By Don Sadler
Despite technological advances and a growing awareness of the problem, infections remain a serious issue in many hospital operating rooms today.
According to the Centers for Disease Control Prevention(CDC), between five and 10 percent of all hospital patients become infected with a healthcare associated infection (HAI) each year. What’s more, as many as one out of every 25 hospital patients has an HAI on any given day.
Even worse, up to 75,000 patients die from HAIs annually. And HAIs cost hospitals between $26 billion and $33 billion annually while lengthening patients’ hospital stays by between seven and 11 days, according to the CDC.
Problems Associated With Infections
Infections can lead to a wide range of patient problems. These include delayed recoveries, extended hospital stays, readmissions (including to the ICU), additional surgeries and, in the worst-case scenario, death.
For hospitals, infections can lead to increased costs, reduced or denied reimbursements, government penalties, patient lawsuits and a tarnished reputation.
“OR staff are some of the most knowledgeable people about infections and the risk that patients face when undergoing a surgical procedure,” says Dr. Sarah Simmons, CIC, FAPIC, science director for Xenex.
“But they may not always understand the relationship between environmental contamination and the patient acquiring an infection,” Simmons adds.
Katherine Velez, PhD, scientist, Clorox Healthcare, says while most OR personnel are aware of the problem of infections, there are still awareness gaps around best practices for preventing infections and areas where current protocols are falling short.
“For example, while experts agree that thorough cleaning and disinfection of environmental surfaces is a critical step in limiting the spread of pathogens, studies suggest that only about 30 to 50 percent of surfaces are adequately cleaned and disinfected,” says Velez.
Velez believes that many factors contribute to gaps between best practice and actual practice.
“These range from pressure to reduce room turnaround times to failure to follow manufacturer’s recommendations for use and use of disinfectants with inadequate antimicrobial activity,” she says.
3M Medical Affairs Director Victor Miranda says that awareness of the problem of infections varies among OR personnel when it comes to knowledge of infections within their own facility.
“Sometimes that information is not shared with frontline staff, and sometimes it’s not even collected,” says Miranda.
“Overall, there is a basic understanding of the problem of infections,” he adds. “But to be truly effective, clinicians have to understand the details of their technique. This comes with education, practice and real-time feedback on how they’re doing.”
Common Types of Infection
According to Velez, surgical site infections (SSIs) account for approximately 23 percent of all HAIs. “The microorganism that most commonly causes SSIs is Staphylococcus aureus,” she says.
“SSIs are obviously devastating for patients,” says Simmons. “But they can cost health care facilities more than $50,000 in additional patient care per infection.”
CLABSI and CAUTI are also common infections in the OR, says Miranda. “The causes of SSIs are multi-factorial, but it all stems from bacterial contamination at the site of the surgical wound,” he says.
The sources of contamination are varied. “But they start with the patients themselves, primarily their skin,” says Miranda. “Infections can also come from clinicians if they haven’t appropriately disinfected or don’t wear the right protective equipment.”
Additionally, infections can come from the environment. “This includes the instruments and equipment used, as well as the beds and linens,” say Miranda. “Environmental contaminants can also be found in the water and the air.”
Simmons says that a lot of attention is being paid to environmental contamination as a cause of infections due to new research showing that a significant amount of contamination remains in the OR even after it has been cleaned with traditional cleaning methods.
“This research has established that the OR environment is far more contaminated than previously thought,” says Simmons. “This contamination is a cause of many infections.”
For example, she notes that studies have shown that contamination builds in the OR during the day even when it is cleaned between procedures. “Staphylococcus aureus, Enterococcus spp., Klebsiella spp. and Pseudomonas spp. are capable of living on OR surfaces anywhere from a couple of hours to more than 30 months,” says Simmons.
Preventing Patient Infections
According to Velez, up to 55 percent of SSIs could be prevented with current evidence-based practices designed to reduce the risk of infection.
The most recent CDC guidelines for the prevention of surgical site infections includes a number of evidence-based recommendations, including the following:
Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or non-antimicrobial) or an antiseptic agent on at least the night before the operative day.
Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines. It should be timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made.
Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated.
Topical antimicrobial agents should not be applied to the surgical incision.
During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL. Also, normothermia should be maintained in all patients.
Importance of Environmental Factors
Simmons believes the environment has long been underappreciated as a factor in SSIs.
“But this is changing given some of the exciting new studies that have been published,” she says.
For example, she points to one study that determined that hospitals using pulsed xenon ultraviolet (UV) after terminal cleanings of the OR have seen dramatic reductions in SSI rates.
In the study, a two-minute cycle of intense pulsed xenon UV light disinfection eliminated 72 percent more pathogens on high-touch OR surface areas than manual cleaning alone.
“The authors noted that the short room turnover time is feasible even for a busy OR,” says Simmons.
“Robots” make in-between case disinfection possible due to their instant-on capabilities, says Simmons. “In just 2 minutes, LightStrike robots are able to destroy microbial contamination on the OR and surgical instrument tables, as well as the anesthesia area at the patient’s head,” she says.
Velez stresses the role of environment in infection prevention.
“Establishing and maintaining thorough daily between-case and terminal cleaning and disinfecting procedures is a corvnerstone of any effective infection prevention and control program, she says.”
“Therefore, when selecting a surface disinfectant product, it’s important to consider factors such as relevant pathogen kill claims, contact times, ease-of-use and safety,” Velez adds.
Clorox Healthcare hydrogen peroxide cleaner disinfectants clean and disinfect in one step, says Velez.
“Contact times on most bacteria and viruses are between 30 seconds and one minute. This cuts down the time it takes to effectively address blood and bodily fluids, she says.”
Evidence-Based Practices are Key
In the end, Velez believes that OR personnel can make the biggest difference in infection prevention by focusing on proper implementation of evidence-based practices like those listed above. “In addition, they should actively partner with other patient safety stakeholders such as infection preventionists, environmental services teams and patients themselves,” says Valez.“The best results are achieved by creating a culture where patient safety is everyone’s responsibility.”