INFECTION CONTROL IN THE OR Mabel Crawford, R.N

The word “infection” has many meanings. Depending on who uses it, the word “infec- tion” can have one meaning to the ORS, her staff (professional and non-professional) , the medical staff, to the laundry personnel and others throughout the hospital, and finally to the patient. Each has problems and each must find the solution to them. Tabers Cyclopedic Medical Dictionary defines infection as “the state or condition in which the body or a part of it is invaded by a pathogenic agent (microorganism or virus) which under favor- able conditions, multiplies and produces effects which are injurious.” What are these “favorable” conditions? Infections may arise without any known injury. They may occur in wounds of accidental origin and develop in operative wounds. It is infection of the operative wound with which we are con- cerned.

Infections are caused by viruses, bacteria Rickettsia, fungi and animal parasites; but the prime offender in an operating room is usually bacterial. What are the sources of bacteria in the OR? First, there are the “airborne infections” originating in the respi- ratory tract, and discharged through the mouth and nose, which settle on the floors,

Mahel Crawford, R.N. is a graduate of the Bishop Johnson College of Nursing in Los Angeles, Calif. She is presently operating room supervisor at the Hospital of the Good Samaritan, Los Angeles, where she has served for many years. She was the first president of the AORN of Los Angeles, and chair- man of the chapter’s research committee. Miss Craw- ford is a member of the AORN Journal Editorial Committee, and has made many contributions to the Journal over the years.

tables and equipment. If this bacteria resists drying, it remains virulent and is transmitted by contact to another area. Frequently, contamination occurs when hands are not washed well or often enough. Handwashing then should occur often, at every given opportunity and be a requirement in definite areas of patient care (Fig. 1 ) .

Secondly, there is “contact infection” (exogenous) , resulting from transmission from person to person, by either contact with the infected individual, or by handling contaminated equipment. Last but not least, is the patient’s self contamination (endoge- nous).

How does an ORS and her staff combat infection in the OR? With the deluge of antiseptics, detergents, disinfectants, sanitiz- ers, bacteriostatics, etc. on the market: the availability of autoclaves using steam under pressure, dry heat and gas sterilization; she is indeed well armed. But, how does she institute sound procedures which best utilize these means? She must do effective research and use what has been tested, approved and found best suited for departmental function. The world of industry has awakened to improvisations used by surgeons and nurses for years, and has made these widely available. We now have disposable drapes, shoe covers, better packag- ing, sterilization and re-sterilization of pack- aged sutures, intravenous solutions, tubing and adapters-an almost endless list of supplies and help received in surgery from interested manufacturers.

However, with the advent of more lengthy surgical procedures, larger incisions, the use

54 AORN Journal

FIGURE 1

Hand Washing Required on A l l Cases

a. Open lesions (on admission)

b. Abscesses

c. Gas Gangrene (clostridium)

a. Positive A F B

b. Suspected

c. Atypical Acid-fast

X X

X X

~~~

~ _ _ _ ~ X X ___--

2. Acute Respiratory Infections

a. Pneumonia

b. Influenza

c. Suspected (fever)

b. Amebiasis

c. Shigellosis

d. Salmonellosis (including

e. Pseudomembranous

typhoid and paratyphoid)

enterocolitis

3. Wound and Skin Infections I l l

X

X X ~~~

X X

X X

d. Herpes Zoster

e. Burns

4. Gastrointestinal Infections

a. Diarrheas

f. Hepatitis (serum and infectious)

of man-made prostheses and transplantation of organs, the patient has become even more susceptible to an infection whose growth will be nurtured by his lowered resistance. As the head of a department, the ORS bears direct responsibility for minimizing infections in the operating room. Obviously, she cannot do this alone. She must resort to a well planned course of infection control policies enlisting

REMARKS

Admit or transfer to 4 West

Afebrile I_ hours and/or cleared by culture

Isolate until lesions are healed and/or cleared by culture Isolate until no drainage and/or cleared by culture

Reverse isolation required

Require needle and syringe precautions

the cooperation of the personnel within the OR and all other departments, including the medical staff, administration and the various hospital committees available to her. The philosophy of the ORS must encompass the patient in a safe, clean environment with the best of techniques.

To develop this philosophy she must set definite goals:

M a y 1970 55

1) Develop technique which will result in procuring quality care for every patient.

2) Recognize her responsibility to the surgical team and the hospital staff by insisting on workable routines.

3) Enforce the hospital rules, regulations and policies, conscientiously seeking and recommending better ones.

4) Participate as an active member of the Infection Control and OR committees.

5) Establish good rapport with the labora- tory department.

6) Strive for effective communication among all members of the team. Patient care cannot be over-emphasized! Upon entering the operating room, the patient is virtually in a helpless state and he places his well-being in the hands of people unknown to him, except for his surgeon and anesthesiolo- gist. Each patient expects and should receive the maximum in aseptic safety as well as quality care. Most OR personnel, by nature of their training, are alert to any break in technique. Nursing responsibility usually in- cludes the surgical prep, the transportation of the patient, the skin prep, the draping, and the sterile supplies, and continued aseptic tech- nique during the course of the operative procedure. The anesthesiologist and the sur- geon are equally responsible. The anesthesiol- ogist for the use of safe, clean anesthesia equipment and the best type of anesthetic for the patient, the surgical team for responsible tissue handling, techniques, with local and systemic chemoprophylaxis. As a team, each one individually and collectively is respon- sible. The ORS is responsible to the surgical teams for making available well trained personnel, materials and equipment. Personnel should be thoroughly oriented to asepsis, routine proce- dures, supplies, equipment and the needs of the surgeon and anesthesiologist. In addition, a surgically clean area maintained by the correct, systematic cleaning by housekeeping personnel and with OR personnel assisting in

every way possible, is basic to minimizing infections in the OR. Clean equipment and frequent hand washing are basic to effective infection control. All equipment must be kept in good working order and be properly prepared for use on the sterile field in the OR. Proper sterilization of supplies and instru- ments utilizing the most effective aseptic technique is essential.

Each member of the surgical team must assume certain responsibilities. Personal hy- giene is one of the greatest offenders in creating conditions for infections. The necessi- ty for frequent handwashing cannot be over- emphasized. The hands come in contact with everything and can quickly transmit bacteria to a new location with one single motion. Bacteria from the nasopharynx by droplet can be easily introduced into the air when a mask is worn improperly. The mask should be changed with each case and conversation limited during the setting up and surgical procedure. Personal hygiene also involves the cleanliness of the skin and hair of the body. The shedding of bacteria is directly associated with the exposed skin areas and, therefore, the use of trousers with closely knitted material around the ankles has been instituted in many surgical suites to reduce the spreading of bacteria. “Panty-hose” are effective. Under no circumstances should personnel with lesions or superficial boils of the skin be in the surgical suite. This applies to the physicians as well as other OR personnel. Why is it that some of the very people who are involved in making the rules and regulations are the first to break them and usually scream the loudest when they are enforced? Their attitude is that the rules are made “for the other guy” but do not apply to them! The responsibility of the ORS for enforcing the rules and regulations made by the medical staff , committees and administra- tion is not a task for a weakling. It requires a great deal of intestinal fortitude, patience and self control to enforce the rules and philoso-

AORN Journal 56

phies of the hospital-rules made for every- one with no exception.

In most cases the OR personnel assimilate this information and willingly follow through. The safety and welfare of the patient must come first at all times. A well planned “on going” education program, making the information available to all the staff, can be done in several ways:

1. The orientation of new personnel to the operating room, done by a co-ordinator of inservice and orientation, if possible, exposes the new individual to the policies, techniques, equipment and function of the department. After the orientation period, the experienced members of the staff who are familiar with the hospital routines can assist in the continuing education.

2. Well planned inservice educational meetings should be conducted at least once a week. Here, new techniques in patient care, equipment, education, meeting reports and products used in the operating room can be introduced to the staff. Questions can be raised and effectively answered about the services, new items, and ideas. Problem areas that need reviewing and revision by the staff can be presented. Other staff members can be given the opportunity to contribute at these meetings by attending seminars, conventions or presenting new literature on a given procedure or piece of equipment. This too is a good place to evaluate the practiced aseptic technique, cleaning procedures, and equip- ment management of the department. In this way all members of the staff are given an opportunity to improve the quality of patient care. Availability of personnel governs staffing pattern, with the individual person and his capabilities always considered when establish- ing a working staffing pattern. Coverage must be provided for the hours demanded by the OR schedule without inflicting impossible situations on the staff or surgeons. The problems of running too many cases at one

time, insufficient time to prepare for a case, or pushing an individual to a point beyond endurance result in sloppy, hurried technique. Carelessness in staffing can create an ideal situation for the introduction of infection. Being human, personnel tend to take short- cuts if rushed or overworked. Assignments can be made utilizing adequate personnel with the necessary experience and capabilities to cover the surgical procedures. Equipment must be kept in good working condition. Faulty equipment is a hazard for it can increase operative time and subject the patient to the increased possibility of an infection. Equipment in need of repair should be recognized quickly and made available again as soon as possible. Manufacturer’s fact sheets should be available at all times pertaining to the equipment used in the department. New equipment and new tech- niques presented to the staff, either by manufacturers or the surgeons themselves, should be fairly evaluated before being instituted. This can frequently be done by distributing the trial product and requesting a written comment by the evaluator. Written procedures, policies and philoso- phies are of no use unless they are clearly communicated and understood by the staff. This is true not only in the area of the OR, but throughout the hospital. There must be understanding and cooperation if standards for high quality patient care and infection control are to be established and maintained. Communication must be considered a two-way project resulting in compromises to obtain needed results. Suggestions to improve patient care must be considered and evaluated without prejudice by all members of the team-surgeons, anesthesiologists, nurses, technicians,-then a firm stand taken when a decision is made. Communications must be kept open. Occasionally a decision made may not prove to be the best. This then must be recognized and steps must be taken to change the situation.

M a y 1970 s7

Figure 2

INDICATE RESPONSES BY CHECKING APPROPRIATE S W E S ;

1. DOES THIS PATIENT HAVE EVIDENCES WHICH COULD INDICATE AN INFECTION? 0 YES = 1 n W . 2 58

2. IF YES. WHAT SITES 7 A. POST-OPERATIVE WOUND 0 YES. 1 59 8. CUTANEOUS 60 C. EYE, EAR, NOSE 8 THROAT :E: 1: 61 D. RESPlRATCtlY 0 YES.1 62 E. CARDIOVASCULAR (IWCLUDINO VEINS) 0 YES = 1 63

G. GENITOURINARY 0 YES’ I 65 H. MUSCULOSKELETAL 0 YES = I 66 I. CENTRAL NERVOUS SYSTEM c] YES = 1 67 J. OTHER 0 YES = 1 68

F. GASTROINTESTINAL 0 YES = 1 64

SPLFIfY

3. WAS THIS PATIENT DISCHARGED OR TRANSFERRED? 0 YES

D o ’ W 1 1 . U

Suspected cases of infection require a definite routine for reporting and care. Personnel involved in the care of the “infected” patient should be oriented, in- structed and supervised in their particular phase of the care of the patient.

There are many methods of reporting infection. The newest one, the infections control computer card, is proving of great value when used with the services of an epidemiologist. The epidemiologist is inter- ested in infection prevention and eradication. If a problem exists, or is suspected, the epidemiologist, a valuable resource person possessing the most current information, should be utilized to perform special investi- gations into causes and effects.

The computer cards (Figure 2) are checked by the floor nurses each day with information each epidemiologist and bacteriologist feels is pertinent. The information is transferred to a master form and sent to each area involved in caring for individual patients, including hospital administration and nursing adminis- tration.

The fact that one can check the surgery schedule in the OR against the daily infection census and be able to know which patients are infected, and be able to prepare for them, is a boon to the prevention and control of the spread of infection in the OR. Similarly, iE a

patient is discovered to be infected during an operative procedure, the OR personnel com- plete a “Septic Report,” color code the chart, and fill in the infections control computer card. This card is kept active while the patient is in the OR, OB, or on the nursing unit, and each day thereafter until released from isolation or discharged from the hospital. This information remains on file, and if the patient is scheduled for re-admittance, present status must be questioned and evaluated.

Infected cases require definitive handling with cooperation of all personnel involved, including the hospital laboratory. This committee concerns itself with review- ing and analyzing charts, reporting infections, resolving problems brought to their attention by the nursing staff or epidemiologist, evaluating the laboratory findings, evaluating nursing and housekeeping procedures, and reviewing the use of antibiotics. The commit- tee is also involved in developing and enforcing the policies of the hospital and the techniques of each department. The physicians on the committee are involved in enforcement of regulations for members of the medical staff.

Since the OR is the area of constant practiced asepsis, the ORS or her representa- tive is an active member of the infection committee. She not only profits from this

58 AORN Journal

experience but contributes her knowledge and experience. She shares in the general problems and at the same time makes the committee aware of specific problems she encounters in carrying out the daily surgery schedule. She becomes a liaison between the OR department and the infections committee, thereby strengthening both areas. An example of one of the problems discussed in infection control committees was to use or not to use floor mats. Facts and figures are necessary to convince a doubting committee to consent to at least a trial use. Figure 3 represents the results of two series so initiated. (We now have mats at the elevator and at all entrances to the “clean” areas.)

Reports to the infections committee are completed on each infected or suspected infected patient. The forms ask for specific information and are completed by the circu- lating nurse at the end of the surgical procedure, then placed with the routine operative record. Examples are shown in Figures 4 and 5 of suggested “Septic Reports.” These forms are submitted to the infections committee for evaluation and follow-up, if necessary. It is noted that an area has been provided for a copy of the culture report from

the laboratory. This becomes a part of the operating room’s records. It is a reference that is easily accessible both to the chairman of the infections committee and to the ORS.

Figure 5 depicts another useful Infection Report developed and used at Loma Linda University Hospital in Southern California. This hospital is fortunate in having a nurse- epidemiologist who understands and assists in infection control within the hospital ; perhaps coming close to an ideal situation in an area where there is usually dilemma, challenge and chaos. The ORS, an active member of the OR Committee, shares in administrative decisions through constant review. This committee assists in formulating standard orders for adequate control of surgical procedures, supplies, scheduling, personnel, equipment and emergencies. Through the chief of surgery, recommendations for policies, prac- tices and procedures are obtained and are established. Through the administrator or his assistant, there is a constant line of communi- cation established in all areas of administra- tion and policy making.

Formulating OR policies and establishing procedures and controls is a challenging task.

SERIES #l CULTURES

#I #2 #3 #4 #5

SERIES #2 CULTURES #l

#3

#4

COLONY COUNTS 5 6 7 8 9 10 15 20 25 30 35 40 45 50 55

x x ~ x x x x ~ x x x x x x ~ x x ~ x x x x ~ x x x x x x x x x x x x x ~ x x x x ~ x x x x ~ x x x x x ~ x x x x ~ x ~ x ~ x x x xxxxx xxxxxxxxxxxxxxxx

FIGURE 3

Surgery Floor Mat Culture Series

DESCRIPTION -Floor in f ront of surgery elevator -Clean mat before placing on floor (DRY) -Floor mat after soaking w i th TERGISYL sol.

-Mat a t 7:OO a.m. fo l lowing overnight soaking -Mat a t 1O:OO a.m. af ter being resoaked w i th

fo r 2% hours

TERGISYL sol. and used

Heavy mixed growth of coliforms and Bacillus species.

Heavy mixed forms o f Staphylococcus epidermidis, coliforms & Bacillus species.

Heavy mixed growth of coliforms and Bacillus species.

Heavy mixed growth o f Staphylococcus epidermidis, coliforms & Bacillus species.

RESULTS OESCRIPTION Culture swabs from floor mat in front of elevator soaked w i th TERGISYL 7:OO a.m.

Culture swab from floor mats in f ront of hallway NOT soaked with TERGISYL 7:OO a.m.

Culture swab from floor mat in f ront of elevator soaked with TERGISYL 3 hours.

Culture swab from floor mats i n f ront of hallway soaked with TERGISYL 1O:OO a.m.

NOTE: None of the cultures taken showed any STAPHYLOCOCCUS AUREUS-COAGULASE POSITIVE or PSEUDOMONAS AERUGINOSA.

M a y 1970 59

FIGURE 4

Report to Infection Control Committee by Operating Room Staff

7 a.m. - 5 p.m. 5 p.m. - 7 a.m.

OBJECTIVES:

Circulating Nurse to complete and forward to OR Control Desk. Charge Nurse to complete and keep w i th Charge Slip a t OR Control Desk. Completed report must accompany patient's chart t o PAR o r ICU.

Proper transportation o f patients to and from the Operating Room. Information for care of patients in the Operating Room, PAR & ICU. Record of organism encountered during a septic case. Systematic control of pathogenic organisms introduced into the OR.

Cleaned By: ~ . ~ ~ .

Circ. Nurse: ~~ ~~ .~ ~

Scrub nurse:-^------ ~

Clean Nurse:-- ~ . ~ ~

Septic Prior OR Culture on Chart

Septic in OR Culture taken Drains/ packings

Post-op Isolation

Patient to PAR Patient to ICU

Anes. Equipment:

Time Received: APM

Type of lsolat ion^_ . .. ~~~ ~ _ _ ~

Comments ~ . . .. .. . . .

- -. . - ..

YES NO Septic Classification B - -_ C- ~ ~ Reverse Isolation . -- ~ ~

I

_ - _ _ - Organism -

Suspected Organism - - ---____-______

Source of Material ..

Requested by Or. - ~ _ _

~- -. __ -_

- -- - _ _

_ _ Requested by Dr. - -____ _. -

HGS-- Drs.--- POST-OPERATIVE CARE REPORT I

Comments OR Supervisor I Infection Committee Chairman Review

AOORESSOGRAPH Report from Pathology Culture taken in OR ~ _____

Date Rec'd. - .___~ ____ -- ~-

To be truly effective, they must be agreed be times when the ORS feels she is trying to upon and understood by administrative, reach an impossible goal, but this must medical and nursing personnel. Policies, in become part of the philosophy of minimizing writing, can be established and controlled by infections in the OR and in creating quality an interested, working committee. There may patient care.

60 AORN Journal

FIGURE 5

Month- -

Discharge Date

Patient's Name: . Age (last) (first)

Room No: Hospital No:------Admission Date:-----

__-. Diagnosis: ___.

SITES: - P.O. Wound Cutaneous EENT Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal CNS OTHER

SIGNS & SYMPTOMS: I

SIGNIFICANT LAB REPORTS:

THERAPY: Start Date Discontinued

POSSIBLE CONTRIBUTORY PROCEDURES: Date I

SURGICAL PROCEDURES: Date ~~~ ~~~

PREDISPOSING HOST FACTORS:

REFERENCES

1. Burden, K. L. and Williams, R. P.: Microbiology, New York, Macmillan Co., 1968. 2. Dineen, P.: The IJse of Polyurethane Sponges in Surgical Scrubbing, Hospital Topics OR Yearbook,

3. Letourneau, C. U.: The Hospital Medical Staff, Hospital Management.

4. Sapp, E.: These OR Nurses Wear Pants-As An

17-34.

Aid In Infection, Hospital Topics OR Yearbook,

5. Sister Mary Louise: The Operating Room Tech- nician, St. Louis, C . V. Mosby Co., 22, 30, 40, 41. 6. Sonneland, J. E.: Does Operating Room Modern- ization Affect the Incidence of Infection? Hospital Topics OR Yearbook, 17-123. 7. Taber's Cyclopedic Medical Dictionary, 11th Edi- tion. Philadelphia, F. A. Davis Co., 1965.

17-121.

M a y 1970 61