STANDARDIZATION OF ISOLATION PRACTICES IN THE PERIOPERATIVE CARE SETTING
Lorrie Ingram, BSN, RN, Infection Control Practitioner; Susie (Treasa) Leming-Lee, MSN, RN, CPHQ, Director of Perioperative Quality Management; Vicki Brinsko, BSN, RN, CIC, Infection Control Practitioner, Dept. Coordinator; Jena Skinner, BSN, RN, CIC, Infection Control Practitioner; Ann H. Benco, MSTD, BSN, RN, CNOR, Perioperative Nurse Educator; Erin Kuhn,
RN, MSN, CNOR, Perioperative Nurse Educator; Audrey H. Kuntz, EdD, RN, Director of Perioperative Education/Operative Services; Stephanie Randa, MHA, RN, Director of Operative Services; Thomas R. Talbot, III, MD, MPH, Hospital Epidemiologist, Infectious Disease, Titus L. Daniels, MD, MPH, Assistant Professor of Medicine-Infectious Disease, Associate Hospital
Epidemiologist; Addison K. May, MD, FACS, FCCM, Associate Professor of Surgery and Anesthesiology
ABSTRACT
2008 APIC Abstract
Isolation Precautions Process
Subject Category - Quality Management Systems/Process Improvement/Adverse Outcomes
Standardization of Isolation Practices in the Perioperative Service Line
Lorrie Ingram, BSN, RN, Infection Control Practitioner; Vicki Brinsko, BSN, RN, CIC,
Infection Control Practitioner, Dept. Coordinator; Jena Skinner, BSN, RN, CIC, Infection Control
Practitioner; Ann Benco, RN, Nurse Educator, Operative Services; Erin Kuhn, RN, MSN,
CNOR, Perioperative Nurse Educator; Audrey H. Kuntz, EdD, RN, Director of Perioperative
Quality Mgmt/Operative Services; Susie Leming-Lee, MSN, RN, CPHQ, Associate Director of
Perioperative Quality Management/Operative Services, Thomas R. Talbot, III, MD, MPH,
Hospital Epidemiologist, Infectious Disease, Assistant Professor of Medicine and Preventive
Medicine, Titus L. Daniels, MD, MPH, Assistant Professor of Medicine-Infectious Disease,
Associate Hospital Epidemiologist
ISSUE:
A cluster of Highly-resistant Acinetobacter baumannii (HR-ACBA) cases in the surgical critical
care unit of a large tertiary care medical center provided the impetus for detailed scrutiny of
isolation practices, particularly for patients requiring multiple trips to surgery. Noncompliance with
aspects of isolation was observed for patients during transport between surgery and critical care.
Further investigation revealed a systems approach to improvement would be needed, not only to
prevent transmission during transport, but to enhance compliance for all areas of patient contact
throughout the perioperative service line.
PROJECT:
A multidisciplinary team was formed with representatives from surgical critical care, perioperative
education, operating room personnel and infection control, to review the existing practices used for
handling patients in isolation and to map out an enhanced process (Figure 1) for improvement.
System barriers to compliance were identified in all phases of the perioperative patient care process.
System enhancements were identified and implemented to facilitate compliance. These included
specific education and training modules developed for all levels of staff, including physicians.
Perioperative isolation practice standards were formally incorporated into the departmental policy
and procedure manual.
RESULTS:
A unified set of isolation practice standards throughout the perioperative service line was
established, which mirrored the existing isolation guidelines practiced throughout the rest of the
medical center. System changes included creating electronic case boarding prompts, (Figure 2) to
actively inquire as to isolation status and type required, as well as electronic reminders to book
airborne isolation cases at the end of the day. The management of operating room (OR) traffic,
environmental cleaning, patient transport, supplies and appropriate signage were other key elements
of concentration identified for practice change. Improved compliance with isolation practices was
observed soon after implementation. While not directly attributable to the perioperative isolation
enhancements (simultaneous interventions were introduced in the critical care areas) no further HRACBA cluster outbreaks were identified (Figure 3).
LESSONS LEARNED:
Although most staff understood the institution’s isolation mandates for contact, droplet and
airborne precautions, problems were identified with communication between departments on
patient isolation status and proper practices for transporting patients between perioperative areas
and critical care. The concept that the OR environment, with respect to routine practices of sterile
and aseptic technique, would inherently prevent cross transmission of organisms from patients in
isolation was deficient as it did not include appropriate practice patterns prior to and after surgery.
This intervention project served to increase awareness and education of the perioperative staff
regarding infection prevention and control practices with their isolated patient population.
Behavioral changes reflecting improved compliance were influenced by staff collaboration, use of
new electronic case boarding prompts and creative methods of communication and education. In
addition, providing a new, concentrated and standardized process algorithm to guide the units/OR
staff in preparing for and organizing the isolation patient’s transport, equipment handling and
environment, was a vital tool for quality improvement. These concepts are reproducible for other
service areas with similar clinical challenges.
INTRODUCTION
A multidisciplinary team was formed with representatives from
surgical critical care, perioperative education, operating room
personnel and infection control to review the existing practices used for
handling patients in isolation and to map out an enhanced process for
improvement. System barriers to compliance were identified in all
phases of the perioperative patient care process. System enhancements
were identified and implemented to facilitate compliance. These
included specific education and training modules developed for all
levels of staff, including physicians. Perioperative isolation practice
standards were formally incorporated into the departmental policy and
procedure manual.
RESULTS
IMPLEMENTATION: DESIGN: FLOW OF WORK PROCESS
SCHEDULING
Surgeon or
surgical resident
boards the surgical
case
Is the pt. on isolation
precautions?
Yes
Thursday October 18TH 2007
PHASE
PRE-SURGERY & Patient Unit PHASE: PREPARATION AND TRANSPORT OF PT. TO OR
Does Scheduler
know the pt.’s type of
isolation
precautions?
Yes
No
Scheduler calls Pt. Care Unit to
ascertain type of pt. isolation
precaution
No
Is pt. on
air borne
isolation?
Is pt. on isolation
precautions?
Yes
Yes
Scheduler
schedules
surgical case
for end of
day if possile
Charge Nurse
reviews E-Board
and assigns
outside runner to
operating room
Continue current surgical care
process
Anesthesia
provider
assesses pt’s
condition and
equipment
needed for
transport
No
No
Scheduler selects
from computer
program one of the
following pt.
precaution status:
·
None
·
Contact
·
Droplet
·
Airborne
Anesthesia
provider
arrives in pt’s
room
Anesthesia
provider
performs
hand hygiene
& dons PPE
before
entering pt.’s
room
Anesthesia
provider and
pt’s bedside
nurse conduct
a handoff which
includes:
Verification of
isolation
precautions
status
a
Does MR Know
the type of isolation
precautions the pt.
is under?
PATIENT UNIT PHASE: PREPARATION AND TRANSPORT OF PT. TO OR
CTI
performs
hand
hygiene
& dons
PPE
before
entering
pt’s
room
a
CTI arrives
in pt’s
room and
verifies
pt. on
isolation
precaution
status
CTI, Anesthesia
provider, and or Nurse
·
place a clean
sheet on patient
·
place all pt.
monitoring
equipment, O2
tank, chart/s (in
clear plastic bag)
on pt.’s bed
·
place isolation
signs on pt.’s bed
·
assigns “Clean
Person” to assist
in transporting pt.
to open doors,
push elevator
buttons, etc.
CTI assist
Anesthesia
provider
and or
Nurse with
the
preparation
to transport
pt. to OR
No
No
Is pt. on
droplet
Isolaton?
Is pt. on
airborne
isolation ?
Yes
Bedside
Nurse
places
surgical
mask on
pt.
Yes
Bedside
nurse
places
surgical
mask on
pt.
CTI ,
Anesthesia
provider, and
or Nurse
transport pt.
directly to
operating
room if
coming from
ICU or on
airborne
precautions
b
Circulator in OR
calls receiving
unit charge nurse
to inform that pt
is ready to be
transported back
and verifies pt.’s
isolation
precautions
status
Anesthesia
provider calls
pt. report to unit
bedside nurse
or unit charge
nurse and
verifies pt.’s
isolation
precautions
status
# of ACBA Clusters Outbreaks
INTRAOPERATIVE PHASE OF CARE
CTI and OR
staff move
pt. from
bed/
stretcher to
OR table
2
Do not
remove pt.
chart from
plastic bag
unless
needed
CTI moves pt. bed into hallway
and follow the requirements for
bed cleaning below:
Circulator in
OR conducts
“rolling call”
to pt.
destination
as pt. leaves
OR
Pt. unit receives
rolling call and
notifies charge
nurse and bedside
nurse that pt. is in
transit and verifies
pt.’s isolation
precautions
3
No
Is pt.
under air borne
isolation
precautions?
Surgery
starts
Surgery
ends
Cleaning Process:
·
Don appropriate PPE
·
Remove sheets from bed and place in linen
bag
·
Spray germicidal disinfectant agent on bed
rails, springs, head board & wipe down bed
·
Place isolation type sign on bed during
drying phase
·
Wait 10 mins
·
Dress bed with clean sheets
·
Drape bed with clear plastic sheet
·
Place isolation
signs on pt’s bed
OR PREP AFTER PT LEAVES
OPERATING ROOM
INTRAOPERATIVE CARE PHASE CONTINUES
CTI,
Anesthesia
provider, &
Surgical
resident don
new PPE for
transport of
pt. to
receiving
unit
Charge Nurse
reviews EBoard and
orders
Hepafilter
OR PREP
BEFORE
PT.
ENTERS
OPERATING
ROOM
MR calls bedside nurse to determine
type of isolation precaution
The management of operating room (OR) traffic, environmental
cleaning, patient transport, supplies and appropriate signage were
other key elements of concentration identified for practice change.
Improved compliance with isolation practices was observed soon after
implementation. While not directly attributable to the perioperative
isolation enhancements (simultaneous interventions were introduced in
the critical care areas) no further HR-ACBA cluster outbreaks were
identified (Fig. 3).
8
Place clean
sheet over
pt. before
leaving OR
b
Blue = New Step
Pt. arrives
in
receiving
unit
Imp l e me n t a t i o n o f
N e w Is o l a ti o n P r e c a uti o n P r o c e s s e s
4
Anesthesia provider recovers non
ICU pt. for 30-50 mins in OR
ICU patient may be recovered in
negative pressure room on their
assigned unit
2
0
July
POST-OPERATIVE CARE PHASE OR TO PATIENT UNIT
CTI, Anesthesia
provider, Surgical
Resident and
assigned “Clean
Person” transport
pt. to receiving unit
6 ACB A Outbr e a ks , J ul y 2 0 0 7
6
Yes
Anesthesia
provider
and bedside
nurse conduct
handoff verifying
pt.’s isolation
precaution status
CTI wipes down all
transport monitors
and other
equipment with a
germicidal
disinfectant
agent before leaving
the patient’s room
CTI, Anesthesia
Provider and
Surgical Resident
remove PPE and
perform hand
hygiene before
leaving pt.’s room
Aug
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
June
Months-2007-2008
(8 months with no ACBA out breaks)
Fig. 3
Red = Verification of Isolation Precaution status
Fig. 1
CONCLUSION & LESSONS LEARNED
METHODOLOGY/TRAINING
Although most staff understood the institution’s isolation mandates for
contact, droplet and airborne precautions, problems were identified
with communication between departments on patient isolation status
and proper practices for transporting patients between perioperative
areas and critical care. The concept that the OR environment, with
respect to routine practices of sterile and aseptic technique, would
inherently prevent cross transmission of organisms from patients in
isolation was deficient as it did not include appropriate practice
patterns prior to and after surgery.
Isolation Precautions Process-Before Pt. Enters OR
Key Fundamental Infection Control Concepts Applied:
1. Strict Hand Hygiene adherence
2. Strict/Consistent use of PPE for specific precautions
3. Appropriate Environmental cleaning/disinfection processes
4. Special indications (i.e. for air handling/exchanges for TB)
Airborne, Droplet, & Contact
Isolation
ProcessEnd of Surgical
Case “booking” process,
5. Continuous
good
communication
during surgery
between the referral/transferring dept.; the Periop Services regarding
patients isolation status
6. Highlights and education pertaining to very specific and highly
transmittable organisms in the healthcare environment reviewed
2
Circulating Nurse
calls the board who
assigns “clean
person” to aid in
transporting pt.
back to ICU
Circulating Nurse
pulls up
Whiteboard and
confirms Pt.’s
isolation status
Yes
3
Is pt. under
air borne isolation
precautions?
No
Anesthesia provider
recovers non ICU
pt. in OR for 30-50
minutes
ICU
ICU pt. may be
recovered in
negative pressure
room on assigned
unit
·
·
Circulating Nurse or
designee post:
“No Traffic” Sign
on OR Door
“Isolation type
precaution” sign
on OR Door
Anesthesia
Technician
cleans
Anesthesia
machine
according to
standard
cleaning
methods
OR Staff removes any
unnecessary
equipment from OR
·
·
·
·
CTI:
Don N95 Respirator
Bring Hepafilter
into OR
Place Hepafilter in
center of room
away from return
air vent
Plug Hepafilter into
electrical outlet
and turns
Hepafilter on
OR Staff closes all
cabinet doors in OR
Hepafilter runs
for one hour
Circulating Nurse
ensures all
surgical case
supplies and
equipment are in
the OR
OR Cleaning Staff
cleans OR
according standard
cleaning
procedures
*No N95 Respirator
needed after
hepafilter has run
for one hour*
All OR Staff dons PPEs
prior to pt. entering OR
CTI wipes outside of
isolation cart with a
germicidal disinfectant and
sends Isolation Cart
to Central Supply for
cleaning and restocking
Yes
Is pt. under
droplet or contact
isolation
precautions?
No
OR Staff cleans OR according
to standard cleaning
methods
OR Staff don
appropriate PPE
Cleans OR
according to
standard cleaning
methods
CTI wipes outside of
isolation cart with a
germicidal disinfectant and
sends Isolation Cart
to Central Supply for
cleaning and restocking
INTRODUCTION
METHODOLOGY/TRAINING
A unified set of isolation practice standards throughout the perioperative service line was
established, which mirrored the existing isolation guidelines practiced throughout the rest of the
medical center. System changes included creating electronic case boarding prompts (Fig. 2) to
actively inquire as to isolation status and type required, as well as electronic reminders to book
airborne isolation cases at the end of the day. The management of operating room (OR) traffic,
environmental cleaning, patient transport, supplies and appropriate signage were other key
elements of concentration identified for practice change. Simultaneous interventions were
introduced in the critical care areas.
Key Fundamental Infection Control Concepts Applied:
1. Strict Hand Hygiene adherence
2. Strict/Consistent use of PPE for specific precautions
3. Appropriate Environmental cleaning/disinfection processes
4. Special indications (i.e. for air handling/exchanges for TB)
5. Continuous good communication during surgery “booking” process, between the referral/transferring
dept.; the Periop Services regarding patients isolation status
6. Highlights and education pertaining to very specific and highly transmittable organisms in the
healthcare environment reviewed
This intervention project served to increase awareness and education of
the perioperative staff regarding infection prevention and control
practices with their isolated patient population. Behavioral changes
reflecting improved compliance were influenced by staff collaboration,
use of new electronic case boarding prompts and creative methods of
communication and education. with similar clinical challenges.
Lessons Learned Include:
1. Ensure need for support of project by visible leadership.
2. Provision of a standardized process algorithm to guide staff adherence
and education was a vital component of this quality improvement
process. These concepts are reproducible for other service areas.
3. Early Solicitation of staff input in the development of this process, as
were the specific tools, was vital to overall success.
4. Education of all perioperative staff and faculty was critical to the
ownership of the process, and for its continued success.
NEW ISOLATION PRECAUTION PROCESS IN ACTION
www.mc.vanderbilt.edu/infectioncontrol
Fig. 2
Acknowledgements
Daniel Beauchamp, MD, Chair of Surgical Sciences
Mike Higgins, MD, MPH, Executive Medical Director of Perioperative Services
Nancye Feistritzer, MSN, RN Associate Hospital Administrator, Director of Perioperative Services
Surgical Site Infection Prevention Collaborative Committee