By Deanna Scatena, RN
Ask surgical staff about their role in infection prevention and they will undoubtedly speak about hand hygiene, gowning and gloving, aseptic technique, and maintaining a sterile field. They will possibly mention disinfection and sterilization of instruments and hazardous waste management. It is far less likely that they will talk about scanning the surgical environment for imperfections in floor, wall and ceiling surfaces or checking equipment for rust. In surgical practice, broadening awareness of environmental impacts on infection risk can be a game-changer.
Understanding the envelope
Infection prevention encompasses the physical environment of the operating room and other sterile areas. Failing to engage those who provide surgical patient care in regular surveillance of the space in which they perform surgery represents a missed opportunity to catch issues early.
Upon entering the pre-operative area and the OR, clinicians should take steps to make a deliberate scan of the space from the perimeter to the surgical table. Look at:
- Doors and door frames which should be intact and well-fit.
- Scrub sinks which should be intact and free from rust.
- Ceiling tiles, for appropriately seated, unchipped, and stain- and moisture-free condition.
- Walls that are free from divots and chipped paint.
- Floors that are intact without visible seam separation.
- Horizontal surfaces that are free from dust, soil and rust.
- Medical equipment must be similarly free from dust, debris, rust, tape and its residue.
- Ceiling lamps and other lighting must be intact, secure and clean with no dust, insects, etc.
- Surgical table pads must be intact, without tears or taped repairs.
Additionally, clinical staff should, at minimum, be aware of expectations for areas for decontamination, cleaning and/or sterilizing equipment.
Cleaning and/or sterilizing equipment and supplies require adequate space, a sink that meets nationally recognized requirements for standard of practice, and air pressure that maintains flow from clean areas to dirty with ASHRAE-defined minimum air exchange rates specific to functional use of the spaces.
ORs are subject to temperature and humidity control which plays a part in infection prevention. Humidity levels in accordance with nationally recognized standards defined by major associations such as ASHRAE and AORN are imperative to maintain the integrity of sterile instruments and equipment and to reduce the risk of bacterial growth. Daily logs of temperature and humidity for anesthetizing locations should be checked against acceptable parameters and, if out of range, immediate corrective action is needed. Furthermore, room turnover, daily terminal cleaning and cycle cleaning should be performed in accordance with a policy that defines collaboration between surgical services, infection prevention and environmental services and is written to align with nationally recognized standards of practice. Written procedures identify detergents and solutions, their preparation in accordance with manufacturer’s instructions, their labeling and use following EPA approved guidelines.
Danger of rust in the OR
Rust is a silent risk in the operating room. Rusty objects increase the potential for healthcare-acquired infections (HAIs) because rust produces irregularities in surfaces making appropriate cleaning impossible thereby creating an environment for potentially dangerous bacteria. Rust found on surgical instruments, medical equipment and other objects during an accreditation or state survey can be a serious finding that requires immediate remediation. Medical equipment includes castors, IV poles, instruments, cabinets, surgical tables and carts. Rust is most commonly found on equipment resting on or close to the floor due to repeated exposure to moisture from cleaning. Nickel plated castors on moveable medical equipment are especially susceptible to rust and should be checked frequently and replaced when necessary.
Multidisciplinary Coordination Supports Success
Just as multidisciplinary patient care promotes improved outcomes, a collaborative relationship between the infection preventionist and the perioperative team is crucial to surgical patient safety.
Accreditation standards set the expectation that an infection preventionist is actively involved in policy development and ongoing oversight of practices in surgical areas that could potentially impact infection rates. Infection preventionists play a key role in integrating the infection prevention and control plan for each department into an overall program. They are also critical to aligning IPC organization-wide with the quality assurance and performance improvement (QAPI) program. CMS recognizes the importance of this role by requiring that an infection preventionist hold responsibility for infection surveillance and reporting, and for triggering surgical site infection (SSI) review by a multidisciplinary team as needed.
The entire perioperative team including leadership, surgeons, circulating and scrub nurses, and surgical assists is crucial to delivering quality care. Building awareness for clinical staff on all infection risks in the OR means many more eyes on compliance with best practice. Clinical staff may not have inherent knowledge of all risks present in the physical environment. Once established, this awareness creates an opportunity for more informed surveillance by individuals who work in the environment daily. In the best-case scenario, stained ceiling tiles, compromised surgical table pads, damaged wall or flooring surfaces, and equipment with rust is observed, reported, and replaced quickly.
– Deanna Scatena is the associate program director for acute care and critical access hospital accreditation at ACHC. Scatena has worked in accreditation since 2017, guiding product development for specialty care certification and providing standards interpretation before moving into her current leadership role. Her passion for quality measurement and outcome improvement was nurtured in a role within a major payor organization where she provided oversight of clinical operations for government programs.
