The Perioperative Suite

Joan Blanchard

Sharon Giarrizzo-Wilson

INTRODUCTION

The perioperative setting remains a high risk area for the patient and the surgical team. In 2008, there were 300,000 Surgical Site Infections (SSI) reported; this was 17% of all healthcare-associated infections (HAIs), second only to urinary tract infections (UTIs) (1). Two percent to 5% of all patients having surgery developed SSIs. There is a 2 to 11 times higher risk of death for a patient developing an SSI compared to patients who do not develop an SSI (2,3). Seventy five percent of deaths in patients with SSIs will be attributed to the SSI (4). Long term disabilities account for morbidity (5). An SSI results in 7 to 10 additional postoperative hospital days. The cost ranges from $3,000 to $29,000 depending on the surgical procedure and the pathogen identified (6,7). This is an overall approximate cost of $10 billion annually (8,3,9).

Stronger collaborative bonds need to be forged between regulatory and recommending agencies that have influence on patient care or give direct patient contact. The agencies that are most closely related to the patients care in the perioperative area are the Association of periOperative Registered Nurses (AORN), American Society of PeriAnesthesia Nurses (ASPAN), American College of Surgeons (ACS), American Society of Anesthesiologists (ASA), Association of Surgical Technologists (AST), Association for the Healthcare Environment (AHE), Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the Society for Healthcare Epidemiology of America (SHEA), the Centers for Disease Control and Prevention (CDC), the American Society for Healthcare Engineers (ASHE), the Centers for Medicare/Medicaid Services (CMS), The Joint Commission (TJC), and the American Hospital Association (AHA).

SURGICAL SITE INFECTION RISK STRATIFICATION

Stratification is the grouping together of patients at similar risk of acquiring a SSI, which allows hospitals to compare their data with other hospitals or compare one surgeon and another surgeon (10).

ANESTHESIA

The American Society of Anesthesiologist Physical Status Classification System (Table 27.1) is used to determine the patient’s physiologic condition at the time of surgery. It provides an evaluation of the severity of systemic diseases, physiologic dysfunction, and anatomic abnormalities (11).

WOUND CLASSIFICATION

Wound classification should be documented by the circulating registered nurse at the time of the surgical procedure to assist in determining the state of the wound (12), in coordination with the surgeon performing the procedure. Table 27.2 is an adaption of BP Simmons’ original wound classifications.

Keep in mind, a break in aseptic technique in a Class1/Clean procedure does not become Class II/Clean contaminated, Class III/contaminated, or a Class IV Dirty-infected procedure. To become a SSI, there would have to have been an inoculation with a pathogen (Table 27.3) that may cause an infection within 30 days following the surgical procedure or within a year if an implant has been inserted. The break in aseptic technique should be reported in an occurrence/incident form which should alert the Infection Preventionist and Risk Manager that the patient should be monitored for a possible SSI following the break in aseptic technique.

SURGICAL SITE INFECTION TOOLKIT

The SSI Toolkit is available through the CDC and may be of assistance in working with SSI information. The Toolkit is available at http://www.cdc.gov/HAI/pdfs/toolkits/SSI_toolkit021710SIBT_revised.pdf. Note: The findings and conclusions presented in the SSI Toolkit are those of the authors and do not necessarily represent the views of the CDC.

TABLE 27.1 The American Society of Anesthesiologist Physical Status Classification System

Status	Definition of Patient Condition
I	A normal healthy patient
II	A patient with mild systemic disease
III	A patient with severe systemic disease
IV	A patient with severe systemic disease that is a constant threat to life
V	A moribund patient who is not expected to survive without the surgical procedure
VI	A declared brain-dead patient whose organs are being removed for donor purposes
Used with permission from the American Society of Anesthesiologists.

TABLE 27.2 Wound Classification(13,14,4)

Class 1/Clean: Clean wounds are uninfected surgical wounds with no inflammation noted: the respiratory, alimentary, genital, or uninfected urinary tract is not entered. Surgical wounds that follow nonpenetrating (blunt) trauma should be included if they meet the criteria.

Class II/Clean contaminated: A surgical wound in which the respiratory, alimentary, genital, or urinary tract are entered under controlled conditions and without unusual contamination. Operations involving the biliary tract, appendix, vagina, and oropharynx are included if there is no evidence of infection or major break in technique.

Class III/Contaminated: Contaminated wounds include open, fresh, accidental wounds, or wounds resulting in major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions with acute, nonpurulent inflammation is found.

Class IV/Dirty-infected: Old traumatic wounds with retained devitalized tissue, tissue with an existing clinical infection or perforated viscera. Microorganisms’ may have been present in the operative site prior to the surgical procedure.

TABLE 27.3 Organisms Causing Surgical Site Infection, January 2006 to October 2007, CDC National Healthcare Safety Network

Staphylococcus aureus	30%
Coagulase-negative staphylococci	15%
Enterococcus spp.	12%
Escherichia coli	10%
Pseudomonas aeruginosa	8%
Enterobacter spp.	5%
Klebsiella pneumonia	6%
Candida spp.	11%
Klebsiella oxytoca	2%
Acinetobacter baumannii	3%
N=	7,025(15,16)

PATHOGEN SOURCES OF SURGICAL SITE INFECTIONS

Sources of SSIs are from endogenous sources; patient flora, skin, mucous membranes, and the gastrointestinal tract; exogenous sources of SSIs are from the surgical personnel (i.e., surgeon and team), soiled attire, breaks in aseptic technique, inadequate hand hygiene, the operating room (OR) physical environment and ventilation, instrumentation, equipment, materials brought to the operative field, and seeding from a distant focus of infection (17).

EPIDEMIOLOGY

Emerging challenges in detecting SSIs are a lack of standardized methods for postdischarge/outpatient surveillance, increasing numbers of outpatient surgeries, and shorter postoperative inpatient stays. With antimicrobial prophylaxis, there is an increasing trend toward resistant organisms which may undermine the effectiveness of existing recommendations. There are additional modifiable risk factors, such as excessive OR traffic, inadequate wound dressing protocol, improper glucose control, colonization with preexisting microorganisms, and inadequate intraoperative oxygen levels (17).

Prevention strategies for SSIs include core intraoperative measures, such as keeping OR doors closed during surgery except as needed for passage of equipment, personnel, and the patient (4). Supplemental preoperative prevention strategies are nasal screening and decolonization of Staphylococcus aureus carriers undergoing elective cardiac and other implant surgical procedures (i.e., orthopedic, neurosurgery procedures with implants) with preoperative intranasal mupirocin, possibly plus chlorhexidine bathing therapy (18,19). Screening preoperative blood glucose levels and maintaining tight glucose control in patients undergoing select elective procedures (e.g., cardiac, arthroplasties, and spinal fusions) should also be done (20). Postoperatively, feedback of surgeon-specific SSI rates should be shared. The supplemental strategies are not part of 1999 Healthcare Infection Control Practices Advisory Committee (HICPAC) Guideline for Prevention of SSIs (17).

PREVALENCE OF RESISTANT PATHOGENS

In 2010, a national prevalence survey of methicillin-resistant S. aureus (MRSA) was repeated in the inpatient setting. This survey was conducted with 590 health care facilities responding; both colonization and infection information was requested. The previous MRSA survey was done in 2006. The 2010 survey showed a reverse from the 2006 survey findings. In 2006, MRSA-infected patients were 34 per 1,000 patients, and MRSA-colonized patients were 12 per 1,000 patients; in 2010, MRSA-infected patients were 25.3 per 1,000 patients and MRSA-colonized patients were 41.1 per 1,000. This may be partially due to more respondents performing active surveillance testing, and the method of testing was a quicker detection of MRSA-colonized patients. MRSA-colonization increases the risk of MRSA infection and the risk of cross-transmission to other patients and the environment (21). Rapid testing results may decrease the need for early preemptive isolation, shorten the isolation protocol when needed, and prevent the MRSA-positive patient’s environment contamination with resultant risk of cross-contamination (22,23).

PATIENT POPULATIONS AT GREATEST RISK OF DEVELOPING A SURGICAL SITE INFECTION

Individuals at risk for developing an SSI include persons who have diabetes (24,25), are aged (26,27,28,29,30,31,32,33), are obese (24,34,35), are malnourished (34,36), or are smokers (24,25).

Persons also at risk for a SSI may be patients who have had hair removal at the surgical site with a razor (37), have microbial colonization (38,39), do not have appropriate skin antisepsis before the surgical procedure (40,41,42,43), have a drain placed during surgery (44,45), have prolonged duration of surgery (25,35), or have a remote infection before surgery (46,47,48,49,50,51,52).

MODES OF TRANSMISSION

Contact, droplet, and airborne are the three modes of transmission. Some organisms may be transmitted by more than one route, both airborne and contact routes depending on the different stages of the disease (53).

NATIONAL HEALTHCARE SAFETY NETWORK SURGICAL SITE INFECTIONS EVENT

A surveillance program includes: the use of epidemiologically-sound infection definitions, effective surveillance methods, stratification of SSI rates based on risk factors associated with the SSI development, and data feedback (54,55).

A CDC National Healthcare Safety Network (NHSN) operative procedure is an inpatient or outpatient in which the procedure is done during an operation, in an OR by a surgeon, making at least one incision through skin, mucous membrane, including a laparoscopic approach, and closing the incision before the patient exits the operating room. Note: If the skin incision edges do not meet (e.g., drains, wires, or other extrusions from the wound) at the end of an operative procedure, the wound is not considered a primary closure, and is therefore not considered an NHSN operative procedure, and any procedure-associated infection is not considered an SSI.

OPERATING ROOM (OR)

A patient room that meets the Facilities Guidelines Institute’s (FGI) or the American institute of Architects’ (AIA) criteria for an OR when the room was constructed or renovated (56). Included are an OR, C-Section room, interventional radiology room, and a cardiac catheterization lab.

IMPLANT

A nonhuman-derived object, material, or tissue which is inserted in a patient during an operative procedure. This may include, but is not limited to: porcine or synthetic heart valves, mechanical heart, metal rods, mesh, sternal wires, screws, cement, internal staples, or hemoclips.

EXCLUDED ARE NONABSORBABLE SUTURES

It is considered as an implant at the site/structures adjacent to the implant until it is manipulated for diagnostic or therapeutic reasons. If an infection results after the manipulation, this would not be attributed to the operative procedure when the implant was inserted; the infection would be attributed to the manipulation. If the infection is considered an NHSN operative procedure, then that subsequent procedure can be considered an SSI (54,55).

The National Healthcare Safety Network, Patient Safety Component: Procedure-associated Module is available at http://www.cdc.gov/nhsn/psc_pa.html.

PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS

HAND HYGIENE

Health care personnel (HCP) should recognize that hand hygiene is one of the most important ways to reduce or stop the spread of microorganisms which are often associated with the transmission of disease. The sequence of transmission involves shedding onto inanimate objects which occurs from a patient’s skin which contains microorganisms. These microorganisms must then be able to survive long enough to be transferred to the HCP’s hands when the inanimate objects are touched. The HCP hand hygiene must then be skipped or done poorly, and then, the HCP’s contaminated hands must come in direct contact with another patient or an inanimate object that will come in contact with the patient (57,58,53).

In reviewing other areas where hand hygiene concerns were found, there is a very good possibility that during the practice of anesthesia the rapid pace of providing patient care and frequent contact with sources that are contaminated, bacterial transmission may occur. Studies conducted by Loftus and Koff have shown that the anesthesia work space can become contaminated within 4 minutes of patient care with pathogens that can potentially cause HAIs; most likely as a result of anesthesia care provider’s contaminated hands or gloves. Sterile intravenous stopcocks were cultured aseptically at baseline and at procedure completion at two sites in the anesthesia work area. The conclusion was transmission of pathogenic bacteria to the anesthesia work area and exterior and interior of the stopcocks (59,60,61).

In a study of nearly 8,000 observations of hand hygiene in anesthesia care providers, the opportunities averaged 34 to 41 per hour. These observations were done over a 4-week period using a World Health Organization Tool. The aggregate failure rate was 82% with a range of 64% to 93% by the provider group. The major categories of failure were preoperative assessment care from patient-to-patient, before, during, and after pain management; use of computer keyboard with soiled hands; placement of intravenous devices and blood draws; preparation of medications and equipment with soiled hands; leaving soiled gloves on after airway placement/manipulation and central and arterial line; and retrieving dropped items on the floor and then using the item (62).

PREOPERATIVE SKIN ANTISEPSIS

Skin antisepsis is done before a surgical procedure to reduce the risk of a SSI. The skin has transient and resident microorganisms; removal of transient microorganisms is more easily accomplished than the removal of resident microorganisms which are more deeply seated and may not be totally removed. Resident microorganisms may be reduced to a sub-pathogenic level with appropriate skin antisepsis (63).

Patients having surgical procedures below the chin should have two showers with chlorhexidine gluconate (CHG) before surgery. Clinical trials found the use of preoperative showers reduced microorganisms on the skin, including S. aureus (64,65,66,67,68).

The U.S. Food and Drug Administration (FDA) skin antiseptics should be approved or cleared for use in preoperative skin preparation. The antiseptic chosen should reduce microorganisms in intact skin, have an antimicrobial ingredient that is nonirritating, be broad spectrum, fast acting, and have a residual effect (69).

Precautions should be taken when using surgical antiseptics which have flammable properties to prevent a surgical fire with a resultant patient burn (70). The skin antiseptic should not touch fabric or be allowed to pool. The skin antiseptic should be allowed to dry and vapors to dissipate before draping, or use of electrosurgery, laser, or other heat source (70,71). Skin antiseptics should be thoroughly removed from the skin at the end of the case unless directed by the manufacturer to remain in place (72,73).

Hair removal is dependent on the site of the surgical incision. If it is not necessary to remove the hair, the hair should be left in place. If it is necessary to remove the hair at the surgical site, it is preferable to use hair clippers and not a razor. Using a razor or depilatory cream to remove hair may result in abrasions which increases microbial growth and increases the risk of a SSI (74,75,76,37). Use of depilatory cream for hair removal may cause skin reactions which may result in cancellation of the surgical procedure (76). Leaving hair in place for neurosurgical procedures has not increased the SSI risk (77,78). Hair removal, if necessary, should be done the day of surgery outside of an OR or procedure room to prevent contamination of the sterile field. Using clippers the morning of surgery results in fewer SSIs (79).

SURGICAL ATTIRE FOR NONSCRUBBED HEALTH CARE PERSONNEL

The U.S. Occupational Safety and Health Administration (OSHA) surgical attire requirements for HCP include the use of personal protective equipment (PPE) which must be worn when there is the possibility of an occupational exposure. The PPE is considered appropriate if it prevents blood-borne or other infectious pathogens going through to the skin of the HCP. The PPE includes: protective eyewear, gloves, fluid-resistant gowns, face shields, and shoe covers (80).

Nonscrubbed HCP surgical attire includes scrub tops and scrub pants, warm-up jacket, head covering, surgical mask, protective eyewear, gloves as needed, and protective footwear. Surgical attire should provide coverage to prevent skin squames from being released into circulating air in an OR. Researchers found in a prospective study that 100% spun-bound polypropylene was effective in decreasing the bacterial load in the air by 50% compared to surgical cotton attire (81). Other researchers found the attire design was not as important as the material (82). Surgical fabrics should be made of tightly woven, stain-resistant, and durable fabric; the fabric also should be comfortable to wear as it refers to the fit, breathability, and the weight of the fabric (83). Cotton fabrics having a porosity of 80 µm or greater in size may allow microorganisms to pass through the interstices of the materials weave presenting a concern for contamination (84,85). Surgical attire made of 50% cotton and 50% polyester with 560 × 395 threads/10 cm is an example of a fabric that would reduce the amount of bacteria that would be shed into the air by two to five times, with the exception of methicillin-resistant S. epidermidis (MRSE) and MRSE-carriers (86).

Jackets

Warm-up jackets should be worn in the semi-restricted and restricted areas of the perioperative suite with cuffs down to the wrists to prevent shedding and jacket snapped up to prevent contamination of the sterile field (81,86).

Cotton fleece jackets should not be worn in the OR. This fabric collects lint which may harbor microbial-laden dust, skin squames, and respiratory droplets. Fleece is made up of a napped surface which has low density, which makes it more flammable (87). Cotton fiber is one of the most flammable fibers. One hundred percent cotton that does not have fire retardant treatment does not meet the federal flammability standard (88). Blending cotton with 10% to 20% polyester could reduce the flammability (88), but this is not always successful (89).

Head Coverings

Head coverings should be disposable or a fabric cap that is laundered daily. The head covering should completely cover the hair (90,91). Human hair can become the source of pathogenic bacteria which includes MRSA. Hair left uncovered becomes a filter and collects bacteria in proportion to its length, waviness, and oiliness. In one study, it was shown that S. aureus and S. epidermidis have a tendency to colonize hair, skin, and the nasopharynx (92). An outbreak of group A ß-hemolytic streptococcus on the scalp of scrub person was identified as the same pathogen that occurred in 20 patients who developed SSIs. Group A Streptococcus is isolated in only 1% of SSIs; an SSI that is caused by group A Streptococcus can be very severe and difficult to treat (93). Another study found that washing the hair with a neutral shampoo without an antimicrobial component has no bactericidal effect on the hair (92). Head covering design should contain hair and scalp skin, which would decrease microbial dispersal. HCP with bald or shaved heads must also wear a head covering to prevent shedding of skin squames (94). Skullcaps do not contain hair at the nape of the neck or in front of the ears and should not be worn in the perioperative suite (95).

Surgical Mask

A surgical mask should be worn whenever sterile supplies are opened (4). HCP are protected from droplets >5 µm in size when wearing a surgical mask (54). A single surgical mask protects the HCP’s mouth and nose from blood or body fluid splashes or splatters and the patient from infectious agents the HCP may have (80,96

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