shut down

for maintenance or malfunction.

The IC team in conjunction with

facility engineers will assist with

determination of need for any

environmental monitoring needed

once the ventilation system is re-

established. At a minimum

positive pressure, inspection of

filters and air changes per hour

should be verified prior to use of

the affected OT after

interruption. The theatre should

be used only after clearance

from the IC team.

Handling of Infectious Patients

A room may be designated for "precaution cases"(infectious/communicable)” of an infectious patient.

If possible the room at the farthest corner of the area shall be assigned for the case, OR it will be scheduled last for

the day, provided it is not a stat case.

Environmental Cleaning

• The inanimate theatre environment should, under normal circumstances, have

a negligible contribution to the incidence of SSI.

• Floors and walls will never be sterile nor is there any point in trying to

achieve that level of cleaning. Floors are rapidly re-contaminated after

cleaning and disinfection and that they should be cleaned at the end of

each session/case. Disinfectant may not be required, except when cleaning

body fluid spillage.

Walls and ceilings are rarely heavily contaminated, cleaning them once a month is reasonable.

Correct site decontamination of blood and other potentially infectious materials should be in compliance with the standards.

Brooms of whatever materials and vacuum cleaners are not to be used; wet mops shall be used instead.

http://www.ems.org.eg/esic_home/data/giued_part2/Operating%20Theatre.pdf

Environmental Microbiologic sampling

Routine microbiologic sampling of the OT air or surfaces is not recommended

because the results obtained are only valid for the time period and for the

location sampled. Instead, such studies should be limited to recommendations

from the IC-Team, investigations of clusters or outbreaks of infection, or to

validate changes in the ventilation system (e.g. installation of new AHU).

http://www.ems.org.eg/esic_home/data/giued_part2/Operating%20Theatre.pdf

Environmental Decontamination

• Aerosolized Hydrogen Peroxide is a new

method of surface area decontamination that is recommended recently by Infection Control experts as an adjunct to our usual manual cleaning. This method eliminates the deficiencies and inconsistencies inherent in manual cleaning contributed by the human factor.

• UV light no-touch environmental disinfection using ultra violet technology

MOBILITY

The number of persons present during an operation must be as small as possible

Walking in and out during an operation must be kept to a minimum. People are the most important source of microorganisms in the OR. It is also certain that the number of microorganisms in the air increases as the numberof people and movements in OR increase. Walking in and out disturbs the flow of air, causing unwanted temperature fluctuations.

OR ATTIRE

• hair covering

• mask

• foot wear

• gloves

•A distinction must be made between the general clothing in the

OR complex(scrub suits) and the sterile clothing to be worn over it

by the surgical team immediately surrounding the operating table

•No wrist watches, jewellery or piercings may be worn

•In the OR complex, operating room clothing is worn. This clothing is not worn outside

the OR.

•In order to maintain the zone system in practice, it is important that everyone complies

with it.

•When someone has to leave the OR complex for a short time, for instance for brief

administrative activities, a white coat or other item of protective clothing be worn over

the scrub suit. This does not apply when examination or treatment of a patient must

take place in the ward.

•Between operations, clothing is changed when it becomes dirty or wet

•Clean operating room clothing must be put on each day

Double Gloving

• The transmission of HBV and HCV from surgeon to patient and vice versa has occurred in the absence of breaks in techniqueand with apparently intact gloves (Davis 2001). Even the best quality, new latex rubber surgical gloves may leak up to 4% of the time.

• Single gloves had a blood-hand contact rate of 14% while surgeons wearing double gloves had only a rate of 5% (Tokarset al 1995; Tokars et al 1992)

Guidelines for Double Gloving

• The procedure involves coming in contact with large amounts of blood or other body fluids (e.g., vaginal deliveries and cesarean sections).

• Orthopedic procedures in which sharp bone fragments, wire sutures and other sharps are likely to be encountered.

• Surgical gloves are reused. (The possibility of inapparent holes or perforations in any type of reprocessed glove is higher than with new gloves.)

Surgical handwash or surgical handrub must be

performed preoperatively by surgical personnel

to eliminate transient and reduce resident hand

flora.

Pre-operative Hand Hygiene

Brushless Surgical Hand Scrub

Name ___________________________ Sex_______ Form Control #: _____________Service provider : Consultant/ Surgeon Resident Nurse Intern Surgical Technician

Department : GS Ortho ENT Uro Others, please specify: ____________________•Purpose

•To decrease the number of resident and transient microorganisms in the skin.•To keep the population of microorganisms minimal during the surgical procedure by suppression of growth•To reduce the hazard of microbial contamination of the surgical wound •Materials

Antiseptic rub, face mask, cap, eye goggles and nail pick

Surgical Scrub Procedure

Activity Done Not Done Remarks

I. Preparation for Surgical Rub Procedure

General Preparation:

•Skin and nails should be kept clean and in good healthy condition.

•Fingernails should not extend beyond fingertips to avoid glove puncture.

•Fingernail polish should not be worn.

•Artificial materials must not cover natural fingernails.

•Remove all jewelry.

II. Preparation Immediately before Surgical Rub

• Inspect the hands for cuts and abrasions.

• Be sure all hair is covered by headgear/bouffant cap.

• Adjust disposable mask snugly and comfortably over nose and mouth.

• Wear eye goggles if needed.

III. Surgical Rub Procedure

1Wash hands and forearms with antimicrobial soap (such as chlorhexidine or approved alternative soap) and running water

immediately before beginning the surgical hand scrub.

2 Clean the subungual areas of both hands under running water using disposable nail cleaner

3aApply 2-3 ml (6 drops) of antiseptic soap from the dispenser to the hands. (or follow manufacturer’s recommendation)

3b

Wash the hands and forearms for 3 – 6 minutes including at least 30 strokes each hand. Pay particular attention to the fingers,

cuticles and interdigital spaces and working the antimicrobial soap to four sides of the forearm. Avoid splashing your surgical attire.

4

Rinse thoroughly hands and forearms under running water, holding hands higher than elbows and away from surgical attire,

allowing water to drip from flexed elbows.

5Dry hands and arms with sterile linen before donning sterile gloves and gown. (Double glove if with cuts or abrasions.)

6

Repeat the above procedure on the following instances:

Relief during handing-off process between scrub personnel.

To start another OR procedure.

To return to the sterile field when you already scrubbed out.

Waterless Surgical Hand Scrub

Visitors

• Visitors to the operating room include visiting doctors from other wards, parents of young children while thay are brought to the OR, partners who attend Cesarean, and technicians

• The number of persons present during an operation must be kept to a minimum. Everyone must be aware of the risks of infections and must maintain the necessary discipline.

• The number of movements must be kept to a minimum.

• Visitors who are present during the operation must wear the standard surgical clothing. For a brief visit (less than or equal to 15mins) overalls with cuffs around the arms and ankles will suffice. In addition, disposable masks and hair covers are worn.

For longer visits (more than 15mins) visitors must follow the clothes changing procedure for the staff

Patients

Patient's Clothing

•The patient wears operating room clothing.

•The patient does not wear shoes.

•In the OR complex, the patient wears surgical

cap.

Transport to and across the transfer area

Transport of the patient to operating room can take place in three ways:

1. On the day of the operation, either in the ward or at the boundary of

the operating area, the patient is lifted onto a clean bed with clean

bedding, which is wheeled next to the operating table. After the

operation, this bed is used again to transport the patient to the recovery

room or the nursing ward.

2. The patient is wheeled to the boundary of the operating room area in

his/her own bed. There, the patient is lifted onto an operating surface on

wheels or a mobilift, after which it is wheeled into the operating room.

After the operation the patient is lifted from this system onto a bed with

clean bedding in the recovery room

Transport to and across the transfer area

3. If it is not possible to lift the patient onto a clean bed or an

operating surface on wheels outside the operating room(for

example if the patient is in a traction bed), an exception can

be made and the patient can be wheeled to the operating

table on his/her own "dirty" bed from the nursing ward. In

that case, the bed must be made up with clean bedding in the

nursing ward and domestically cleaned insofar as possible.

•The risk of infection is the same in every part of the transfer

area. No link has been demonstrated between one of the

above-mentioned systems of transport and the chance of

infection. The choice between these three methods can be

based on practical and economic considerations.

•The bed a patient was lying in his/her ward may only be

wheeled to the operating table in exceptional cases.

SSI Prevention

Bundles of Care in SSI

Pre-Operative Showers

• 4% Chlorhexidine

solution used,

preferred night before

and morning of

surgery

• Cochrane review,

showed no clear

evidence or advantage

• Pre-operative shower

reduces SSIs

Re-use of Single use Items

• Big issue

• Little available evidence of harm from reuse, FDA says oversight is warranted

• Problems involved- thousands of equipment and supplies, re-processing differs, need for authority, issue of efficacy

• Single-use equipment

Reuse of disposable/ single-use equipment is not recommended. Chemical disinfection and sterilization processes may damage or weaken the integrity of single-use items and make them unsafe for use.

Centralized Sterilization Area

• Training

INFECTION CONTROL IN THE

BURN UNITMa. Laarni D. Canceran, R.N.

Department Manager, St. Luke’s Medical Center- Global City

Burn Wound Patient

• Among patients at highest risk for hospital-

acquired infections

• Have lost a portion of their integument that

would ordinarily be a strong barrier to

invasion of microorganisms

• Necrotic tissue in the burn eschar– combined

with the presence of serum CHON, provides

a rich culture for MOs

Infections

• Most common cause of death in burn patients

• Most common site of infection are the burn wound

and lungs

• May also initiate a septic response accompanied

by multi-organ failure

Types of Burns

• Majority of Burns– caused by thermal injury

• Adults– flame burns

• Children– scalding and flames

• Others– chemical, electrical, fire cracker injuries

Epidemiology of Burn Wounds

The development of infection depends on the

presence of three conditions:

• Source of organisms-

• A. Burn wound of patient

• B. Environment

• C. Endogenous flora

• Mode of transmission

• Susceptibility of the patient.

Sites of Environmental Contamination in

Burn Care Facilities

Site Microorganism

Hydrotherapy equipment P. Aeruginosa, E. Cloacae

Sink faucets P. Aeruginosa

Faucet handles P. Aeruginosa

Bars of soap P. Aeruginosa

Towel racks P. Aeruginosa

Sink basins P. Aeruginosa

Transportation equipment P. Aeruginosa

Water supply P. Aeruginosa

Sink drains P. Aeruginosa

Sites of Environmental Contamination in

Burn Care Facilities

Site Microorganism

Nebulizer/humidifier water P. Aeruginosa

Counter surface P. Aeruginosa

Bed Rails P. Aeruginosa

Air Providencia stuartii

Chair (hydrotherapy area) E. cloacae

Filling hose E. cloacae

Matresses Acinetobacter calcoaceticus

P. Aeruginosa

Mode of Transmission

• Contact-- either via the hands of the

personnel caring for the patient or from

contact with inappropriately decontaminated

equipment.

• Droplet spread.

• Airborne spread.

In general, the larger the burn injury, the greater the

volume of organisms that will be dispersed into the

environment from the patient.

Patient Susceptibility

What Lowers Physical Defenses:

• Invasive devices, such as endotracheal tubes,

• Intravascular catheters and urinary catheters,

Bypass the body’s normal defense mechanisms..

Mode of Transmission Risk Factors

• Duration of hospitalization

• Burn wound size

• Transfusions

• Resistance of microorganisms to topical

antibiotic agents

• Resistance of microorganism to systemically

administered antimicrobial agents

Characteristics of Burn Wound Infection

• Focal gangrene that spreads throughout the wound

• Conversion of a partial-thickness wound to a full-thickness wound

• Hemorrhagic discoloration of sub-eschar tissue

• Focal, multi-focal or generalized dark brown, black or violaceous discoloration

• Changes in the unburned skin at the wound margins char. by edema and violaceousdiscoloration

Burn Wound Infection

Definitions for Burn Wound Infections

Burn infections must meet the following criteria:

Criterion 1: Patient has a change in burn wound

appearance or character, such as dark brown,

black or violaceous discoloration of the eschar,

or edema at wound margin

And Histologic examination of burn biopsy

shows invasion of organisms into adjacent

viable tissue



Criterion 2: Patient has a change in burn wound

appearance or character, such as dark brown,

black or violaceous discoloration of the eschar,

or edema at wound margin

And At least one of the following:

a. Organisms cultured from blood in the absence of other

identifiable infection

b. Isolation of herpes simplex virus in biopsies



Criterion 3: Patient w/ a burn has at least two of the following signs or symptoms with no other recognized cause: fever (>38˚C) or hypothermia (<36 ˚C), hypotension, oliguria (<2oml/hr), hyperglycemia at previously tolerated level of dietary carbohydrate, or mental confusion

And at least one of the following:a. Histo exam of burn biopsy shows invasion of organisms

into adjacent viable tissues

b. Organisms cultured from blood

c. Isolation of herpes simplex virus in biopsies

REMINDERS:

• Purulence alone at the burn wound site is not adequate for the diagnosis of burn infection; such purulence may reflect incomplete wound care.

• Fever alone in a burn patient is not adequate for the diagnosis of a burn infection because fever may be the result of tissue trauma or the patient may have an infection at another site.

Prevention and Control

There is evidence that improvements in the

prevention and control of infections in burn

patients has led to improvements in patient

survival

BURN WOUND INFECTION CONTROL

MEASURES

Goals:

• Control the transfer of endogenous organisms to

the burn sites

• Prevent the transfer of exogenous organisms from

other persons to patients

GENERAL MEASURES

Ward setting

• Burn cases should be accommodated in Burns Unit

• Burns Unit must be physically separated from other areas

• Single rooms should be provided for isolation

Ventilation

• Filtered air at positive pressure into individual rooms,

extracted in the corridor outside each room

• Air from ventilated rooms should be extracted to the

exterior

• No direct airflow between Burns Unit and other areas

GENERAL MEASURES

Environmental hygiene

• Daily mopping of furniture, bedside lamps, door

handles or knobs

• No sharing of wash bowls, or furniture (e.g., beds

and chairs)

• Restrict stuffed toys and items which cannot be

effectively decontaminated

• Minimize linen agitation

GENERAL MEASURES

Visitors and Traffic Control

• Orient all visitors to burn unit infection control

practices ( i.e. Hand washing, gowning and

isolation precautions)

• Limit amount of visitors present at any one time

• Screen visitors for infection and restrict if present

• Monitor visitors for compliance with infection

control practices

GENERAL MEASURES

Hand Washing

• Hand washing should be done before and after

each patient contact with antiseptic .Hand washing

sinks should be conveniently accessed

• Antiseptic hand rub is an alternative for hands

without visible dirt


Use of Barrier Techniques

- Used to prevent contact transmission ofmicroorganisms from patient to patient viacontaminated hands and clothing of HCW who providedirect care

• Use of gloves and gown made of impermeablematerial

• Washing of hands before donning of gloves and afterremoval of gloves– need not be sterile for routine non-invasive patient care

• If sink is not directly accessible, alcohol should alwaysbe at bedside (this is a necessity)

On Gowns and Aprons...

• Protective gown or apron is worn to prevent soiling

and in-apparent contamination of personal

uniform

• Should be replaced in-between patients

On gloving...

• Gloves should be worn when contact withblood, body fluids, secretions and excretions

• Gloves(sterile) should be worn for burnwound dressing

• Gloves should be changed whencontaminated with secretions or excretionsfrom one site prior to contact with another site,even if care of the patient is not completed

• Hand washing after removing gloves


Prevention of Cross-Contamination From Inanimate Surfaces and Food

• Each patient should be assigned his or her ownstethoscope, blood pressure cuff, box of cleandisposable gloves and container(s) of topicalantimicrobial agent

• Items of equipment that must be shared betweenpatients should be thoroughly cleaned and disinfectedbetween patients

• Covers on mattresses should be inspected betweenpatients and mattresses with damaged covers shouldnot be used


Prevention of Cross-Contamination From

Inanimate Surfaces and Food

• Raw vegetables have been shown to be a

source of P. Aeruginosa microorganisms that

cause burn wound infections. Patients, as

much as possible should not be fed raw fruits

and vegetables


Prevention of Cross-Contamination From Convalescent Patients

• Convalescent burn patients may be a reservoir ofmicroorganisms for cross-contamination andinfection of burn patients in the acute phase of care

• They are least likely to become infected but may beignored as reservoir for patients in intensive care

• Ideally, there should be a separate area forconvalescent patients and nursing staff shouldhandle patients without crossover between thesetwo patient care areas


Hydrotherapy

• Also considers the use of barrier techniques but is aseparate entity in the prevention and control ofinfection because of its emphasis on cross-contamination

• Hydrotherapy is provided in a common area usingcommon equipment and involves exposure to water

• Effective decontamination of complex equipmentbetween patients in a limited period may be a majorchallenge to burn care personnel

• Always remember that water contacts the entire burnwounds surface

BATHING

AREA


Topical Antimicrobial Agents

Daily Wound Care

• Aseptic technique for wound manipulation and

dressing

• All dressing should preferably be done on bedside

• Expose, clean and re-wrap less infected areas first


Topical Antimicrobial Agents

• Applied to the burn wound surface to diminishcolonization and multiplication ofmicroorganisms on the surface of the wound

• Most commonly used agents:1. Silver sulfadiazine

2. Cerium-nitrate-silver-sulfadiazine

• Microbial resistance has been reported

• Administer topical antimicrobial agentsaseptically


Systemic Antimicrobial Agents

• Extensive use frequently leads to selection of

resistant microorganisms

• Continued use of the same antibiotics provides a

selective advantage for these microorganisms and

are able to proliferate and displace susceptible

microorganisms in and on burn wounds

• Continued colonization may lead to an outbreak

• Appropriate use of antibiotics– use in clearly

indicated situations with appropriate basis

ANTIMICROBIALS AND BURNS

• The burn wound will always be colonized with

organisms until wound closure is achieved and

administration of systemic antimicrobials will

not eliminate this colonization but rather

promote emergence of resistant organisms.

• If antimicrobial therapy is indicated to treat a

specific infection, it should be tailored to the

specific susceptibility patterns of the organisms,

ANTIMICROBIALS AND BURNS

• Empiric antimicrobial therapy to treat fever

should be strongly discouraged because burn

patients often have fever secondary to the

systemic inflammatory response to burn injury.

• Prophylactic antimicrobial therapy is

recommended only for coverage of the

immediate peri-operative period surrounding

excision or grafting of the burn wound. This

should be discontinued within 24 hours.

CULTURING

Why?

• To provide early identification of organisms colonizing the

wound

• To monitor the effectiveness of current wound treatment

• To guide peri-operative or empiric antibiotic therapy

• To detect any cross-colonizations which occur quickly so that

further transmission can be prevented.

When?

• when the patient is admitted and at least weekly until the

wound is closed.

Burn Wound Infection Prevention and Control

Summary of Approaches:

• Use of barrier techniques

• Prevention of cross-contamination from inanimate

surfaces and food

• Prevention of cross-contamination from convalescent

patients

• Hydrotherapy

• Application of topical anti-microbial agents

• Appropriate use of systemically administered

antimicrobial agents

Acknowledgement

Acknowledgement:

Mary Joann Foronda, RN

ICN, Jose Reyes Memorial Medical Center

St. Luke's Medical Center's legacy of excellence surpasses all expectations. For

over a century, St. Luke's superior brand of healthcare service has made it truly

world class.

With astounding success anchored on five pillars of expertise-expert doctors,

state-of-the-art technology, guaranteed patient safety, excellent success rate

and passionate customer service, St Luke's Medical Center is the first hospital in

the country to be accredited by the Joint Commission International(JCI).

Thank you!

Operating Room and Burn Unit

Healthcare

Transcript of Operating Room and Burn Unit