Surgical
Asepsis and
Infection
Prevention
Kathleen McMullen,
MPH CIC
Objectives
 At
the completion of this activity, the
learner should be able to:



Use the OR observation tool presented as a
template
Utilize ideas offered to standardize
feedback of OR observations
Explain the idea of a one-page dashboard
and compose a similar document for their
administration
Items for Discussion
 OR




Observations
Methods for completion
Guidelines referenced (slides with AORN
reference in the footnote)
Feedback formats
Thoughts on increasing compliance
Background
 Barnes


Jewish Hospital
1250 bed tertiary care hospital associated
with Washington University School of
Medicine
St. Louis, Missouri
 Peri-operative


services
5 suites of operating rooms, 1 ambulatory
surgery center (66 total operating rooms)
40,000 inpatient and outpatient procedures
in 2013
Background
 Hospital
Epidemiology and Infection
Prevention


9 Infection Preventionists (7 cover most of
the OR)
Surgical site infection (SSI) surveillance for 11
operative procedures at the hospital; all
procedures at the ASC
First Meetings: Building
Relationships
 General





tips for building relationships
Be prepared
Allow them to make decisions
Act as a consultant, not the police
Pay attention to the details!
It takes time
Operating Room Observations
 Includes


2 main sections
Surgical attire – based solely on
perioperative services’ surgical attire policy
(AORN guidance)
IP Technique
 General
 Site
IP Principles
Prep
 Anesthesiology
 Environment
Operating Room Observations
 Full



observations
All questions answered
Takes around 1-2 hours to complete
Done twice a month for each OR suite
 Partial



observations
Surgical attire and environment only
Takes about 10 minutes to complete
Done 4 times a month per suite
What should I audit?
 Many
AORN standards
 Biggest bang:



Its likely to have variety
Don’t have forcing functions
Smaller, non-obvious errors
OR Observation Tool
 Surgical

Attire
Include all personnel who enter the OR
room at any time during the observation
 Main
personnel: nursing, surgeons, anesthesia,
anesthesia techs and vendors


Give the number compliant over the
number observed
Observe scrubs, mask, hat, eyewear,
jewelry, fingernails/hands and surgical scrub
Surgical Attire
 Human
body is a major source of
microbial contamination and transmission
of microbes


Promote worker safety
Promote a high level of cleanliness and
hygiene within the perioperative
environment
 Not
intended to address sterile surgical
attire worn at the surgical field or all PPE
AORN Perioperative Standards and Recommended Practices, 2014 Edition
Surgical Attire – What to wear
 Helps
contain shedding of squamous
epithelial cells and bacteria from the skin

The material used and weave of the cloth is
important to consider to maximize
protection against shedding
 Wearing
clean clothes into the OR ensures
that additional contaminants aren’t shed
in to the environment
AORN Perioperative Standards and Recommended Practices, 2014 Edition
Surgical Attire – Where to wear it
 Don
if entering Semirestricted or Restricted
areas of the surgical setting
 Remove when leaving the facility

Even if traveling between campuses
AORN Perioperative Standards and Recommended Practices, 2014 Edition
OR observation – Surgical attire




Facility approved scrubs not visibly soiled
Scrub top should be secured at the waist, tucked
in or fit close to the body
Attire made of fleece should not be worn
Jackets



Buttoned or snapped closed, not tied around the
waist
Disposable jackets shall be worn over reusable
jackets
Personal clothing is to be contained within the
surgical attire


Crew neck T-shirts, v-neck T-shirts and tank top
type shirts are acceptable
T-shirt sleeves and tails are not to extend beyond
the surgical attire
Surgical Attire – Jewelry



Jewelry that cannot be contained or confined
within the surgical attire should not be worn
Necklaces on the skin may contaminate the front
of the sterile gown
Wearing finger rings, nose rings, and ear piercings
increases bacterial counts on skin surfaces both
when the jewelry is in place and after removal.


Earrings had bacterial counts more than 21 times
higher beneath the earrings than on the surface of
the earrings.
Bacterial counts were nine times greater on the
skin beneath finger and nose rings than on the
rings themselves
AORN Perioperative Standards and Recommended Practices, 2014 Edition
OR observation – Jewelry
 Non-scrubbed





personnel
Up to three rings on one finger
1 watch
1 necklace
No bracelets
Earrings must be confined within surgical
headgear
 Scrubbed
personnel: all jewelry removed
or confined within attire/headgear
Surgical Attire – Head covers
 All
personnel should cover head and
facial hair, including sideburns and the
nape of the neck, when in the
semirestricted and restricted areas
 Head coverings contain skin squames
and hair shed from the scalp
AORN Perioperative Standards and Recommended Practices, 2014 Edition
OR observation – Head covers
 Should
cover head and facial hair,
including sideburns and necklines
 Disposable bouffant hats should be worn
over reusable head gear
 Skull caps may not be worn if hair touches
shirt collar of a collared shirt
Surgical Attire – Masks


All individuals entering the restricted areas
should wear a surgical mask when open
sterile supplies and equipment are present
A surgical mask is worn to protect the health
care provider from contact with infectious
material from the patient (e.g., respiratory
secretions, sprays of blood or body fluids) and
to protect the patient from exposure to
infectious agents carried in the provider’s
mouth or nose
AORN Perioperative Standards and Recommended Practices, 2014 Edition
OR observation – Masks
 Should
be worn when open sterile
supplies, sterile equipment and scrubbed
personal are present
 Should fully cover mouth and nose and
be secured in a manner that prevents
venting
Surgical Attire – Eye wear
 Health
care personnel must wear eye
protection when splashes, spray, spatter,
or droplets of blood or other potentially
infectious materials can be reasonably
anticipated
 Appropriate eye protection includes
goggles, face shields, and full-face
respirators

Prescription eyeglasses and contact lenses
are not considered eye protection
AORN Perioperative Standards and Recommended Practices, 2014 Edition
OR observation – Eye wear
 Must
be worn when a procedure is in
progress
 Acceptable eyewear includes reusable or
disposable goggles, masks with eye
shields and personal glasses equipped
with side shields
 Eyewear should be put on before surgical
skin prep starts; in scrubbed personnel, it
should be put on prior to the scrubbing
process
Surgical Attire – Fingernails
 Health
care personnel should keep
natural fingernails no more than onequarter inch long

Long fingernails pose a risk of developing
tears in gloves or injuring a patient during
positioning and caring for the patient
 Chipped
removed

fingernail polish should be
May harbor large numbers of pathogens
AORN Perioperative Standards and Recommended Practices, 2014 Edition
OR observation – Fingernails
 Must
be clean, short (not to extend past
fingertip), natural and healthy
 Nail polish should not be chipped
Surgical Hand Scrub
 Surgical
hand scrub should be performed
by health care personnel before donning
sterile gloves
 Use of either an antimicrobial surgical
scrub agent intended for surgical hand
antisepsis or an alcohol-based antiseptic
surgical hand rub

Three-minute surgical hand scrubs are as
effective as five-minute
AORN Perioperative Standards and Recommended Practices, 2014 Edition
OR observation – Surgical Hand
Scrub
 Masks
should be worn
 Method of scrub


Traditional scrub – minimum 3 minutes,
maintain cleanliness after scrub, while
drying hands
Avaguard use – if hands appear socially
clean, can be first scrub of the day
OR Observation Tool
 Techniques:
groups of yes/no questions
(yes is always the “compliant” answer)





General Infection Prevention Principles
Site Prep
Medications/Solutions
Anesthesia
Environment
General Infection Prevention
 Hand


hygiene
Glove change between dirty and clean
procedures
Hand hygiene when gloves are changed or
removed
 Attention


to the sterile field
Non-scrubbed individuals always attentive
to the sterile field
Sterile individuals always face the sterile
field, remain sterile during X-rays
General Infection Prevention
 OR
door remained closed except when
used for entry/exit
 Instrument used:


Were instrument tray filters checked prior to
placing instruments on the sterile field? (ie –
filter is present, filter does not have
holes/tears)
All items sterilized by traditional methods
(no immediate use or flash sterilization)
General Infection Prevention
 Members
of the surgical team appear to
be healthy (no coughing, sneezing, etc.)
 Solutions used:


Solutions supplied in single-use containers
Solutions used are liquid or solid (i.e. - no
sprays; exclude rectal cases)
 Vendors
use a pointer to indicate
instruments, etc .on the scrub tables
Site Prep
 Operative
site cleaned prior to scrub if
necessary (visible soil, trauma, etc.)
 Hair removal done with clippers and
contamination minimized
 Perineal area prepped or covered, if
applicable
 Surgical site prep used, application done
correctly, single use prep used, prep
allowed to air dry
Anesthesia
 Alcohol
foam available for use in their
area
 Central lines


Placed with sterile technique
Sterile dressing applied after
Anesthesia
 IV


therapy
Needleless connectors prepped prior to
injecting
Stopcocks capped between use
 Hand


Hygiene
Gloves worn to start IV, intubate and
measure urine
Gloves removed and hand hygiene
performed after these tasks
Anesthesia - Components with
Caveats/Removed
 Caveats:

Needleless connectors: only need to be
prepped with alcohol if a syringe or cap
was not in place prior to the injection
 Removed:


Drape between anesthesia and patient
above level of anesthesiologist’s nose and
mouth
Do the anesthesia personnel lean over
drape during a procedure
Environment
 Free
of visible dust
 Surfaces cleaned correctly between
cases
 Floor mopped correctly between cases
 Non-essential items covered if stored in
OR
Environment – Cleaning details
 Between



Cases:
Break down OR table and thoroughly
disinfect both sides of mattress, all hard
surfaces and base, all to air dry
Disinfect all equipment, including surgical
lights, light switches, door handles,
telephones, mayo stands and tables
Single use disposable cleaning cloths used;
one for the table, several others for the rest
of the room
Environment – Cleaning details
 Floor



Mopping:
In this order: Floor within operating field (use
floor scrubber if heavily soiled), around and
under OR table (table should be moved),
then outside operating field
For heavily soiled areas use disposable mop
head
Mop away wheel tracks/foot prints as
exiting the room
Additional Counts
 Number
of personnel in room not directly
involved in case
 Number of times door opened in a 10 min
period while sterile packs were open
 Number of times door opened in a 10 min
period while incision was open
Still Building the Relationship
 Allow
stakeholders to make decisions
 Deliver on your promises in a timely
fashion
Methods of Observing



IP wants to build a collegial relationship with
the OR staff and not be viewed as “police"
Deficiencies found during the observations
should be used to educate all members of
the suite and not result in any punitive action
In response to management feedback, OR
observations include a room number and
time of observation
Methods of Observing


Observation tool shared with staff so they are
aware of what is being observed; feedback
they offer is appreciated
IP introduces themselves as they enter the OR


Remind staff that these are routine observations
Ask staff if they have any additional concerns to
share

Ensure you remember to follow-up on those
concerns!
Individual Observation
Feedback
 Completed
observation
 Emailed to:




within 2 days of the
OR nurse manager and resource nurse
Anesthesia educator
Anesthesia tech manager
Environmental services supervisor
OR Observation Dashboard


Completed monthly after all observations are
finished
Emailed to Peri-operative Services
Performance Improvement Committee which
includes:





OR nurse managers
OR educators
Director of Peri-operative Services
Chief of Surgical Services
Chief of Anesthesiology
Feedback of Observations
 At
the time of observation (anesthesiology
only)

Verbal can be problematic:
 Patients
may be awake
 Providers may not take criticism well

Slips of paper with results seem to work
better
Example – Anes Feedback
Maintaining the Relationship

Stay in touch by celebrating achievements





The more conversations, the closer the
connection
Priorities and areas of interest ebb and flow
Make it a standing meeting
Continue to stress that you are here to
consult, help
Deliver on your promises in a timely fashion
How to deal with setbacks
 Leadership
change (sometimes you have
to start all over!)
 Bad data
 Communication breakdowns
 Poor compliance
Educational Efforts
 Annual


clinical skills days
Completed several times a year to catch
all staff
In person, hands on, small class size to
facilitate discussions
 Newsletter

articles
More frequent quick blurbs with scientific or
regulatory reasons for IP requirements
SURGICAL MASKS
INCORRECT

CORRECT


Masks should be worn
whenever sterile supplies
and equipment are open
Mask straps should be
tied around the top of the
head and at the neck
Masks should fully
cover the nose and
mouth and be secured
in a manner that
prevents venting
SURGICAL EYEWEAR
INCORRECT

CORRECT


Eyewear should be
donned before an
incision is made, and
worn throughout the
entirety of the operative
procedure
Acceptable eyewear
includes reusable or
disposable goggles, and
masks with eye shields

Eyewear protects
healthcare workers from
splashes and sprays of
infectious or harmful
material to the eyes
Personal glasses alone
(without side pieces) are
NOT acceptable
eyewear
SURGICAL HEAD COVERING
INCORRECT


CORRECT


Disposable bouffant
and hood style covers
are preferred
Disposable hats should
be worn over reusable
cloth headgear when
entering restricted and
semi-restricted areas
Personnel should cover
head and facial hair,
including sideburns
and necklines
Single use headgear
should be removed
and discarded in a
designated receptacle
as soon as possible
after daily use
HAND HYGIENE
INCORRECT

CORRECT


Perform hand hygiene
after glove removal
Gloves should always
be worn when:
Emptying urine
containers, intubating,
starting IVs, drawing
blood from any line,
and suctioning

Glove change and
hand hygiene should
be performed
between dirty and
clean tasks
Hand hygiene should
be performed before
donning sterile gloves
and after any glove
removal
Newsletter Articles
 Common
errors
 CAUTI and CLABSI best practices
 Nail hygiene
 Process changes with OR observations
and feedback
 New cleaner used in ORs
And the journey continues…
 Building
the business case for eyewear
 Need for contact isolation in the OR
 Use of personal bookbags
Eyewear
 Compliance
continues to be a problem
 Need to sell the need for eyewear as
protection for the wearer
 Developing education with real-life
examples of close-call splashes and
bloodborne pathogen exposure data
Contact Isolation in the OR
 All
non-scrubbed personnel should wear
gowns and gloves for contact with the
patient or the patient’s stretcher

IV pumps, stethoscopes and anesthesia
machines should be considered potentially
contaminated and gloves should be worn
when in contact with them
 At
the end of the case or when the
equipment is no longer needed, it should
be cleaned and disinfected
Contact Isolation and Transport

Gloves and gowns do not need to be worn
during transport unless activities are in
progress that result in contact with the patient
or bed


If so, a “clean” healthcare worker who is not
having contact with the patient (no
gown/gloves), should be designated to touch
surfaces
After delivery to the patient room or the PACU,
gloves and gowns removed, hand hygiene
performed
AORN - Personal Bags

Fanny packs, backpacks, and briefcases
should not be taken into the semirestricted or
restricted areas of the perioperative suite.


Constructed of porous materials, may be
difficult to clean or disinfect adequately and
may harbor pathogens, dust, and bacteria.
The type of environmental surface and its ability
to support microbial growth will influence
microbial carriage.
AORN Perioperative Standards and Recommended Practices, 2014 Edition
Personal Bags
 Have
to balance healthcare workers’
need to access reference materials and
items to do job well
 Stipulations:




Require the bag be dedicated to hospital
use only
Be made of material that can be cleaned
Be stored away from the immediate patient
care area
Hand hygiene be done before accessing
bag
Conclusions
 Standardization
of feedback by multiple
IP to multiple areas helps keep involved
parties informed
 Compilation of multi-pages of feedback
into one-page dashboards helps keep the
message focused
Conclusions
 The
credibility our department has built
with all groups has allowed us to tackle
some more challenging topics
 Overall, our continued efforts have
resulted in a better relationship, which
leads to better care for our patients
Questions, Comments,
Discussion?
Kathleen McMullen
kmm2742@bjc.org