Infection Control in the OR Myths and Misconceptions

1. Infection Control in the ORMyths and Misconceptions Bruce Gamage Infection Control Consultant BCCDC

2. Outline • Dressing for the theatre – is it just a fashion statement? • Masks – should we wear them? • Food in the OR! • Cleaning the environment – How clean is clean? • Super Bugs – is hand washing enough? • Surgical Hand Scrubs – Alcohol vs. CHX • Instruments – is flashing good enough? • Cleaning challenging instruments – “acetabular reamers” • Artificial Fingernails – there’s no place for them in HC • I’ve never seen a body piercing there before! • The OR of the future – designed with IC in mind.

3. Dressing for the Theatre

4. Evolution of OR Attire • Origins of Scrub attire • Paralleled aseptic and sterile technique in late 19th century • Hunter – advocated a complete change of costume rather than don a sterilized coat and trousers • Mayo (1913) –operating team wore gowns caps and masks • 30s and 40s scrub dresses replaced “surgeons uniforms” • 60s Pantsuits and scrub dresses replaced full skirts to reduce risk of clothing contaminating the sterile field

5. IC issues • “Germ theory” evolved in the early 19th century • Principles of asepsis developed in mid-19th century • The garment of the HCW is part of the environment that can become contaminated • Microbes (e.g. Staph, Strep, Pseudomonas) can adhere to fabrics

6. Survival of Microbes on fabric • Study done at Shiners Hospital in Cincinnati • Staph and Enterococci can survive for extended periods of time on materials commonly worn by HCWs (e.g. 100% cotton or 60/40 cotton blend)

7. Laundering of Scrubs • “Contaminated” scrubs should be washed in 160F (71C) water with 50-150 ppm chlorine bleach and dried in a hot dryer

8. Home laundering? • University of Florida conducted a 4 year study to determine the effect on perinatal infection rate of wearing home laundered scrubs in L&D. Prior to study rate was 1.7% - after study rate was 1.0%. • Practice was found to  costs without in  SSI

9. Opinions in flux • Hospitals see scrub attire as a huge cost. • Experts in IC say “ there is no empiric data that shows that home laundering leads to  infections than commercial laundering. Risk factors for SSI are pre-existing morbidity, obesity, diabetes and  age.

10. Expert Opinion? • APIC/CDC – there is little evidence that scrubs in the OR setting is a means of infection control in a health care facility • AORN – Scrub attire is not intended to be protective in any way: it is simply a uniform. It’s assurance that people coming into the OR are wearing freshly laundered attire that hasn’t been sat upon by the dog” Dorothy Fogg

11. AORN Position • “Surgical Attire should be laundered under controlled conditions where the laundry facility has specific formulas and they monitor the concentration of chemicals” • AORN does not support home laundering.

12. WHO/CDC • All persons entering the surgical theatre must wear surgical attire restricted to being worn only within the surgical area. • The design and composition of surgical attire should minimize bacterial shedding into the environment • No recommendations on how or where to launder scrub suits, on restricting use of scrub suits to the OR or for covering scrub suits when out of the OR.

13. Masks – should we wear them?

14. Masks – should we wear them? • AORN – all persons entering the restricted area of the OR suite should wear a mask when open sterile items and equipment present. • AORN acknowledges that there is a difference of opinion. • CDC states “a surgical mask that fully covers the mouth and nose when entering the OR if surgery is about to begin, is already underway or if sterile equipment is open.”

15. What’s the evidence? • Recent reports in the literature advocate wearing of masks by non-scrubbed staff with forced ventilation is not necessary • Studies from Europe show that oral bacteria expelled during talking by non-scrubbed personnel not in the immediate vicinity of the operating site posed no risk of infection.

17. What is the risk? • The risk of contamination depends on • Airflow • Traffic • Personal practices. • Best practice would require wearing of mask, independent of distance until research provides definitive answers.

18. Personal Protection • As part of Routine Practice • Wearing a mask as part of PPE to reduce the risk of exposure to potentially infectious material.

19. Food in the OR?

20. Food in the OR? • Eating in the OR is not acceptable! • Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses in work area where there is reasonable likelihood of occupational exposure to infectious materials is prohibited. • This is an OH&S issue!

21. How clean is clean?

22. Cleaning the environment : • Airborne bacteria must be minimized and surfaces kept clean. • When visible soiling or contamination with BBF occurs during an operation, use disinfectant to clean areas before next operation. • There is no need to perform special cleaning or closure of OR after contaminated or dirty cases.

23. Recommendations • Wet vacuum the OR floor after the last operation of the day with disinfectant. • Tacky mats at the entrance to the OR have no IC purpose • There is no recommendation on disinfection of surfaces or equipment in the OR between operations if there is no visible soiling. • Routine environmental sampling is not recommended. Perform only as part of an epidemiologic investigation.

24. WHO recommends: • Cleaning of all horizontal surfaces every morning • Cleaning and disinfection of horizontal surfaces and surgical items between procedures • Complete cleaning of the OR at the end of the day • Complete cleaning of the entire OR annex once a week.

25. Super Bugs – is hand washing enough?

26. Super bugs • CDC recommends: • Exclude from duty surgical personnel who have draining skin lesions until infection has been ruled out or personnel have been treated and infection has resolved. • No need to routinely exclude personnel colonized unless there is epidemiological evidence of spread in the health care setting.

28. ARO Precautions • There is no evidence that wearing gloves when touching colonized patients is necessary. • There is no evidence to support all staff wearing a gown to enter the room. • There is no evidence for wearing a mask when caring for a patient with ARO (may  likelihood of HCW touching their nose). • There is no evidence that enhanced cleaning is necessary to  transmission.

29. ARO Precautions • There is no evidence that wearing gloves when touching colonized patients is necessary. • There is no evidence to support all staff wearing a gown to enter the room. • There is no evidence for wearing a mask when caring for a patient with ARO (may  likelihood of HCW touching their nose). • There is no evidence that enhanced cleaning is necessary to  transmission.

30. Current Recommendations • Wash your hands! • Follow Routine Practices • Use contact precautions if will be having direct (skin to skin) contact with the patient or their BBF. • Use regular cleaning practices. • Antibiotic resistance ≠ disinfectant resistance.

31. Hand Scrubs – Alcohol vs. CHX

32. Hand Scrubs – Alcohol vs. CHX • A surgical hand disinfection should be performed by all persons participating in the operative procedure. • The AORN continues to recommend the traditional hand scrub with an antimicrobial hand scrub agent. • AORN acknowledges that alcohol is an excellent skin antiseptic with a persistent effect for up to three hours.

33. Alcohol scrubs • Care should be exercsed to use these products if the procedure is <3 hours. • At the present time there is sparse evidence showing that alcohols are more or less effective than CHX scrubs • Recommend: • Alcohol has no cleaning ability • First thoroughly wash hands and forearms with soap and water • Then apply alcohol based surgical hand scrub according to manufacturer’s instructions.

36. Instruments – is flashing good enough?

37. Instruments – is flashing good enough? • Flash sterilization should only be used for patient care items that will be used immediately (e.g. to reprocess an inadvertently dropped instrument) • Instruments should not be flash sterilized because it is convenient or because you don’t have enough sets or to save time!

38. Flash Sterilization • A chemical integrator that confirms temperature, pressure and steam saturation was achieved. • Instruments must be cleaned before they can be sterilized. • Cycle 3 minutes at 132C for non-porous, non-lumen • Cycle 10 minutes at 132C for porous or lumened instruments. • Complex instruments – only at manufacturer's recommendation. • Implants – not recommended. • Ensure staff are educated, process monitored and audited.

39. Cleaning challenging instruments

40. Cleaning challenging instruments • Reusable endoscopic instruments that are not (or can’t be) properly cleaned and sterilized are a major cause of nosocomial infections (CDC). • Decontamination and removal of all possible biomaterial is the most important step in the sterilization process • “When in doubt, throw it out”

41. “The infection control dream” • “an instrument that is never reused does not present and infection risk to another patient!”

42. Problems with Endoscopes • Long narrow shaft are difficult if not impossible to clean. • The more complicated the device the harder it is to clean. • Focus is on function, not on cleaning in the design phase. • Forces sterile processing technicians to do what they can and hope for the best…

43. Other challenges… • Keeping the instruments free of gross soil. • Minimize time between use and cleaning process. • Making sure the SPD staff know and use the correct procedures. • Having the right cleaning equipment and solutions in the right place • Complex instruments that requires time-consuming disassembly, cleaning and reassembly before processing…

44. Proper Steps • Begin cleaning as soon as possible (don’t let blood and tissue dry and cake - covering with a wet cloth is not enough. • Place the instruments in a basin of solution as soon as they come off the procedure table. • Wipe down surfaces and flush lumens to remove gross debris. • Separate general from specialized instruments. • Transport to SPD. • Clean and disinfect or sterilize according to manufacturer's written instructions.

45. Manufacturer’s Responsibility • Manufacturer’s must incorporate “cleanability” into design. • “Manufacturer’s should provide documentation from an independent laboratory that proves the device can actually be cleaned.” Dennis Maki.

46. “Acetabular Reamers” • In January 2004, a technician at a hospital in Canada discovered that some of these instruments could be partially disassembled prior to cleaning. This may have not been known by some hospitals using this equipment and the information originally received from the manufacturer did not adequately describe the disassembly procedures.

47. What about artificial fingernails?

48. What about artificial fingernails? • Some folks think it’s OK to wear acrylic nails if they are only circulating… • Artificial should not be worn in the perioperative setting • AORN: Artificial nails should not be worn.

49. Rationale • The is not evidence that artificial nails increase the risk of SSI. • These nail may harbour organisms and prevent effective handwashing. • High numbers of gram-negative organisms have been cultured from personnel wearing artificial nails!

50. I’ve never seen a body piercing there before!