Better Together

CETHER
Focusing
on processes
and
complianceto prevent
hospital-acqu
i red i nfections
by LorriDowns,RN, BSN,MS,CIC
hen bacteria lurking on, for instance,a medical device, a
bed rail, a bandageor a caregiver's hands find their way
into a patient's body via a surgical wound, a catheter,a
ventilator, or some invasiveprocedure,the disturbingly frequent result is
a serious, sometimesdevastating,infection, In regard to preventing hospital-acquiredinfections(HAIs), the CDC,IDSA and SHEA havedeveloped a compendium of the various best practices available, so we know
the information is out there.However, more often than not, surveysshow
that the world of clinical practice falls short when it comes to implementing theseevidenced-based
guidelines.
For example, studies have shown that the most effective way to
prevent the most common HAI urinary tract infections is to avoid
calheterization, yet data indicates that approximately one quarter of
patients admitted to hospitals have urinary cathetersinserted. In 30
percent to 50 percent of those patients, a urinary catheter was not
medically indicated, but was inserted for either an unclear or inappropriate indication, such as urinary incontinence.
Likewise, hand hygiene, the number one defenseagainsthealthcareacquired infections, has been proven to have an important role in
prevention. The CDC estimates that adherenceto handwashing procedures alone could prevent the deaths of 20,000 patients each year,
Studieshave shown, however,that despitebeing a proven effective practice, hand hygiene compliance among healthcareworkers is poor, with
the world Health organization reporting an averagecompliance rate of
40 percent.
The CMS reimbursementchangesthat took effect in October 200g
helped to bring the issueto the forefront somewhat,as healthcareprofessionals dealt with the mandate that they eliminate certain HAIs and
improve patient safety or risk losing Medicare reimbursement doilars.
However, the Health and Human Services department's 2009 quality
report to Congress"found very little progress" on eliminating hospitalacquired infections. of five major types of serious hospital-related
infections, rates of illnesses increased for three and one showed no
progress.
Such data and findings leads to a simple conclusion. preventing
hospital-acquired infection is not all about policies and procedures-it
has a lot to do with processesand building in compliance.
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Let's take a look at an example of a HAI
prevention process-surgical skin preparation-followed by some ideas on how to
reinforce compliance to aseptic technique. Of
course, it goes without saying that these ideas
can be applied to measuring and validating
skill and competencies for sterile techniques
relatedto most bestpracticesfor preventingHAIs.
Surgical site infections (SSIs) are the third
most frequent hospital-acquired infection.
Twenty-seven million people undergo surgery
each year, and approximately 500,000 will
acquire an SSI. Fifteen percent of elective
surgery patients and 30 percent of patients
receiving contaminated or dirty surgery are
estimated to develop a postoperativewound
infection. SSIs continue to occur despite
advancesin infection control practices such as
improved operating room ventilation, sterilization, surgical technique, and availability of
antimicrobialprophylaxis.
We know that bacteria commonly found
on the skin are a frequentcauseof SSIs.Thus,
effective preoperative skin preparation is our
first line of defense against postoperative
wound infection. According to the CDC, effective skin preparation depends on three key
factors: preoperativeantiseptic showers,preoperative hair removal and immediate surgical
site preparationin the operating room.
PreoperativeShowers
The Centers for Disease Control and
Prevention (CDC) "strongly recommends"
(Category 1B) that healthcare facilities
"require patients to shower or bathe with an
antiseptic agent on at least the night before the
June 20'10
operative day." A preoperative antiseptic shower or bath decreases
microbial colony counts on the skin. Products containing chlorhexidine
gluconatehave been shown to decreasebacterial colony counts nine-fold
but require severalapplicationsto attain maximum antimicrobial benefit.
Therefore, repeatedantiseptic showersare usually indicated.
.
PreoperativeHair Removal
Whatis the"bestpractice"for hairremoval?
Hereis whatcunent .
evidencesuggests:
.
Refrain from hair removal unless it interferes with the surgical
procedure or wound closure.
.
If hair is removed, it should be done with a clipper or depilatory
cream in an area outside the room where the procedure will be
performed.
.
Razors have no place in the operating room. In one study, SSI rates
were 5.6 percent in patients who had their hair removed by razor
shave, compared to a 0.6 percent rate among those who had their
hair removed by depilatory or who had no hair removed. Clipping
hair immediately before an operation has also been associatedwith
a lower risk of SSI than shaving or clipping the night before an
operation;results are 1,8 percent comparedto 4.0 percent.Although
the use of depilatories has been associatedwith a lower chance of
SSI than clipping or shaving, depilatories can produce hypersensitivity reactions.
Surgical $ite Preparation
practices,preoperativeskin
According to AORN Recommended
preparationshouldbe performedonly minutesbeforethe start of the
procedure.But, first AORN statesthat:
'
Theconditionofthe skinat thesurgicalsiteshouldbe assessed
prior
to preparationfor rashes,skin eruptions,andabrasions.
. The skin shouldbe freeof grosscontamination,
suchasdirt or soil,
or any otherdebrisbeforeskin preparationis initiated.
.
Assuring "best practice" when greaterthan
90 percent of all surgical patients arrive on
the morning of surgery and must be relied
upon to properly perform a preoperative
shower when they were instructedeither in
a physician office visit or in a preadmission telephonecall or interview;
Addressing surgeons that provide physician orders contrary to best practice;
Measuring competency and validating
skills of perioperative staff members to
assure that standards are adhered to on
every surgical procedure.
PatientCompliance
From a patient's perspective,perioperative
care begins in the surgeon's office, progresses
to the surgical facility, continues with
discharge to home and ends in the surgeon's
office. The patient is typically given oral
instructions, preprinted forms and educational
materials that explain the surgeon's orders
prior to and the day of surgery.These instructions should teach the patient four essential
things:
1. What to expect;
2. When and how it will happen;
3. Where it will take place;
4. Why it is necessary.
In other words. it is important to anticipate
and answer the patient's questionsbefore they
arise. The most effective way to establish an
effective preoperativeeducation program is to
Immediatesurgicalsitepreparationcanbe performedwith a variety
develop a standardized approach that is
of antisepticagentsat the actual incision site. Most commonare
adopted by the perioperative staff, including
iodophors,alcohol-containing
products,and chlorhexidinegluconate the surgeon.
(CHG).TheU.S.FoodandDrugAdministration
(FDA) haslongrecog_
nizedalcoholasthe mosteffectiveandrapid-actingskin antiseptic.Few
surgicalprofessionalswould dismissthe proven efficacy of alcohol;
however,the debatecontinuesaboutthe superiorityof surgicalpreps
containingcHG andalcoholversussurgicalprepscontainingiodineano
alcohol.In a recentstudy,the efficacyof threedifferentsurgicalskin
prepswas compared.Resultsvaried for a variety of reasons,suchas
differencesin applicationmethodand patientrisk factors.But overalL
resultsclearlypointedto the combinationsolutionswith alcoholas the
mosteffectivein reducingbacterialcounts.
The Question of Compliance
Npw thatwe'veestablished
best-practice
standards
for surgicalskin
preparation,
we needto takea look at compliance.
Therearethreemain
challenees:
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Surgeon Compliance
As mentioned,the surgeon'ssoundjudgment and proper techniquehave a great impact
on the prevention of surgical site infections.
What influences surgeons to change their
opinion and subsequentlytheir technique? It
typically occurs in one of two ways:
.
Through the presentation of overwhelming, substantialdata;
.
Through peer pressureto change.
A third influencer might be reimbursement
pressureresulting from negative outcome data.
In our data-drivenworld, tracking,measurement,
June2010
2.
PrincipleNo. I
Scrubbedpersonsfunctionwithin a
sterilefield.
Steriledrapesare usedto createa
sterilefield.
PrincipleNo"3
All items used within a sterilefield
mustbe sterile.
P r i n c i p l eN o . 4
All items introducedonto a sterile
fieldshouldbe opened,dispensed,
and transferredby methodsthat
maintainsterilityand integrity.
A sterilefieldshouldbe maintained
and monitoredconstantly.
P r i n c i p lN
e o .6
All personnel
moving
withinor
arounda sterilefieldshould
do so in a manner
to maintain
the
sterilefield.
PrincipleNo. 7
Policiesand proceduresfor maintaininga sterilefieldshouldbe written,
reviewedannually,and readily
availablewithinthe practicesettino.
Include an introductionto (or review of) policies and procedures in the orientation and
ongoingeducationof staff membersto assistin
the developmentof knowledge,skills, and attitudesthat affect patientoutcomes.
For clinicians, aseptic principles and techniques are the cornerstone of infection control
efforts. Aseptic techniquesare the practices that
restrict microorganisms in the environment and on
equipment and supplies,and that prevent normal
body flora from contaminatingpatients.Although
the principles appearto be basic,logical and intuitive, non adherenceto one or more is common for
a multitudeof reasons.Time factors,staffingissues,
expectations from coworkers, pressure from
surgeonsor anesthesiologists,
poor traffic control,
and inefficientsupplylogisticsare someof the most
common influencers. Even fear of reprisal can
interferewith the maintenanceof a sterilefield.
Proper adherenceto aseptic technique minimizes and often eliminatesmodes and sourcesof
contamination. Consistent observance of the
boundariesestablishedin the principles by each
member of the team still provides the best way to
ensurethat aseptictechniqueis followed. How can
we all be reminded to comply? Here are a few
suggestionsthat can help satisfy this basic need,
simply and effectively.
AnnualReview
and reportingof healthcareoutcomesarebecomingmore common.
\\'eb sites such as www.healthgrades.com,
www.RateMDs.com,
and u rr'rr.phvsicianreports.com
make it easyto find physiciandata;
this can and is influencingphysiciancompliancewith best-practice
policies and procedures.While thesedata sourcesare not always
consideredreliable.objectiveclinical datacan be trackedby hospitals throu_shthird-pafiy companiesthat contractwith a facility to
obtain and monitor data trends.Two such companiesthat provide
theseservicesare MedMined (www.medmined.com)and Cereplex
(www.cereplex.com).
StaffOompliance
In the final parallel, the patient encountersan assortmentof
perioperativeteam members at each location with varied roles and
responsibilities.To provide consistencythroughoutthe continuum,
AORN offerstwo suggeqtions:
1. Use the AORN recommendedpracticesfor skin preparationas
for developin_e
policies and proceduresin the prac_euidelines
tice settin_s:
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Annual review can take place in the form of a
scheduledinserviceto review principles,policies,
and procedures.Consider developing skits and
scenariosthat depict proper and improperpractices
and techniques.These can be entertaining while
pointing out the common breachesin aseptictechnique that can and do occur in every facility.
Traditional methods include modular study guides
followed by a multiple-choicetest.
$kills Validation
Validation of competencyfollows training and
is typically accomplishedthrough clinical observations in the operating room setting by a trained
observer, and through written tests that are
conductedannuallyand recordedin the employee's
perrnanent record. An alternative form of written
validation or testing can be conducted using
pictures and/or actual clinical staging. A sketch or
picture of a healthcare setting that includes both
obvious and subtle breaches in aseptic technique
June2010
Forclinicians,
asepticprinciples
and
techniques
arethe cornerstone
of
infectioncontrolefforts.
can be presentedto a clinician, who would be askedto identify the
breachesand correct the situation according to recommendedprac_
tices and standards.Additionally, a simulation can be stagedin a
vacant room; clinicians would be asked to enter the room, identify
and correct all breachesin aseptic technique, and document their
findings on the testingform provided.Either of thesetestscould be
graded and placed in a personnelrecord.
VisualReminders
Posters,signs,and stickerscan serveas effectivepromptswhen
placed appropriatelywithin the healthcaresetting. Becausethese
tools will be viewed by the public, they shouldlook as professional
as possible;they shouldalsobe durableenoughto withstandnormal
wear and tear. It is important to follow facility protocols regarding
the use of visual reminders.Some facilities are adding specially
designedstickersto the outsideof commonly used supplieswithin
the OR to remind personnelof importantproceduresand processes.
For educationalmaterialson hand washing and aseptictechnique
that can be printed and posted in your facility, check out
*'u u'.engenderhealth.org/ipimiw/index.html.
ClinicalDocumentation
A separateform or checklistincluding the principlesof asepsis
can be incorporatedinto the perioperativerecord. Adherence to
aseptictechniquecan be documentedby having the nursingcirculators sign the perioperativerecord. A sample patient record from
AORN includes an outcome statement in the postprocedure
Assessmentand Evaluation section stating, ,.patient'ssurgery
performed using aseptictechniqueand in a manner to preventcross_
contamination." This not only serves as a consistent and frequent
reminder to adhere to these principles, but also provides a review
each time the circulator performs his or her duties. Most often, a
separateform is not neededunless there have been unrelenting
issueswith following the principlesof asepsiswithout improvement
over time in a _uiven
facility. Typically,the incorporationof a check_
list. signature.or outcome statementattestingto adherenceof the
principlesis sufficient.
Reviewof Departmental
InfectionRates
Infection rates should be shared with the clinical staff on a
routine basis. The decision to share this data with staff may be
controversial for fear that the data would be misinterpreted.
Through trending and coding of sensitivedata, both by specialty
and discipline, satisfactory methods of data analysis and presenta_
tion can be developed,making it possible to shareinformation that
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Patientand operationcharacteristics
that may influencethe risk of
surgicalsite infectiondevelopment
Patient
'
Age
.
Nutritional
status
.
Diabetes
.
Smoking
.
Obesity
.
Coexistentinfectionsat a remotebody site
.
Colonizationwith
microorganisms
.
Alteredimmuneresponse
.
Lengthof preoperativestay
Operation
. Duration
of surgical
scrub
.
.
.
,
.
.
.
.
.
.
Skinantisepsis
Preoperative
shaving
Preoperative
skinprep
Duration
of operation
Antimicrobialprophylaxis
Operating
roomventilation
Inadequate
sterilization
of instruments
Foreign,material
in thesurgical
site
lurslcal
iraln1
Surgicaltechnique
- Poorhemostasis
- Failureto obliterate
deadspace
- Tissuetrauma
Source;CDC'sGuidetine
for Prevention
of
SurgicatSitetnfection,
1999
Lorri Downs, RN, BSl/, MS, AC is a board
certified infection preventionist and vice president
of Infection Prevention at Medline Industries Inc.
Ms. Downs possessesa diverseporfolio of more
than 25 years in the nursingprofession.Her expertise
has focused on infection prevention surveillance
at large acutecare organizations,plusambulatory
and public health settings.Ms. Downs has crafted
hospital infection control programs, local emergency preparednessplans as well as lectured on
various infection prevention topics.
June2010