section 2.18 - recommended practices for prevention of...

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Patient and Worker Safety

2013 Perioperative Standards and Recommended Practices Last revised: December 2012. Copyright © 2013 AORN, Inc. All rights reserved.

T he following Recommended Practices for Pre-vention of Transmissible Infections have been approved by the AORN Recommended Prac-

tices Advisory Board. They were presented as pro-posed recommendations for comments by members and others. They are effective December 15, 2012. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice set-tings and/or clinical situations that determine the degree to which the recommended practices can be implemented. AORN recognizes the various settings in which perioperative nurses practice, and as such, these recommended practices are intended as guide-lines adaptable to various practice settings. These practice settings include traditional operating rooms (ORs), ambulatory surgery centers, physicians’ offices, cardiac catheterization laboratories, endos-copy suites, radiology departments, and all other areas where surgery and other invasive procedures may be performed.

PurposeThe rapidly changing health care environment pres-ents health care personnel with continual challenges in the form of newly recognized pathogens and well-known microorganisms that have become more resis-tant to today’s therapeutic modalities. Protecting patients and health care practitioners from poten-tially infectious agent transmission continues to be a primary focus of perioperative registered nurses (RNs). The prevention and control of multidrug- resistant organisms (MDROs) requires that all health care organizations implement, evaluate, and adjust efforts to decrease the risk of transmission.

There are three principal elements required for an infection to occur:

• a source or reservoir,• a susceptible host with a portal of entry to

receive the infectious agent, and• a method of transmission.1

These recommended practices are intended to guide perioperative RNs in implementing standard precautions and transmission-based precautions (ie, contact, droplet, airborne) to prevent infection in the perioperative practice setting. Additional guidance is provided for bloodborne pathogens; personal protec-tive equipment (PPE); health care-associated infec-tions and multidrug-resistant organisms (MDROs); immunization; and activities of health care workers with infections, exudative lesions, and nonintact skin. Finally, the document includes guidance for

ongoing education and competency evaluation, docu-mentation requirements, policies and procedures, and quality assurance and performance improvement processes.

Prevention of transmissible infections is a priority in the perioperative environment and includes con-siderations for environment of care, sharps safety and safe injection practices, hand hygiene, sterile tech-nique, and sterilization. These topics are addressed in separate recommended practices and although they are mentioned briefly where applicable (eg, stan-dard precautions), the broader discussions are out-side the scope of this document.

Evidence ReviewA medical librarian conducted a systematic search of the databases MEDLINE®, CINAHL®, Scopus®, and the Cochrane Database of Systematic Reviews for meta-analyses, systematic reviews, randomized con-trolled trials, guidelines, and additions to the Mor-bidity and Mortality Weekly Report. The report was also regularly consulted for newly added, relevant entries. Search terms included infectious disease transmission, infectious skin diseases, soft tissue infections, blood-borne pathogens, gram-negative bacteria, gram-positive bacteria, gram-negative bacte-rial infections, gram-positive bacterial infections, viral hepatitis, viral meningitis, viral skin diseases, HIV infections, disease outbreaks, infectious disease transmission, needlestick injuries, occupational acci-dents, occupational health, occupational diseases, droplet precautions, standard precautions, isolation precautions, airborne precautions, patient isolation, microbial drug resistance, methicillin-resistant Staphylococcus aureus, methicillin resistance, Staph-ylococcus aureus, vancomycin resistance, vaccina-tion, immunization, disaster planning, emergency preparedness, bioterrorism, and chemical terrorism.

The search was limited to articles published in English between 1989 and 2011. The librarian estab-lished continuing alerts on the transmissible infec-tion topics. The authors and medical librarian identi-fied relevant guidelines from government agencies and standards-setting bodies. In addition, the authors requested articles that highlight the causes, identifi-cation, and treatment of transmissible infection, including some that were beyond the scope of this search.

Articles identified by the search were provided to the project team for evaluation. The team consisted of the lead author, three members of the Recommended Practices Advisory Board, and a doctorally prepared evidence appraiser. The lead author divided the

Recommended Practices for Prevention of Transmissible Infections in the Perioperative

Practice Setting

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RP: Transmissible Infectionssearch results into topics and assigned members of the team to review and critically appraise each article using the Johns Hopkins Evidence-Based Practice Model and the Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score as agreed upon by consensus of the team. The appraisal score is noted in brackets after each reference, as applicable.

The collective evidence supporting each interven-tion within a specific recommendation was summa-rized and used to rate the strength of the evidence using the Oncology Nursing Society Putting Evidence into Practice (ONS PEP®) schema. Factors considered in review of the collective evidence were the quality of research, quantity of similar studies on a given topic, and consistency of results supporting a recommenda-tion. The evidence rating is noted in brackets after each intervention.

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Litera-ture Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, Netherlands. ONS PEP is a registered trademark of the Oncology Nursing Society, Pittsburgh, PA.

Recommendation I

Health care workers should use standard precautions when caring for all patients in the perioperative setting.

Standard precautions are the foundation for preventing transmission of infectious diseases. They apply to all patients and across all health care settings (eg, hospi-tals, ambulatory surgery centers, free-standing spe-cialty care sites, interventional sites). Standard precau-tions include practices for hand hygiene, PPE, patient resuscitation, environmental control, respiratory hygiene/cough etiquette, sharps safety, and textiles and laundry.1

I.a. All personnel in the health care organization should follow established hand hygiene prac-tices.1,2 [Recommended for Practice]

Hand hygiene is one of the most effective ways to prevent disease transmission and con-trol infections in health care settings.3

I.b. Perioperative personnel should wear PPE when-ever the possibility exists for exposure to blood or other potentially infectious materials. [Recommended for Practice]

The use of PPE protects the health care pro-vider’s mucous membranes, airway, skin, and clothing from coming into contact with blood, body fluids, and other potentially infectious materials.1,4 (See Recommendation VI.)

I.c. The health care provider should use a mouth-piece, resuscitation bag, or other ventilation

device during resuscitation. [Recommended for Practice]

Respiratory droplets are generated during cardiopulmonary resuscitation (CPR),1 and if CPR is given to a patient with a transmissible infection, disease transfer is possible.5-7 Mouth-pieces, resuscitation bags, pocket masks with one-way valves, and other ventilation devices allow caregivers to perform CPR without expos-ing their nose and mouth to oral and respiratory fluids.1

I.d. The patient should be provided a clean, safe environment.8-11 [Recommended for Practice]

Hospital surfaces are often contaminated with health care-associated pathogens and may be responsible for cross-transmission.12 Infec-tions have been associated with surface contam-ination in hospital rooms, and the level of patient-to-patient transmission has been directly related to the level of environmental contamination.13 In one case of an adenovirus outbreak in a military facility, during which 15 trainees were hospitalized for pneumonia, investigators recovered the infection serotype from several hospital surfaces.14 The researchers concluded that there was a need to reinforce infection control guidelines.

Improved cleaning and disinfection of envi-ronmental surfaces can reduce the spread of numerous pathogens (eg, methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant Enterococcus spp [VRE], norovirus, Clostridium difficile, Acinetobacter spp).13

Research has demonstrated that by consistently cleaning frequently touched items in the patient care environment (eg, toilet handholds, light switches, door knobs, nurse call devices, bed-side rails), infections can be reduced.10

I.e. All people who enter the health care facility should practice respiratory hygiene and cough etiquette. [Recommended for Practice]

Following an outbreak of severe acute respi-ratory syndrome (SARS) in 2003, the Centers for Disease Control and Prevention (CDC) expanded its guideline for infection prevention to include respiratory hygiene and cough etiquette.1 Trans-mission of the virus was believed to occur because simple hygienic measures were not fol-lowed in health care facilities. Failure to use respiratory hygiene and cough etiquette may result in transmission of a respiratory tract infection.1,15

I.e.1. Respiratory hygiene and cough etiquette should include• covering the mouth and nose with a tis-

sue or a sleeve rather than the hand when coughing or sneezing;

• disposing of used tissues quickly;• performing hand hygiene after coming

into contact with respiratory secretions;

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RP: Transmissible Infections• having the person who exhibits signs of

respiratory infection wear a surgical mask if he or she is able; and

• separating those who have a respiratory infection from others by more than 3 feet when possible.1

I.e.2. Health care organizations should promote proper respiratory hygiene and cough eti-quette by• providing resources and instructions for

performing hand hygiene in or near wait-ing areas,

• placing alcohol-based hand rub dispens-ers in convenient locations,

• keeping supplies for hand washing where sinks are available,

• offering surgical masks to coughing patients during periods of increased community respiratory infections (eg, as indicated by increased school absences or patients seeking care for such infections),

• encouraging patients who exhibit signs of respiratory infection to stay at least 3 feet away from others in common areas when possible, and

• posting signs at entrances and in strate-gic places within ambulatory and inpa-tient settings in all languages that are applicable to the population served and that provide instructions for proper respiratory hygiene and cough etiquette.1

I.e.3. Perioperative nurses should promote com-pliance with respiratory hygiene and cough etiquette by educating health care person-nel, patients, and visitors to cover their mouth or nose with tissue or to sneeze or cough into the crook of their arm, especially during seasonal community outbreaks of viral respiratory infections (eg, influenza, adenovirus), and by providing products (eg, tissues, surgical masks, no-touch waste receptacles, hand hygiene products) as con-trol measures for minimizing contact with respiratory secretions.1,15

I.f. Perioperative team members should use safe injection practices (eg, one syringe and one nee-dle, complying with sharps safety measures).1,16

[Recommended for Practice]Using needles and syringes more than once

increases the risk of infection, and unsafe medi-cation injection practices have been implicated in outbreaks of hepatitis B and hepatitis C.1,17-19 The CDC conducted investigations of four large outbreaks in ambulatory surgery facilities and found there is a need to reinforce safe injection practices.19 The breaks in infection control prac-tices were reinserting used needles into a multi-dose vial or solution container (eg, saline bag) and using a single needle or syringe to adminis-ter IV medication to multiple patients.

Appropriate methods to protect health care workers from exposure to hazardous materials or bloodborne pathogens and to decrease the risk of disease transmission through sharps injuries are specified in US Occupational Safety a n d H e a l t h A d m i n i s t r a t i o n ( O S H A ) regulations.4

I.f.1. A syringe and needle should be used only once to administer a medication to a single patient, after which the syringe and needle should be discarded. When administering incremental doses to a single patient from the same syringe is an integral part of the procedure, the same syringe and needle may be reused, with strict adherence to aseptic technique, for the same patient as part of a single procedure. The syringe should never be left unattended and should be discarded immediately at the end of the procedure.16

I.f.2. Perioperative RNs should collaborate with pharmacists to procure and store single-dose vials rather than multidose vials.16

Reuse of multidose vials of medication is a concern as a cause of iatrogenic blood-borne pathogen infection.18,20 Outbreaks of hepatitis B and C viruses in New York, Oklahoma, and Nebraska were attributed to unsafe injection practices that led to patient-to-patient transmission, including contamination of multidose medication vials and reuse of syringes and needles.19

HIV can be transmitted either parenter-ally or across mucous membranes. The risk of transmission from mucocutaneous expo-sure is estimated at 0.03%, and the risk of infection as a result of intact skin exposure is below detection.20 Health care providers are among at-risk populations for occupa-tional exposure to HIV, and transmission is significantly associated with procedures involving a needle placed in the source patient’s blood vessel.21

Following fundamental infection-control principles (eg, safe injection practices, appropriate aseptic techniques) helps reduce the risk of bloodborne pathogen transmission.18,19

I.g. Reusable health care textiles should be changed and laundered after each patient use or when soiled. Health care textiles should be laundered in a health care-accredited laundry facility.22 [Recommended for Practice]

Health care textiles (eg, patient gowns, bed linens, privacy curtains, washcloths) may become contaminated by bacteria and fungi dur-ing wear or use, and microbes can survive on textiles for extended periods.23,24 Contaminated textiles could contaminate the environment or health care providers’ hands or clothing.1

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Recommendation II

Contact precautions should be used when providing care to patients who are known or suspected to be infected or colo-nized with microorganisms that are transmitted by direct con-tact or indirect contact.

Contact precautions are in addition to standard precau-tions, including PPE (eg, gloves, gowns, masks, face protection). Additional precautions include flushing mucous membranes and washing skin that is exposed to blood or other potentially infectious materials, tak-ing special considerations for patient transport, increasing environmental cleaning, adequate cleaning and disinfection of patient care equipment and items, and coordinating with an infection preventionist.

Contact with infected patients or contaminated sur-faces leads to pathogen transmission 45% of the time, according to a review of 1,022 health care-associated infection outbreaks.25 Health care providers are at risk of spreading health care-associated infections (eg, S aureus, VRE) through contact, according to a study in which researchers saw positive cultures from imprints of health care providers’ hands after contact with sur-faces near 34 out of 64 patients.26 Adherence to contact precautions helps prevent transmission of infectious agents, including MDROs.1,27-29

Clostridium difficile is known to be transmitted by contact with contaminated people or environmental surfaces,12 and skin contamination and environmental shedding of the pathogen can persist after symptoms resolve for up to four weeks after therapy.30 An out-break of staphylococcal bullous impetigo during a five-month period in a maternity ward was caused by con-tact with an auxiliary nurse, who was an asymptomatic nasal carrier of the strain.31 In a study of VRE transmis-sion, researchers cultured the intact skin of 22 colo-nized patients and sites in the patients’ rooms before and after care by 98 health care providers.32 The health care providers touched 151 VRE-negative sites after touching a VRE-positive site. The researchers found that VRE was transferred via health care providers’ hands or gloves 10.6% of the time.

Contact precautions, as part of an overall infection control program, have been shown to decrease MRSA infection and transmission33,34 and multidrug resistant Acinetobacter baumannii infection.35

II.a. Personal protective equipment should be worn in the perioperative setting as part of contact precautions. [Recommended for Practice]


II.a.1. Perioperative personnel should don PPE upon room entry and discard PPE upon exiting the room when caring for a patient who requires contact precautions.1

Donning a gown and gloves when treat-ing a patient who requires contact precau-

tions and discarding them when leaving the patient’s room helps contain pathogens, especially those that can be transmitted through environmental contamination (eg, VRE, C difficile, norovirus).1

Although PPE as part of contact precau-tions may help contain pathogens, there is some conflicting evidence. One cluster- randomized trial in an intensive care unit setting indicated that contact precautions (ie, gloves, gowns, hand hygiene) were not significantly more effective in preventing transmission of MRSA or VRE than univer-sal gloving.36 In six months, there were 5,434 admissions to 10 intervention inten-sive care units compared with 3,705 admis-sions to eight control intensive care units, and the rate of colonization or infection per 1,000 patient-days at risk did not differ sig-nificantly between the intervention and control sites. However, the providers did not use contact precautions as often as required: when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts.36

II.b. Health care providers must wash their hands and skin with soap and water or flush their mucous membranes with water immediately or as soon as possible after coming into direct con-tact with blood or other potentially infectious materials.1,4 [Recommended for Practice]

Exposure to environmental pathogens (eg, Aspergillus spp, Legionella spp) can cause ill-ness among health care providers and adverse patient outcomes.9 There is a risk of bloodborne disease transmission from splash injuries dur-ing endourology and other minimally invasive procedures, according to a study of 118 proce-dures performed by five surgeons.37 The researchers noted that mucocutaneous and transconjunctival exposure are important por-tals for transmission. In a study of 25 consecu-tive patients who were undergoing dental sur-gery for impacted mandibular third molars, investigators concluded that surgeons were exposed to possible bloodborne infections by splashing in nearly 90% of the procedures.38

II.c. When patient transport is necessary, precau-tions should be taken to reduce the opportunity for transmission of microorganisms to other patients, personnel, and visitors and to reduce con tamina t ion o f the env i ronment . 1 [Recommended for Practice]

II.c.1. Patient transport should be limited to essen-tial diagnostic and therapeutic procedures that cannot be performed in the patient’s room.1

II.c.2. When transport is necessary, appropriate barriers should be used on the patient to

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RP: Transmissible Infectionscover affected areas if infectious skin lesions or drainage are present. These barri-ers should be consistent with the route and risk of transmission.1

II.c.3. When a patient who requires contact pre-cautions is transported from one area to another, the nurse should notify the receiv-ing team members that the patient is com-ing and what precautions should be taken to prevent transmission.1

II.d. Environmental cleaning should be included as part of a program to control the transmission of MDROs.27 [Recommended for Practice]

Environmental reservoirs have been impli-cated in transmission of VRE and other MDROs. Thorough cleaning and disinfection practices, including of frequently touched surfaces (eg, bedrails, charts, bedside commodes, door-knobs), can help control the spread of MDROs.27 Improved environmental cleaning can reduce the transmission of multidrug-resistant A bau-mannii, MRSA, VRE, Acinetobacter spp, and C difficile.13,39-41

II.d.1. Patient care areas of patients infected with C difficile should be cleaned with a 10% bleach solution and allowed to air dry.

Contamination of environmental surfaces contributes to the spread of C difficile.42 Clostridium difficile is a spore that can sur-vive for months in the environment and is not killed by standard processes for envi-ronmental cleaning.39

Educating housekeeping personnel on environmental cleaning practices signifi-cantly reduces the amount of contamina-tion, according to a prospective, six-week before-and-after study.42 When housekeep-ing personnel used 10% bleach solution to disinfect frequently touched surfaces (eg, bed rails, bedside tables, call buttons, tele-phones, toilet seats, door handles), contami-nation was significantly reduced, from nine rooms with positive cultures before clean-ing to two rooms with positive cultures after cleaning.

II.e. All noncritical equipment (eg, commodes, IV pumps, ventilators, computers, personal elec-tronic devices) should be cleaned and disin-fected before use on another patient and should be handled in a manner to prevent health care provider or environmental contact with poten-tially infectious materials.1 [Recommended for Practice]

II.e.1. Dedicated noncritical equipment such as stethoscopes, blood pressure cuffs, and electronic thermometers may be used.1,43

II.f. Routine cleaning of environmental surfaces (eg, floors, walls) should be performed according to

facility policy and more frequently when neces-sary.11 [Recommended for Practice]

Surface cleaning and disinfection practices are recommended to manage outbreaks caused by Acinetobacter spp, C difficile, MRSA, norovi-rus, and VRE.13 Cleaning may need to be more thorough or performed more frequently depend-ing on the patient’s level of hygiene, the degree of environmental contamination, and the type of infectious agent (eg, if the infectious reservoir is the intestinal tract).1

II.g. An infection preventionist should be consulted for guidance when measures are indicated to prevent the spread of highly transmissible or epidemiologically important pathogens.1 [Recommended for Practice]

II.h. Perioperative nurses should evaluate and man-age any negative patient outcomes that may be caused by using contact precautions. [Recommended for Practice]

Studies have shown that health care provid-ers are half as likely to enter the rooms of or examine patients who require contact precau-tions.44,45 Patients may experience increased anxiety and depression and decreased levels of satisfaction under isolation precautions.27,46

A systematic review of 15 studies from 1989 to 200846 indicated four adverse outcomes related to contact precautions:

less patient-to-health care provider contact,changes to systems of care that produce delays and more noninfectious adverse events,increased symptoms of depression and anxi-ety, anddecreased satisfaction with care. Although the majority of patients believe that

contact precautions protect them and others, it is important to carefully consider whether con-tact precautions are necessary and to communi-cate the primary function of using contact pre-cautions to the patient.47

By educating a patient who requires contact precautions and his or her family members, the perioperative nurse may be able to minimize feelings of isolation, depression, and anxiety. Nurses are in a position to evaluate patients for negative feelings, improve social contact, and provide education and frequent communication to the patient.

Recommendation III

Droplet precautions should be used throughout the periopera-tive environment (ie, preoperative, intraoperative, postopera-tive) when providing care to patients who are known or sus-pected to be infected with microorganisms that can be transmitted by large droplets.1

Droplet precautions in addition to standard precau-tions reduce the risk of pathogens that spread through close respiratory or mucous membrane contact (eg,

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RP: Transmissible Infectionsadenovirus, group A streptococcus, influenza, Neisse-ria meningitides, pertussis, rhinovirus).1 Droplet pre-cautions include donning PPE, considering patient placement to minimize contact with other patients, consulting with an infection preventionist, and placing a mask on the patient during transport.

Droplets in exhaled breath (ie, mouth or nose breathing, coughing, talking) may carry microorgan-isms that can be transmitted over short and long dis-tances,48 and infected droplets may originate during certain procedures (eg, suctioning, endotracheal induc-tion, CPR).1,5 During the 2003 SARS outbreak in Toronto, Canada, 26 health care providers contracted the virus from seven patients. Researchers concluded that close contact with the ill patients’ airways (eg, during intubation, transportation) and failure to pre-vent exposure to respiratory secretions through infec-tion control practices were associated with transmission.49

III.a. When a patient believed to have mumps, rubella, or pertussis enters the health care facil-ity, droplet precautions should be implemented and followed, and only health care providers with presumptive immunity should be exposed to the patient.50 [Recommended for Practice]

III.b. Personal protective equipment should be worn in the perioperative setting as part of droplet precautions. [Recommended for Practice]


III.b.1. Perioperative personnel should don surgical masks when in close contact with a patient who requires droplet precautions.1

Surgical masks prevent the transmission of large droplets (ie, greater than 5 microns) and, worn correctly, protect health care pro-viders who are within close proximity of a patient who requires droplet precautions.1 Masks serve as protection from infectious microorganisms from patients (eg, respira-tory secretions, blood spatters, body fluid).

III.b.2. Health care providers should change PPE and clothing when they are exposed to patient secretions or droplets.

Changing PPE can help prevent cross-contamination of influenza viruses.51

III.c. Patients who require droplet precautions should be placed in a single-patient room before and after surgery. [Recommended for Practice]

Single-patient placement in an isolation room helps prevent the spread of infection from patient to patient.1,27,52 Special air handling and ventilation are not required as a part of droplet precautions.1

III.c.1. If single patient placement is not possible, the perioperative nurse should collaborate

with the facility infection preventionist to establish optimal preoperative and postop-erative placement for a patient who requires droplet precautions.1

The infection preventionist can help assess and mitigate the risks associated with non-isolation placement options (eg, cohort-ing, keeping the patient with an existing roommate) to minimize the potential for cross-contamination.

III.c.2. Patients who require droplet precautions should be placed at least 3 feet away from other patients.1

The defined risk area (ie, > 3 feet) around the patient is based on epidemiologic and simulated infection studies.1

III.c.3. If possible, draw curtains or close doors.Curtains and doors help to separate the

patients and reduce transmission of infec-tious organisms.

III.d. When transporting the patient from one area to another, the patient should wear a mask.1 [Recommended for Practice]

Masks prevent possible spread of infectious respiratory secretions from the patient to other individuals.

Recommendation IV

Airborne precautions should be used when providing care to patients who are known or suspected to be infected with microorganisms that can be transmitted by the airborne route.

Some procedures performed in the perioperative set-ting require access to the airway; therefore, special infection-control considerations for preventing trans-mission of airborne disease are necessary.53 Airborne precautions in addition to standard precautions for the OR include consultation with an infection prevention-ist, respiratory protection, PPE, patient placement and transport precautions, administrative controls, and environmental controls.9,53

Airborne transmission can occur when small parti-cles that contain infectious agents that remain infective over time and distance are inhaled.1 This is specific to particles that are approximately 1 µm to 5 µm and that remain airborne for prolonged periods by normal air currents, which allow them to spread throughout a room or building.53 The use of airborne precautions can help minimize transfer of diseases that are spread by the airborne route54 (eg, Mycobacterium tuberculosis [TB], rubeola, Varicella zoster1).

IV.a. An infection preventionist should be consulted to determine necessary supplemental controls for patients requiring airborne isolation.53 [Recommended for Practice]

IV.b. When a patient suspected of measles infection enters the health care facility, all health care personnel should use respiratory protection, regardless of presumptive immunity, when

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Measles vaccination can fail and is ineffec-tive for preventing measles about 1% of the time. Measles is highly contagious and trans-mission can occur anywhere from four days before presentation of a rash to four days after the rash resolves.50

IV.c. When a patient with confirmed or suspected varicella infection enters the health care facility, airborne and contact precautions should be implemented and followed, and only health care providers with evidence of immunity should provide care to the patient .50 [Recommended for Practice]

IV.d. Personal protective equipment should be worn in the perioperative setting as part of airborne precautions. [Recommended for Practice]


IV.d.1. Perioperative personnel should don a surgi-cal mask or N95 or higher level respirator, depending on disease-specific recommenda-tions, before entering the room of a patient who requires airborne precautions.1

Wearing an N95 or higher level respira-tor, or a mask if a respirator is not available, reduces the risk of airborne transmission.1

IV.d.2. Respiratory protective devices worn during care of a patient with TB should be• certified by the CDC/US National Insti-

tute for Occupational Safety and Health (NIOSH) as a nonpowered particulate fil-ter respirator (N-, R-, or P-95, 99, or 100), including a disposable respirator or pow-ered air-purifying respirator with high efficiency filters,55 and

• available in different sizes and models to accommodate the different facial sizes and characteristics of health care providers.53

IV.e. An airborne infection isolation room should be used if available for patients who require air-borne precautions, including during surgery and postoperative recovery.1,53 [Recommended for Practice]

Use of special air handling and ventilation systems such as an airborne infection isolation room helps prevent the spread of airborne pathogens, particularly TB, rubeola, and vari-cella zoster, and is recommended during pro-cedures that can generate infectious aerosols (eg, endotracheal intubation, bronchoscopy, suctioning, autopsy procedures involving oscillating saws).1(p31)

IV.e.1. If no airborne infection isolation room is available, a portable anteroom system (PAS)-high-efficiency particulate air (HEPA) combination unit may be used.

A pilot study comparing freestanding HEPA filter units placed inside the OR with a novel PAS-HEPA combination unit that was placed outside the OR showed that the PAS-HEPA unit was more effective.56 The PAS-HEPA unit achieved a downward evac-uation of plume, away and toward the main entry door from the sterile field. Compara-tively, the portable freestanding HEPA unit inside the OR moved the plume vertically upward and directly into the breathing zone where the surgical team would be during a procedure. Results indicated that the PAS-HEPA system effectively removed more than 94% of an initial release of at least 500,000 submicron particles per cubic foot within 20 minutes after release.

IV.f. When transporting the patient from an airborne infection isolation room to the OR, the patient should wear a mask if clinically appropriate.1 Patients should be transported directly to the OR, bypassing the preoperative area, and trans-ferred directly to an airborne infection isolation room in the postanesthesia care unit or other part of the hospital at the end of the procedure. [Recommended for Practice]

IV.g. After cough-inducing procedures are performed in the OR, sufficient time should be allowed for 99% or more of airborne particles to be removed before sterile supplies are opened for subse-quent patients. [Recommended for Practice]

Performing cough-inducing procedures such as intubation, extubation, and bronchoscopy increases the likelihood that droplet nuclei will be expelled into the air.53 For example, by wait-ing to place another patient in the room, the risk of airborne transmission of TB is reduced. The length of time required to expel more than 99% of airborne contaminants varies by the effi-ciency of the ventilation or filtration system.

IV.h. Elective surgery should be postponed for patients who have suspected or confirmed TB until the patient is determined to be noninfec-tious. If surgery cannot be postponed, perioper-ative personnel should follow airborne precau-t ions and consul t wi th an infect ion preventionist.9,53 [Recommended for Practice]

Postponing elective surgery may prevent transmission of TB.

IV.h.1. A single-use, disposable bacterial filter should be placed between the anesthesia circuit and the patient’s airway.

Placing a bacterial filter between the anesthesia circuit and the patient’s airway prevents contamination of the anesthesia equipment and release of tubercle bacilli

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RP: Transmissible Infectionsinto the room.9,53 The preferred filter will fil-ter particles 0.3 µm or larger in size in both loaded and unloaded states and will have a filter efficiency of 95% (ie, filter penetration of < 5%) at the maximum design flow rates of the ventilator for the service life of the filter.53

IV.h.2. The patient should be intubated and extu-bated and placed for recovery in an airborne infection isolation room. If intubation or extubation must be performed in the OR, a portable, industrial-grade HEPA filter should be used to supplement air cleaning in the following manner: • position the unit near the patient’s

breathing zone, • obtain engineering consultation to deter-

mine the appropriate placement, • switch the portable unit off during the

surgical procedure, and • provide fresh air according to ventilation

standards for the OR.9

Switching the unit off during the proce-dure is recommended because after the patient is intubated, the airway is circulat-ing in a closed system; therefore, the porta-ble units do not serve any purpose while the patient is intubated. Fresh air must be provided because portable units do not meet the requirements for the number of fresh air changes per hour.9

IV.h.3. If the patient is intubated or extubated in the OR, the OR doors should remain closed until adequate time has passed for air changes per hour to clean 99% of airborne particles from the air (eg, 15 air exchanges per hour for 28 minutes to remove 99.9% of airborne contaminants).9

IV.h.4. Standard cleaning and disinfection proce-dures should be followed after surgery on a patient who has TB, and should only be performed after the appropriate amount of time for air ventilation. Personal respiratory protective equipment is not necessary for cleaning an OR if the appropriate ventila-tion time is allowed. If room cleaning activ-ities begin before the appropriate amount of time for air ventilation, cleaning personnel should wear N95 respirators or powered air-purifying respirators.53

IV.i. Administrative controls should be established to reduce the risk of TB exposure to patients and personnel. Administrative controls should include

implementing work practices for managing patients with suspected or confirmed TB;ensuring potentially contaminated equip-ment (eg, endoscopes) is properly cleaned and sterilized or disinfected;

training and educating health care providers about TB prevention, transmission, and symptoms;establishing a TB screening program to screen and evaluate health care providers who are at risk for TB or who might be exposed to M tuberculosis; andimplementing a respiratory protection pro-gram for personnel requiring fit testing and certification to use an N95 respirator.53

[Recommended for Practice]

IV.j. Environmental controls should be established to prevent the spread of airborne diseases. Envi-ronmental controls should include

controlling the source of infection by using local exhaust ventilation (eg, hoods, tents, booths),53

diluting and removing contaminated air with general ventilation,53

controlling airflow to prevent contamination of air in areas adjacent to the source,53

cleaning the air using HEPA filtration or ultraviolet germicidal irradiation,53

using central wall suction units with inline filters to evacuate minimal surgical smoke,9,57 andusing a mechanical smoke evacuation system with HEPA filtration to manage large amounts of surgical smoke.9

[Recommended for Practice]The CDC recommends environmental con-

trols to prevent the spread of airborne infections (eg, TB)53 and to minimize exposure to laser plume that may contain infectious material (eg, human papilloma virus).9

Recommendation V

Health care personnel must follow the OSHA bloodborne patho-gens standard when there is a risk of exposure to blood or other potentially infectious materials.4

Bloodborne pathogens are pathogenic microorganisms that are present in human blood and can cause disease (eg, hepatitis B, HIV).4 Federal and state regulations and organizational standards58,59 mandating bloodborne pathogen guidelines are intended to reduce health care provider exposure to bloodborne pathogens and to minimize the risk of infection.

There has been a focus on preventing bloodborne transmission of hepatitis B, hepatitis C, and HIV in particular.1,19,60-62 These viruses are more easily trans-mitted parenterally or across mucous membranes.20

Methods for preventing bloodborne pathogen expo-sure include using PPE, implementing engineering and work practice controls, following infection prevention precautions, and establishing and following an infec-tion control plan.

V.a. Health care personnel must wear PPE in the perioperative setting as part of the bloodborne pathogens standard.4 [Recommended for Practice]

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RP: Transmissible InfectionsThe use of PPE protects the health care pro-

vider’s mucous membranes, airway, skin, and clothing from coming into contact with blood, body fluids, and other potentially infectious materials.1,4 Appropriate PPE does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration that the PPE is used.4 (See Recommendation VI.)

V.a.1. If a garment is penetrated by blood or other potentially infectious materials, the health care provider must remove the garment immediately or as soon as possible.4

V.a.2. Health care personnel must wear gloves when hand contact with blood, other poten-tially infectious materials, mucous mem-branes, or non-intact skin can be reasonably anticipated; when performing vascular access procedures; and when handling or touching contaminated items or surfaces.4

V.a.3. Health care personnel must wear masks in combination with eye protection devices whenever splashes, spray, spatter, or drop-lets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.4

Eye protection devices include goggles, glasses with solid side shields, and chin-length face shields.

V.a.4. Health care personnel must wear gowns, aprons, and other protective body clothing when exposure to blood or other potentially infectious materials is anticipated.4

V.a.5. Health care personnel must wear surgical caps or hoods and shoe covers or boots when gross contamination can be reason-ably anticipated (eg, orthopedic surgery).4

V.b. Food and drink must not be taken into the semi-restricted or restricted areas of the perioperative suite. Food and drink must not be kept in refrig-erators, freezers, shelves, or cabinets or on counter tops or work spaces where blood or other potentially infectious materials are pres-ent.4 [Recommended for Practice]

V.c. Perioperative personnel must use engineering and work practice controls.4 [Recommended for Practice]

Engineering controls isolate or remove the risk of exposure, and work practice controls reduce the likelihood of exposure by changing the method of performing a task.4

Engineering controls includeneedleless systems,4,63,64

self-sheathing needles,4 andsharps storage and disposal containers.4

Work practice controls include

prohibiting risky handling of needles and sharps,prohibiting recapping of needles by a two-handed technique,4 using a neutral zone or hands-free technique for passing sharps,4,65 anddouble gloving during all surgical procedures (See Recommendation VI.b.).

V.d. Health care organizations must establish a writ-ten exposure control plan, make it accessible to employees, and review and update it at least annually.4 [Recommended for Practice]

Recommendation VI

Perioperative personnel must wear PPE when exposure to blood or other potentially infectious materials is anticipated.4

The OSHA standard requires employers to provide appropriate PPE to health care providers at no cost to reduce the risk of skin and mucous membrane expo-sure to blood, body fluids, and other potentially infec-tious materials.4

All health care providers are responsible for ensur-ing the safety of patients, other health care providers, their own family members, and the community.66 According to the Workers’ Family Protection Task Force, there are limited data to quantify household exposures to potentially infectious organisms; how-ever, workers who may not exhibit negative effects from workplace exposure still may expose their family members by taking infectious pathogens home (eg, occupationally acquired hepatitis C or HIV). Existing standards that require employers and employees to reduce occupational risks (eg, using PPE, engineering controls) protect the workers’ families as well.

It is the employer’s responsibility to ensure that PPE is available and readily accessible, alternatives are available for employees with allergies, and that person-nel use the appropriate PPE. Personal protective equip-ment includes gloves, gowns, eye protection, masks, and respirators.

VI.a. Gloves must be worn when hand contact with blood or other potentially infectious materials, mucous membranes, or non-intact skin can be reasonably anticipated,4 including when

performing vascular access procedures3,4;coming into direct contact with patients who are colonized or infected with pathogens (eg, VRE, MRSA, respiratory syncytial virus)27; andhandling or touching contaminated patient care items or environmental surfaces.4

[Recommended for Practice]Gloves help prevent health care providers’

hands from becoming contaminated by patient blood, body fluids, and other potentially infec-tious materials.3,4,26,32,67,68 Gloves have been found to protect health care providers’ hands from VRE contamination69 and to reduce the risks of sharps injuries.70

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RP: Transmissible InfectionsVI.a.1. Unsterile gloves should be visually

inspected upon donning, before contact with potentially contaminated surfaces, and periodically throughout use.71 After use, perioperative personnel should remove gloves, discard them, and perform hand hygiene.

VI.a.2. Sterile gloves should be visually inspected immediately upon donning and before con-tact with sterile supplies or the sterile field.

Gloves may have perforations or tears that occur in the manufacturing process or as gloves are donned.

VI.a.3. Sterile gloves should be changed• after each patient contact;• when a visible defect is noted;• when suspected or actual contamination

occurs; and• when a suspected or actual perforation

occurs.4,72,73

Breaches in the glove barrier pose a risk for transmission of bloodborne pathogens during surgical procedures. Glove perfora-tion also increases the risk of surgical site infection (SSI).74

Depending on the duration of wear, sur-gical gloves can develop microperforations that are not immediately recognizable to the wearer.75-77 These perforations allow bacte-ria from the surgical site to pass through to the wearer’s hands. One method for pre-venting this is to mandate regular glove changes in organizational policy. Changing gloves at regular intervals may decrease the incidence of glove perforation and bacterial c o n t a m i n a t i o n d u r i n g s u r g i c a l procedures.73,77,78

VI.a.4. Use of polyvinyl chloride or vinyl gloves should be limited to brief, low-risk exposures.

Research has shown that vinyl and poly-vinyl gloves have a higher failure rate in use than nitrile or latex gloves.71,79-81 In a study of 137 procedures, researchers noted higher microbial contamination of the health care providers’ hands and a higher frequency of leaks with vinyl gloves compared to latex.71 Similarly, a study of 886 examination gloves showed vinyl gloves were much more likely to leak than latex (51.3% vs 19.7%) as demonstrated by a standardized clinical protocol designed to mimic patient care activities.79 Research also has indicated polyvinyl chloride gloves fail to protect against virus exposure 22% of the time.82

Comparisons of different glove types have supported the decreased durability of vinyl and polyvinyl chloride gloves. Researchers evaluated 2,000 gloves (ie, 800 latex, 800 vinyl, 400 nitrile) and tested them immediately out of the box and after

manipulations designed to simulate in-use conditions.81 Vinyl gloves failed 12% to 61% of the time, whereas latex and nitrile had failure rates of 0% to 4% and 1% to 3%, respectively.

Another comparison involving 5,510 medical examination gloves (1,464 nitrile, 1,052 latex, 1,006 copolymer, 1,988 vinyl) showed that vinyl and copolymer (ie, poly-vinyl chloride) gloves were less effective barriers than latex and nitrile.80 Results showed 8.2% failure rates for the vinyl and copolymer gloves compared to 1.3% for nitrile and 2.2% for latex.

VI.b. Perioperative team members should wear two pairs of surgical gloves, one over the other, dur-ing surgical and other invasive procedures with the potential for exposure to blood, body fluids, or other potentially infectious materials. When double gloves are worn, perforation indicator systems should be used. [Recommended for Practice]

Glove barrier failure is a common occurrence in the perioperative setting. Glove failures can be caused by punctures, tears by sharp devices, or spontaneous failures. Breaches in the glove barrier pose a risk of transmission of bloodborne pathogens during surgery. Wearing double gloves helps prevent SSI and protect health care providers’ hands.83-89

According to a study of 155 surgeons and res-idents in Canada, double gloving is an effective means to reduce the risk of percutaneous injury.90 Double gloving also minimizes the amount of blood that is transferred to the health care provider’s hands during a needlestick injury,91 reduces the risk of glove perforation associated with lengthy surgical procedures,92

and reduces the risk of perforation of the inner-most glove.85

Double gloving or double gloving with an indicator glove system may increase the wear-er’s awareness of a perforation and thereby pro-tect against exposure to bloodborne pathogens during surgery.86,89,93,94 In one 24-month study,86 researchers investigated the effects of double gloving with inner indicator gloves and found that the frequency of seeing blood on the hand after surgery was higher with single gloving than double gloving. They also noted that surgi-cal team members were more likely to change their gloves during surgery when they double gloved with an indicator system compared with double gloving alone.

VI.b.1. When the invasive procedure is completed, perioperative personnel should remove both pairs of gloves, discard them, and per-form hand hygiene.2

VI.c. Perioperative personnel must wear fluid- resistant attire during activities that generate splashes, spatter, sprays, or aerosols of blood or

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RP: Transmissible Infectionsother potentially infectious materials. 4 [Recommended for Practice]

The CDC recommends wearing fluid-resistant gowns for all patient contact.1 Fluid-resistant attire protects health care providers’ skin from being exposed to blood, body fluids, and other potentially infectious materials. Surgical scrub attire, laboratory coats, or jackets worn over per-sonal clothing are not considered PPE.1

VI.d. Health care personnel must wear eye protection when splashes, spray, spatter, or droplets of blood or other potentially infectious materials can be reasonably anticipated.4 [Recommended for Practice]

The CDC recommends eye protection as part of standard precautions1 and when there is a risk of infectious materials entering the eye.95 Using eye protection helps prevent exposure to bloodborne pathogens and other diseases (eg, SARS, TB, Neisseria meningitidis) during aerosol-generating procedures, including bron-choscopy, endotracheal intubation, and open suctioning of the respiratory tract.1

Infectious diseases, including adenovirus, herpes simplex, S aureus, hepatitis B, hepatitis C, and HIV, can be transmitted through the mucous membranes of the eye (ie, conjunc-tiva).95 These infectious agents can be intro-duced directly to the eye by blood splashes or respiratory droplets that are generated during coughing or suctioning or from touching the eyes with contaminated fingers or other objects.95

The type of eye protection that is necessary depends on the circumstances of exposure, other PPE that is being used, and personal vision needs; however, regular prescription eye-glasses and contact lenses are not considered eye protection.95 Appropriate eye protection includes goggles, face shields, and full-face res-pirators. The CDC recommends selecting eye protection based on other PPE requirements to ensure proper fit and optimal protection.95

VI.d.1. Goggles should fit snugly, especially at the corners of the eye and across the brow, be indirectly vented, and have anti-fog properties.

Fitted, indirectly vented goggles with a manufacturer’s anti-fog coating are the most reliable and practical means of protecting health care providers’ eyes from splashes, sprays, and respiratory droplets. They can be fit over prescription glasses. Safety glasses do not provide splash or droplet protection and are not recommended for infection control purposes.95

VI.d.2. Face shields should be selected for circum-stances where eye protection alone is not sufficient.

Face shields provide protection to the eyes and other areas of the face. Face

shields that have crown and chin protection and wrap around the face to the point of the ear allow for the best face and eye protec-tion from splashes and sprays. Although disposable face shields that fit loosely and are made of light-weight films with attached surgical masks are available, these may not provide complete protection.95

VI.d.3. Full facepiece elastomeric respirators and powered air-purifying respirators should be selected based on the respiratory hazard in an infection control situation.95

Full facepiece elastomeric respirators and powered air-purifying respirators pro-vide highly effective eye protection in addi-tion to respiratory protection.95 These devices require prescription inserts for health care providers who wear glasses to avoid compromising the seal around the face. Another option for health care provid-ers who wear prescription glasses is a pow-ered air-purifying respirator that is designed with a loose-fitting face piece or with a hood that completely covers the head and neck.

VI.d.4. Eye protection should be removed by han-dling only the portion of the equipment that secures the device to the head.

By removing eye protection by the plas-tic temples, elasticized band, or ties rather than handling the front or sides, health care providers can minimize the risk of contami-nation of their hands.95

VI.d.5. Non-disposable eye protection should be placed in a designated receptacle for subse-quent cleaning and disinfection, and health care providers should each be given their own eye protection when possible.95

VI.e. Perioperative personnel must wear surgical masks when splashes, spray, spatter, or droplets of blood or other potentially infectious materi-als may be generated and nose or mouth con-tamination can be reasonably anticipated.4 [Recommended for Practice]

Masks protect the mucous membranes of the nose and mouth, which are susceptible to infec-tious agents.1,4 Masks are used to prevent con-tact with respiratory secretions or sprays of blood and body fluid as part of standard and droplet precautions.1

Splash injuries are common during endo-scopic and laparoscopic urologic procedures, a fact that has implications for all minimally invasive procedures, according to a four-month study of 118 endoscopy procedures.37 The investigators collected 236 masks from sur-geons, surgical assistants, and perioperative nurses and analyzed them for blood macroscop-ically and using forensic techniques. Results indicated 48.5% of the surgeons’ masks, 29.5%

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RP: Transmissible Infectionsof the assistants’ masks, and 31.8% of the nurses’ masks were splashed with blood.

Masks also are used as part of sterile tech-nique to protect patients from exposure to infec-tious agents that may be carried in the health care provider’s mouth or nose.1 Surgical masks have been shown to reduce bacterial contamina-tion produced by dispersal of organisms from the wearer’s upper airway96 and are believed to protect the surgical site from becoming contami-nated.97 During cataract surgery, for example, there is significantly less bacterial contamina-tion of the surgical site when the surgeon wears a face mask.98 Visor masks are recommended as a standard practice during oral surgery when high-speed rotary instruments are used because these procedures result in splashing nearly 90% of the time.38

The Society for Cardiovascular Angiography and Interventions recommends wearing a mask to protect patients during cardiac catheteriza-tion procedures.99 The Society noted that mask use has become more important with increased use of the catheterization laboratory as an inter-ventional suite for device implantation. Signifi-cantly less bacterial contamination of the opera-tive field during cardiac catheterization occurs when health care providers wear full masks compared to no masks, and there is a nonsignifi-cant trend of increased bacterial colony counts when masks are worn below the nose as opposed to above the nose.100

The two types of masks available in health care settings are surgical masks and procedure masks. Surgical masks, which are evaluated by the US Food and Drug Administration for fluid resistance, bacterial filtration efficacy, differen-tial pressure, and flammability, are appropriate for use as PPE in the perioperative setting.1

Whether to wear a mask or respirator depends on disease-specific recommenda-tions,101 but the CDC notes that it is good prac-tice to don a mask within 6 to 10 feet of a patient or on entry to the patient’s room when exposure to an “emerging or highly virulent pathogen” is likely.1

VI.e.1. Employers should provide masks in a vari-ety of shapes (eg, molded, non-molded), sizes, filtration efficiencies, and methods of attachment (eg, ties, elastic, ear loops).

Providing several varieties may be neces-sary to meet individual health care provid-ers’ needs.1

VI.f. Perioperative personnel should wear N95 or higher level respirators during aerosol- generating procedures involving patients who have TB, SARS, or avian or pandemic influenza viruses.1 [Recommended for Practice]

Wearing an N95 or higher level respirator when caring for a patient who requires airborne

precautions reduces the likelihood of airborne infection transmission.1

One review of 21 studies indicated that N95 respirators are more protective against influenza and similarly sized particles than surgical masks.102 However, the investigators noted that additional research is needed to support the World Health Organization guidelines for wear-ing surgical masks for all patient care and N95 respirators for aerosol-generating procedures. In another review of 45 articles, researchers were unable to determine which specific hygienic measures were most effective in reducing MRSA rates, but they noted that a combination of measures—masks, gloves, gowns, and hand hygiene—are effective together.103

VI.g. Perioperative personnel must replace PPE and clothing as soon as possible after exposure to blood or other potentially infectious materials.4 [Recommended for Practice]

Replacing PPE and clothing after exposure to secretions and droplets that contain viruses is effective for preventing cross-infection.51

VI.h. Perioperative personnel must remove all PPE before leaving the work area and must place used PPE in an appropriately designated area or container for storage, washing, decontamina-tion, or disposal.4 After removing PPE, hand hygiene should be performed.2 [Recommended for Practice]

VI.h.1. Perioperative personnel should stand 3 feet away from the disposal container when removing soiled gloves.

One study of glove removal procedures indicated that when personnel stood 3 feet away from the garbage bin as opposed to 2 feet, there was less contamination on the cover of the bin and the front of the removed gloves.104 There was no significant difference in hand contamination levels based on distance to the disposal container.

Recommendation VII

Perioperative personnel should take action to prevent the trans-mission of health care-acquired infections.

Several types of infections may be acquired in the peri-operative setting and are affected by perioperative care, including SSIs, MDROs, central line-associated blood stream infections, and catheter-associated urinary tract infections. The entire perioperative team is responsible for collaborating to prevent these types of infections.

VII.a. Perioperative team members should adopt a sys-tematic approach for reducing the risk of surgi-cal site infections.97 [Recommended for Practice]

Despite advances in infection control prac-tices (eg, improved OR ventilation, sterilization methods, barriers, surgical technique, antimi-crobial prophylaxis), SSIs remain a substantial

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RP: Transmissible Infectionscause of morbidity and mortality among hospi-talized patients.97 Surgical site infections occur in 2% to 5% of US patients who undergo sur-gery in inpatient facilities for a total of approxi-mately 500,000 SSIs each year, at a cost of up to $10 billion annually.105 Furthermore, these infections are associated with seven to 10 addi-tional postoperative days per SSI and increase the risk of death by as much as 11 times.

According to the Hospital Infection Control Practices Advisory Committee Guideline, SSI is the third most frequently reported health care-associated infection and accounts for between 14% and 16% of all health care-associated infections in hospitalized patients.97 Among sur-gical patients, SSIs account for 38% of health care-associated infections, and 77% of deaths in surgical patients who develop an SSI are related to the infection.97,105

The pathogens that contribute most fre-quently to SSI include S aureus, coagulase- negative staphylococci, Enterococcus spp, and Escherichia coli, and increasingly include Can-dida albicans and MRSA.97 Most SSIs are caused by the patient’s endogenous flora (eg, gram-positive cocci, anaerobic bacteria, gram-negative aerobes), but they also can be caused by exogenous sources of pathogens such as members of the surgical team; the OR environ-ment and air; and all devices, instruments, and materials that are brought to the sterile field.97

Surgical site infection prevention measures (ie, an action or a set of actions taken to reduce the risk of SSI) focus on reducing opportunities for microbial contamination of the patient’s tis-sues or sterile surgical instruments. Specific methods for preventing SSI include adhering to sterile technique, implementing environmental cleaning protocols, using appropriate barriers and surgical attire, performing proper skin anti-sepsis and hand hygiene, minimizing traffic in the OR during surgical procedures, using ade-quate sterilization methods, treating carriers of S aureus preoperatively, and using preoperative antimicrobial prophylaxis.97

VII.a.1. Perioperative personnel should implement sterile technique when preparing, performing, or assisting with invasive procedures.11,73,106

Sterile technique performed by all peri-operative team members is the foundation of SSI prevention.97 Failure to adhere to the principles of asepsis is independently related to the risk of SSI.1,73,107

VII.a.2. A c l e a n e n v i r o n m e n t s h o u l d b e maintained.11,97

VII.a.3. Perioperative personnel should wear clean surgical attire.22

Although few controlled trials have eval-uated whether the use of surgical attire has an effect on reducing SSIs, the Hospital Infection Control Practices Advisory Com-

mittee recommends the use of barriers (eg, scrub suits, masks, surgical caps, hoods, shoe covers, sterile gloves, gowns, drapes) to minimize the patient’s exposure to the skin, mucous membranes, and hair of surgi-cal team members.97

Wound infections may result when pathogens that adhere to the hair or scalp (eg, S aureus, Group A streptococcus, Staphylococcus epidermidis) are released into the operative air and settle into the sur-gical incision.108-110

VII.a.4. Preoperative skin antisepsis of the surgical site should be performed.111

Antiseptic skin preparation of the surgi-cal site is intended to reduce the risk of postoperative SSI by removing soil and transient microorganisms from the skin; reducing the resident microbial count to subpathogenic levels in a short period and with the least amount of tissue irritation; and inhibiting rapid, rebound growth of microorganisms.

VII.a.5. Perioperative personnel should follow proper hand hygiene practices.2

Hand hygiene helps reduce the bacterial colony count on perioperative team mem-bers’ hands and is believed to reduce the risk of SSI.97,112 In one study, the introduc-tion of a hand sanitizer with 70% isopropyl alcohol and 0.5% chlorhexidine gluconate and training perioperative team members on its use reduced SSI overall and superfi-cial SSI in particular among patients under-going neurosurgery.113

VII.a.6. Traffic in and out of the OR should be mini-mized during surgical procedures.114

The air in the OR may contain microbe-laden dust, lint, skin squames, or respiratory droplets, and the microbial level in the air is directly related to the number of people who are moving around in the room.97

VII.a.7. Perioperative personnel should provide reusable surgical items that are free of con-tamination at the time of use. Reusable sur-gical items should be subjected to cleaning and decontamination, followed by a disin-fection or sterilization process.115

Inadequate sterilization of surgical instruments can contribute to SSI outbreaks.97

VII.a.8. Perioperative nurses should collaborate with medical colleagues to evaluate testing or decolonizing patients preoperatively for carriage of S aureus and using preoperative prophylaxis on carriers.

S aureus is carried in the nasal nares of 20% to 30% of healthy individuals, and this carriage has been found to be “the most powerful independent risk factor for SSI” in

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RP: Transmissible Infectionspatients undergoing cardiothoracic sur-gery.97 Among 135 orthopedic surgeons at a teaching hospital, 1.5% tested positive for MRSA and 35.7% tested positive for methicillin-sensitive S aureus.116

Mupirocin ointment may be an effective topical therapy for removing S aureus from the nares of colonized patients and health care providers, and the ointment can lower the risk of SSI when it is used on patients regardless of carrier status.97,117 The evi-dence is conflicting, however. Another study failed to demonstrate an overall reduction in SSI when intranasal mupirocin was administered to carriers of S aureus preoperatively, and the study only showed a trend for decreased health care-associated infections caused by S aureus.118

Researchers in the Netherlands found that decontaminating endogenous microor-ganisms in the nasopharynx and orophar-ynx with chlorhexidine gluconate preopera-tively reduces health care-associated infection after cardiac surgery.119

VII.a.9. Perioperative nurses should verify that pre-operative antimicrobial prophylaxis is administered according to health care orga-nization policy.

Surgical antimicrobial prophylaxis is a critically timed adjunct therapy intended to reduce the microbial burden of surgical contamination to a level that cannot over-whelm the patient’s defenses.97 The surgeon decides which antimicrobial agent to use by anticipating the surgical wound class for a given procedure. Comparisons of various antibiotics for short-term treatment have been shown to be equally effective against SSI in patients undergoing elective implant surgery120 and orthopedic surgery.121 To maximize the benefits of antimicrobial pro-phylaxis, the Hospital Infection Control P r a c t i c e s A d v i s o r y C o m m i t t e e 9 7

recommends • using an antimicrobial agent for all pro-

cedures or classes of procedures for which use has been shown to reduce SSI rates or for procedures from which inci-sional or organ/space SSI would be catastrophic;

• using a medication that is safe, inexpen-sive, and bactericidal with an in vitro spectrum that covers the most probable intraoperative contaminants for the surgery;

• timing the initial dose of the medication so that a bactericidal concentration is established in serum and tissues by the time of the incision; and

• maintaining therapeutic antimicrobial levels in both serum and tissues during

the procedure and until a few hours after the incision is closed.The Society for Healthcare Epidemiology

of America/Infectious Diseases Society of America practice recommendations105 include • delivering IV prophylaxis within one

hour before the incision is made, or two h o u r s f o r v a n c o m y c i n a n d fluoroquinolones;

• using an antimicrobial agent that is con-sistent with published guidelines; and

• discontinuing use of the antimicrobial agent within 24 hours after surgery, or 48 hours for cardiothoracic procedures in adult patients.

VII.b. To limit or slow the spread of MDROs, perioper-ative personnel should collaborate with an infection preventionist to determine the best and safest plan for surgical patients who are diagnosed with an MDRO. [Recommended for Practice]

Methicillin-resistant S aureus and VRE are not the only MDROs that present an infection prevention challenge. Other MDROs continue to emerge as a publ ic hea l th concern . Carbapenem-resistant Enterobacteriaceae has become a serious threat to public health. These organisms have the potential to spread and are associated with high mortality rates, and they often carry genes that cause high levels of resis-tance to many antimicrobial agents, leaving extremely limited options for treatment.122,123

When MDROs are introduced into a health care setting, several factors determine the likeli-hood of transmission and persistence of the resistant strain:

vulnerability of patients (ie, patients in the hospital are more likely to get an infection because their immunity is weakened from the disease state),numbers of colonized patients,increased antimicrobial use, andeffect of and adherence to prevention efforts.27

Successful approaches to preventing and controlling MDROs are often a combination of strategies,27,124 including

garnering administrative support (eg, com-mitment of fiscal and staffing resources, implementation of system changes, expert consultation, laboratory support, adherence monitoring, data analysis)27,125;following and improving hand hygiene practices13,27,34,41,69,126-130;using contact precautions until patients are culture negative27,34,41,127;performing enhanced environmental cleaning13,27,32,41,127; managing vascular and urinary catheters27;preventing lower respiratory tract infection in intubated patients27;

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RP: Transmissible Infectionsaccurately diagnosing infectious etiologies27;following the recommendations of the CDC Campaign to Prevent Antimicrobial Resistance27,131;limiting and carefully selecting antimicrobial agents27,121,132-136;conducting MDRO surveillance as part of an MDRO control program27,41,127,137,138;using active surveillance cultures27,34,126;educating staff members to encourage behav-ior change through better understanding of MDROs27,41,139; andimproving communication about patients with MDROs within and between health care facilities.27

Several studies also promote cohorting patients,140,141 using designated beds or units, universal screening,142 and closing units when necessary to control transmission of MDROs.27

VII.c. Perioperative personnel should implement CDC guidelines to prevent central line infections, including using sterile technique and maximal sterile barrier precautions (ie, hair covering, mask, sterile gown, sterile gloves, a sterile full body drape) when inserting central catheters.143 [Recommended for Practice]

Central line infections cause significant prob-lems for patients and health care facilities in terms of increased length of stay and increased cost. It is a national imperative to eliminate cen-tral line-associated blood stream infection among patients, and the CDC Healthcare Infec-tion Control Practices Advisory Committee has specific recommendations for all health care providers who insert central catheters, which includes anesthesia professionals. It is the peri-operative nurses’ responsibility to make sure this evidence-based guideline is followed to promote safety in all perioperative patients.143

One study from the United Kingdom demon-strated that 39% of hospital-acquired MRSA bacteremia cases were caused by a central line. The researchers recommended a focus of infec-tion prevention efforts should be on improving insertion and care of central lines.144

Intraoperative stopcock contamination increases the rate of patient mortality, and patient and provider reservoirs contribute to 30-day postoperative infections, according to a multicenter study.145 Researchers observed stop-cock transmission events in 274 ORs and col-lected reservoir bacterial cultures. They identi-fied stopcock contamination in 23% of procedures and concluded that although patients, provider hands, and the environment may have contributed to the transmission events, the environment was the most likely source. The researchers recommended design-ing multimodal programs to target each reser-voir in parallel and introducing a comprehen-sive approach to reducing intraoperative bacterial contamination.

VII.d. Perioperative nurses should follow the CDC guidelines for the prevention of catheter- associated urinary tract infections146 and the health care organization’s policies and proce-dures for urinary catheter insertion to prevent urinary tract infections.

Catheter-associated urinary tract infections are considered health care-associated infec-tions. They are preventable by following evidence-based recommendations.146

One UK study showed that 51% of hospital-acquired MRSA bacteremia cases were caused by urinary catheters. The researchers recom-mended focusing infection prevention efforts on improving the insertion and care of urinary catheters.144 [Recommended for Practice]

VII.d.1. Perioperative personnel should• insert catheters only for medically indi-

cated conditions;• use urinary catheters for surgical patients

only as necessary as opposed to routinely;

• document the date and time of catheter insertion and remove the catheter as soon as possible postoperatively, prefera-bly within 24 hours;

• strictly follow sterile technique when placing a urinary catheter; and

• allow only trained persons who are familiar with correct sterile technique and maintenance to insert urinary catheters.

Recommendation VIII

Health care personnel should be immunized against vaccine-preventable diseases.

The CDC Advisory Committee for Immunization Prac-tices recommends that health care providers receive immunizations if they come into contact with patients or infectious material from patients that may put them at risk for exposure and possible transmission of vaccine-preventable disease.50 Including vaccinations as part of an organizational infection control and pre-vention program reduces the risk of occupationally acquired infections and, therefore, harm to patients from vaccine-preventable diseases.4,50

The CDC recommends that health care providers receive vaccinations for diseases for which routine vaccination or documentation of immunity is recom-mended because of risks in the workplace (ie, hepatitis B, seasonal influenza, measles, mumps, rubella, per-tussis, varicella).50

VIII.a. Employers must make the hepatitis B vaccina-tion series available to all perioperative employ-ees whose work involves a reasonable risk of exposure to blood or other potentially infec-tious materials and must provide post-exposure evaluation and follow-up to all employees who have an exposure incident.4,50 [Recommended for Practice]

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RP: Transmissible InfectionsHepatitis B is highly contagious and is trans-

mitted via percutaneous exposure (eg, needle-stick injury) or mucosal exposure to infected blood or body fluids. The risk of acquiring hepa-titis B infection from occupational exposure depends on the frequency of percutaneous and mucosal exposure to blood or body fluids that contain the virus.50 Risks to health care provid-ers from sharps injuries and blood and body fluid exposure has been reduced as a result of widespread hepatitis B vaccination.17

Although rare, health care personnel who have hepatitis B or hepatitis C can transmit them to patients.147

VIII.a.1. Serologic testing should be repeated after hepatitis B vaccination for health care per-sonnel who are at “high risk” of occupa-tional percutaneous or mucosal exposure to blood or body fluids. If antibody levels are too low (< 10 mIU/mL), the health care pro-vider should be revaccinated and tested again after completing the series.50

Performing serologic testing one to two months after the last dose of the vaccine helps determine whether there is a need for revaccination and guides post-exposure prophylaxis in the event of an exposure incident.50

VIII.a.2. In the event of blood or body fluid exposure (ie, percutaneous, ocular, mucous mem-brane, nonintact skin), the need for post-exposure prophylaxis should be evaluated immediately based on the hepatitis B sur-face antigen status of the source and the health care provider’s vaccination history and vaccine-response status.50

VIII.b. All health care personnel who have no contrain-dications should receive annual influenza vacci-nations. [Recommended for Practice]

Health care providers are exposed to patients who have influenza and are therefore at risk of occupationally acquired influenza and transmit-ting the disease to patients and other providers.50

VIII.b.1. Health care organizations should imple-ment strategies to improve influenza vacci-nation rates among perioperative personnel.

Strategies that can improve vaccination rates include • establishing evidence-based educational

and promotional programs to communi-cate about the disease and the vaccine,50,148,149

• capitalizing on the belief in ethical responsibility and protecting patients,150

• running a campaign that emphasizes the benefits of vaccination for personnel and patients,50,151

• implementing a vaccine declination policy,50

• encouraging senior medical staff mem-bers or opinion leaders to ge t vaccinated,50

• removing administrative barriers (eg, costs),50,151

• providing incentives for get t ing vaccinated,50,151

• providing the vaccine in locations and at times that are easily accessible to health care providers,50,151 and

• monitoring and reporting provider vacci-nation rates.50

In January 2007, the Joint Commission began requiring accredited facilities to pro-vide staff members, including volunteers and licensed independent practitioners, with influenza vaccinations and to report coverage levels.50 As of January 2013, the Centers for Medicare & Medicaid Services will require acute care hospitals to report vaccination rates among providers as part of its hospital inpatient quality reporting program.50

Despite the fact that annual vaccination has been recommended for health care pro-viders and is a high priority for reducing morbidity associated with the virus in health care settings, vaccination rates among health care providers still need to improve.50,148,152

According to a survey of 304 health care personnel at a German tertiary care univer-sity hospital, concern about adverse effects was a primary reason to avoid vaccina-tion.148 Health care providers who are less likely to get vaccinated include• women152;• nurses, technicians, and administrative

workers152; and • those who did not receive a vaccine the

previous year.152 According to a survey conducted across

eight university medical centers in the Netherlands,153 health care providers are more likely to get an influenza vaccination if they• are older than 40 years of age, • have a chronic illness, • are aware of personal risk or the risk of

infecting patients, • trust that the vaccine is effective for

reducing the risk of infecting patients, • believe in the health care provider’s

responsibility to “do no harm” and ensure continuity of care, and

• have convenient access to the vaccine.Social pressure for vaccination also increased the likelihood of health care pro-viders getting vaccinated.

Health care personnel are more likely to accept the influenza vaccine if they have a desire to protect themselves or patients or

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RP: Transmissible Infectionshave a perception that the vaccine is effective.50

Establishing a mandatory vaccination program is feasible and leads to high vacci-nation rates, as demonstrated by a five-year study conducted at a tertiary care center in Seattle, Washington.154 In the first year of the program, 4,588 of 4,703 health care pro-viders (97.6%) were vaccinated, and rates stayed above 98% for the subsequent four years. Of those who declined vaccination, 0.7% did so for religious reasons and were required to wear a mask during influenza season, and less than 0.2% opted to leave the facility. Although 72% of survey respondents at another facility in which mandatory vaccination was implemented reported feeling that the policy was “coer-cive,” more than 90% agreed that the policy was ethically responsible and important for protecting patients and staff members.150

VIII.c. Perioperative personnel should have presump-tive evidence of immunity to measles, mumps, and rubella, and this information should be documented and readily available in the health care setting.50 [Recommended for Practice]

Presumptive evidence includes written docu-mentation of vaccination with two doses of measles-mumps-rubella vaccine administered at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or birth before 1957.

Measles and mumps are highly contagious and can have serious consequences. Rubella was declared eliminated from the United States in 2004, but there is a risk of resurgence from importation.50

Exposure to measles, mumps, or rubella in the health care setting can be expensive and dis-ruptive because of containment measures, nec-essary personnel furloughs or reassignments, and potential closures.50

VIII.d. Health care personnel should receive a single dose of tetanus toxoid, reduced diphtheria tox-oid, and acellular pertussis (Tdap) as soon as feasible upon hire if they have not been vacci-nated previously.50 [Recommended for Practice]

Pertussis (ie, whooping cough) is a highly contagious bacterial infection and is transmitted via contact and droplet routes.50 Pertussis out-breaks in health care facilities can be costly in terms of personnel, testing, treatment, and pro-phylaxis, but adult vaccination may reduce the disease burden.155 The Tdap vaccine protects against pertussis and reduces the risk of trans-mission to patients, other health care providers, family members, and the community.50

In October 2010, the CDC Advisory Commit-tee for Immunization Practices recommended expanding the use of the Tdap vaccine.156 According to CDC, although there is a high rate

of coverage for pertussis vaccination in chil-dren, the disease is “poorly controlled in the United States;” Tdap coverage is 56% among adolescents and less than 6% among adults.156

VIII.d.1. Health care organizations should establish programs to increase Tdap vaccination among personnel, including providing con-venient access to the vaccination, giving the vaccination free of charge, and educating health care providers about the benefits of vaccination.50

VIII.e. Health care organizations should ensure that all health care personnel have evidence of immu-nity to varicella, and providers who have no evidence of immunity should receive the vari-cella vaccine. This information should be docu-mented and readily available in the health care setting.50 [Recommended for Practice]

Varicella is highly infectious and is transmit-ted via contact, droplet, and airborne routes. Primary infection usually results in lifetime immunity, and the US vaccination program that began in 1995 has led to greater than 85% declines in varicella incidence, hospitalizations, and deaths.50

Despite the reduced incidence, health care-associated transmission is still a risk and the disease can be fatal. Varicella is more likely to spread in hospital settings and long-term care facilities.50 Varicella exposure among patients and health care providers can disrupt patient care and cost the facility in terms of identifying susceptible patients and staff members, manag-ing those who are exposed, and mandating fur-loughs for exposed staff members.

VIII.e.1. When a patient with confirmed or sus-pected varicella infection enters the health care facility, airborne and contact precau-tions should be implemented and followed, and only health care providers with evi-dence of immunity should provide care to the patient.50

VIII.f. Health care organizations should review health care provider vaccination and immunity status at the time of hire and at least annually thereaf-ter. [Recommended for Practice]

Regularly reviewing vaccination and immu-nity status helps ensure that health care provid-ers are up to date with respect to the recom-mended vaccines.50

VIII.f.1. All health care personnel should receive baseline TB screening upon hire. Follow-up testing should be performed in the case of exposure to TB.53

Recommendation IX

Activities of health care personnel with infections, exudative lesions, and nonintact skin should be restricted when these activities pose a risk of transmission of infection to patients

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RP: Transmissible Infectionsand other health care providers. State, federal, and professional guidelines and strategies should be followed to determine the need for work restrictions for health care personnel with blood-borne infections.20,28

Restricting activities of personnel who have transmis-sible infections reduces transmission between provid-ers and patients depending on the mode of transmis-sion and epidemiology of the disease.28 Infections that may require restrictions from providing direct patient care, entering the patient’s environment, or handling instruments or devices that may be used during a sur-gical or invasive procedure include

• viral respiratory infections (eg, influenza, respira-tory syncytial virus),28

• keratoconjunctivitis or purulent conjunctivitis caused by other microorganisms,28

• acute gastrointestinal illnesses (ie, vomiting or diarrhea with or without nausea, fever, or abdom-inal pain),28,157

• diphtheria (ie, identification as an asymptomatic carrier),28

• exudative lesions that cannot be contained (eg, eczema, impetigo, smallpox),28,29,31,109

• herpes simplex infections of the fingers or hands (ie, herpetic whitlow),28

• pediculosis,28

• scabies,28 and• meningococcal infection (ie, until 24 hours after

the start of effective therapy).28

Work restrictions for health care personnel with bloodborne infections who provide direct patient care depend on several factors, including circulating viral burden and category of clinical activities.20

IX.a. An employee health nurse, infection preven-tionist, or physician should assess any health care provider with an infection, exudative lesions, or nonintact skin before he or she is allowed to return to work providing direct patient care or handling medical devices that are used in surgical or other invasive proce-dures. [Recommended for Practice]

Medical clearance is necessary before health care providers who have an infection, exudative lesions, or nonintact skin can return to work with patients or other health care providers.28

IX.b. Health care personnel should report exposures as soon as they occur and infections as soon as the disease process is noted. [Recommended for Practice]

Early self-reporting of exposures and infec-tions helps prevent transmission to patients and other health care providers. Health care provid-ers can be encouraged to self-report exposures or infections when facility policies are designed to prevent judgement or penalty (eg, loss of wages, benefits, job status) for self-reporting.28,97

IX.c. The health care organization should have a written policy regarding health care personnel who have a potentially transmissible infection. The policy should establish responsibility for

reporting the condition, work restrictions, and guidelines for clearing the employee for work after an illness that required a restriction.28,97


Recommendation X

Perioperative personnel should receive initial and ongoing edu-cation and competency validation of their understanding of the principles of infection prevention and the performance of stan-dard, contact, droplet, and airborne precautions for prevention of transmissible infections and MDROs.

Education and competency validation are prerequisites for ensuring standard and transmission-based precau-tions are understood and followed.158 Ongoing devel-opment of knowledge and skills and documentation of personnel participation is a regulatory and accredita-tion requirement for both hospitals and ambulatory settings.159-162

Initial and ongoing education on infection preven-tion practices facilitate the development of knowledge, skills, and attitudes that affect safe patient care. Peri-odic education programs provide the opportunity to reinforce the principles of infection prevention, the necessary precautions to take when providing care to a patient who has a transmissible infection (eg, stan-dards, contact, droplet, airborne), and the actions to take when a health care provider has a transmissible infection.

Competency validation measures individual perfor-mance; provides a mechanism for documentation; and verifies that perioperative personnel have an under-standing of infection prevention, MDROs, and facility policies. Every nurse is personally accountable for maintaining competency validation.163

There are no universally accepted or mandated ways to perform or validate competency, and strategies differ between states. Some states mandate specific topics that affect public health (eg, bioterrorism) or that are specific to certain areas of nursing. The goal of competency strategies are to reassure the public that nurses have the knowledge, skills, and judgment to provide safe and effective care.164

X.a. Education, training, and competency validation should address

standard precautions;contact precautions;airborne precautions;droplet precautions;MDROs;procedures for transporting patients who require infection precautions;use of N95 or powered air-purifying respirators;bloodborne pathogens;double gloving;sharps safety; andperioperative considerations to prevent cen-tral line-associated blood stream infections, catheter-associated urinary tract infections,

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RP: Transmissible InfectionsS S I s , a n d c a r b a p e n e m - r e s i s t a n t Enterobacteriaceae.

[Effectiveness Not Established]Standard precautions are used for all patients

in the perioperative setting, and transmission-based precautions can be modified depending on local conditions and patient characteristics (Table 1). Including each topic in education and training helps ensure appropriate follow-through in the event of a suspected or identified case of infection. Understanding the scientific premise of these precautions allows health care providers to follow and modify the precautions safely based on identified changes, resources, and health care settings.

X.b. Health care personnel who are occupationally exposed to blood or other potentially infectious materials must receive training before assign-ment to tasks where occupational exposure may occur, at least annually thereafter, and when changes to procedures or tasks affect occupa-tional exposure.4 [Recommended for Practice]

Employers are responsible for providing training on the bloodborne pathogens standard during working hours at no cost to the employee. Employers are also responsible for ensuring employees participate in the training program and for offering materials in appropri-ate languages and at appropriate literacy levels.4

Providing the basis for the prevention of bloodborne pathogen exposure may instill an understanding of the processes that need to be followed and thereby prevent disease transmis-sion. Education and training efforts are equally important in promoting awareness of hazards and acceptance of safe work and material- handling procedures in the workplace.66 Educat-ing employees on safe work practices (eg, using PPE) can help protect staff members, their fam-ily members, and the community from take-home transmissions.

X.b.1. Employee education must include • an explanation of the modes of transmis-

sion of bloodborne pathogens and an explanation of the employer’s exposure control plan;

• an explanation of the use and limitations of methods for reducing exposure (eg, engineering controls, work practices, PPE); and

• information on the hepatitis B vaccine, its efficacy and safety, the method of administration, and the benefits of vaccination.4

X.c. Perioperative personnel should receive educa-tion and competency validation on preventing the spread of MDROs as part of the health care organization’s infection prevention program. Education should include

mechanisms of infection transmission,

case-based scenarios for managing infected patients,participatory decision-making exercises about the implementation of precautions in addition to standard precautions, andpractice in the use of PPE for patients who require additional precautions.

[Effectiveness Not Established]Implementing a mandatory, organization-

wide infection-control program can significantly improve the rate of health care-associated MRSA infections.139

X.d. Perioperative personnel should participate in programs to educate health care personnel about the importance of being immunized against epidemiologically important pathogens. [Effectiveness Not Established]

Programs that deliver educational and pro-motional messages about the benefits of vacci-nation can improve vaccination rates among health care personnel.151

X.e. Health care personnel should be educated on the benefits of reporting infections, exudative lesions, and nonintact skin in a timely manner a n d o n r e l a t e d w o r k r e s t r i c t i o n s . [Recommended for Practice]

Institutional policies and procedures that guide work restrictions because of infections are designed to protect patients. Health care provid-ers have an ethical responsibility to promote their own health and well being, and a responsi-bility to remove themselves from care situations if it is clear that there is a significant risk to patients despite appropriate preventive measures.20

X.f. Health care personnel should receive education and training on the facility emergency prepared-ness plan. [Recommended for Practice]

It is important for health care personnel to be prepared to respond to threats of intentionally released pathogens and to treat patients who are exposed to biological agents.165

X.g. Perioperative personnel should participate in educational programs to improve infection con-trol practices. [Effectiveness Not Established]

Surgical teams at a large UK teaching hospi-tal implemented a “clean practice protocol” that increased adherence to overall infection control practices from 63% to 89% in three months, as demonstrated by undisclosed infection-control audits held before and after the education proto-col.166 The protocol combined the use of a reminder poster and auditing several surgical units for activities related to hand decontamina-tion, correct use of gloves, instrument cleaning, garment contamination, and notes contamina-tion. After the audits and education, hand decontamination and the correct use of gloves and aprons improved significantly.

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Table 1. Guide for PerioPeraTive Personnel CarinG for PaTienTs wiTh Transmissible infeCTions1

Type of precaution

Type of organism/ disease

Transport Protection for unscrubbed personnel*

Preoperative area Environmental measures

Contact Draining abscess, infectious wounds, Clostridium difficile, acute viral, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), vancomycin-intermediate/resistant S aureus (VISA/VRSA), extended-spectrum beta-lactamase (ESBL), resistant pneumonia, influenza, and chicken pox

Cover or contain the infected or colonized areas of the patient’s body.

Remove and dispose of contaminated personal protective equipment (PPE) and perform hand hygiene before transporting the patient.

Don clean PPE to handle the patient at the transport destination.

Standard precautions plus the following:

Wear gloves whenever touching the patient’s skin or items that are in close proximity to the patient.

Wear a gown when it can be anticipated that clothing will come into contact with the patient or contaminated environmental surfaces.

Don a gown upon entry into the room, remove and perform hand hygiene before exiting.

Hold the patient in a single patient room if possible; otherwise keep ≥ 3 ft separation between patients.

Clean the room (eg, OR, airborne infection isolation room [AIIR]) immediately after patient use. Focus on frequently touched surfaces.

Droplet Diphtheria, haemophilus influenza type b, seasonal influenza, pandemic influenza, meningococcal disease, mumps, mycoplasma pneumonia, group A streptococcus, pertussis, adenovirus, rubella

Instruct the patient to wear a mask and follow respiratory hygiene and cough etiquette.

The transporter is not required to wear a mask.


Wear a mask upon entry into the room.

Hold the patient in a single patient room if possible; otherwise keep ≥ 3 ft separation between patients.

Draw a privacy curtain between beds to minimize the opportunity for close contact.

Routine

Airborne Tuberculosis, disseminated herpes zoster, rubeola, monkeypox, smallpox, varicella zoster

Instruct the patient to wear a mask and follow respiratory hygiene and cough etiquette.

Cover and contain affected skin lesions.

The transporter is not required to wear a mask


Wear a fit-tested N95 or higher level respirator that is approved by the National Institute for Occupational Safety and Health.

Place the patient in an AIIR, if possible.

Provide at least six (existing facility) or 12 (new construction/renovation) air changes per hour.

Consult an infection preventionist before patient placement to determine the safety of an alternative room that does not meet AIIR requirements.

If an AIIR is not available, the OR should remain vacant postoperatively for the appropriate time to allow for a full exchange of air, generally one hour.

* “unscrubbed personnel” include anesthesia professionals, circulating RN, and preoperative and postanesthesthia care personnel.

Infection control professionals should modify or adapt this table according to local conditions and special patient considerations.

RefeRence1. Siegel JD, Rhinehart E, Jackson M, Chiarello L; the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions:

Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007;35(10 Suppl 2):S65-S164.

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Recommendation XI

Documentation should reflect activities related to infection prevention.

Documentation is a professional medicolegal stan-dard.167 Documentation related to infection prevention is applicable at the systems level and the patient care level. At the systems level, documentation serves as a basis for monitoring compliance, measuring perfor-mance, maintaining employee records, and logging exposure incidents. At the patient care level, docu-mentation facilitates continuity of patient care through clear communication and supports collaboration between health care team members.

XI.a. Employers must maintain training records related to bloodborne pathogens for three years.4 The records must include

training dates,content or a summary of the training,names and qualifications of trainer(s), andnames and job titles of trainees.


XI.b. All incidents of occupational exposure to blood or other potentially infectious materials must be documented.4 Documentation should include

the route of exposure;the circumstances associated with the exposure;the source individual’s serological status, if known;the employee’s name and social security number;the employee’s hepatitis B vaccination status and other relevant medical information for both individuals, including vaccination dates and any medical records related to the employee’s ability to receive vaccinations;results of all related examinations, medical tests, and post-exposure evaluation and follow-up procedures;a licensed health care professional’s written opinion; anda copy of the information provided to the employee.

[Recommended for Practice]Documenting each exposure incident pro-

vides a record of the incident, what follow-through was taken, and the current status of the incident.

XI.b.1. Employers must maintain a sharps injury log to document all percutaneous injuries from contaminated sharps and must main-tain the log in such a way that an injured employee’s identification remains confiden-tial.4 At a minimum, a sharps injury log must include • the type and brand of device involved in

the incident,• the department or work area where the

exposure incident occurred, and

• an explanation of how the incident occurred.Some health care employers may be

exempt from maintaining a sharps injury log. The requirement to establish and main-tain a sharps injury log applies to any employer who is required to maintain a log of occupational injuries and illnesses under 29 CFR §1904.4

XI.b.2. Documentation related to exposure inci-dents must be maintained for the employ-ee’s duration of employment plus 30 years.4

XI.c. Records and results of TB screening should be maintained for each employee in the employee’s health record.53 If an employee has symptoms of TB, the symptoms should be recorded in the employee health record or medical record.53 [Recommended for Practice]

XI.d. Vaccination records should be maintained for each employee. All employee vaccinations should be documented in each employee’s health record. Records of any vaccinations administered during employment should include

the type of vaccine given;the date on which the vaccine is given;the name of the vaccine manufacturer and the lot number;any documented episodes of adverse reac-tions to a vaccination;the name, address, and title of the person who administered the vaccination; and the edition and distribution date of the language-appropriate vaccine information statement provided to the employee at the time of vaccination.50

[Recommended for Practice]Accurate vaccination records make it possi-

ble to quickly identify health care personnel who are susceptible to infection during an out-break and can reduce costs and disruptions to health care operations.50

XI.d.1. Each employee’s immunity status for vaccine-preventable diseases, including documented disease, vaccination history, and serology results, should be recorded in the employee’s record.50

XI.d.2. The health care organization should use a secure computerized system to manage vac-cination records for health care personnel.50

Computerized systems allow records to be retrieved easily and as needed.50

XI.e. Wound class should be documented according to the CDC Surgical Wound Classification sys-tem at the conclusion of the procedure.97 [Recommended for Practice]

The surgical wound classification system has been shown to be a predictor of the relative probability that a wound infection will

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RP: Transmissible Infectionsoccur.97,168 In addition, the classification allows for comparison of wound infection rates associ-ated with different surgical techniques, sur-geons, and facilities. The comparison may be useful for research and also may serve to alert infection prevention personnel to wounds at increased risk for infection, enabling health care providers to implement appropriate surveil-lance and preventative measures.97,168

The definitions of the four CDC wound clas-sifications are

Class 1—Clean wounds: These are uninfected operative wounds in which no inflammation is encountered, and the respiratory, alimen-tary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and, if necessary, drained with closed drainage (eg, Jackson-Pratt). Operative incisional wounds that follow non-penetrating (blunt) trauma should be included in this category if they meet the criteria.Class 2—Clean-contaminated wounds: These are operative wounds in which the respira-tory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appen-dix, vagina, and oropharynx are included in this category, provided no evidence of infec-tion or major break in technique is encoun-tered (eg, spillage from the gastrointestinal tract).Class 3—Contaminated wounds: These include open, fresh, accidental wounds; operations with major breaks in sterile tech-nique (eg, a procedure performed with unsterile instruments) or gross spillage from the gastrointestinal tract; and incisions in which acute, nonpurulent inflammation is encountered.Class 4—Dirty or infected wounds: These include old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated vis-cera. This definition suggests that the organ-isms causing postoperative infection were present in the operative field before the operation.

XI.e.1. Perioperative nurses should use educational tools to assist in accurately identifying sur-gical wounds.

The AORN Surgical Wound Classifica-tion Decision Tree can help perioperative nurses accurately identify surgical wounds (Figure 1).

XI.f. Breaks in sterile technique should be docu-mented per organization policy in consultation with infection prevention personnel.73 [Effectiveness Not Established]

Thoughtful assessment, collaboration with the surgeon and surgical team members, and the application of informed clinical judgment is required when determining whether contamina-tion resulting from a break in sterile technique is significant enough for an infection to occur and the wound classification to be changed.

XI.g. Results of documented surveillance should be shared with perioperative personnel. [Likely to be Effective]

Sharing documented surveillance can help to reduce morbidity and mortality.169 Monitoring performance helps in assessing the effectiveness of quality improvement interventions, and shar-ing surveillance strategies and results helps in identifying best practices for implementing evidence-based guidelines for preventing health care-associated infections.

Surveillance of both process measures and the infection rates to which they are linked are important for evaluating how effective infection prevention efforts are and identifying what needs to be changed. Surveillance is an ongo-ing, systematic collection, analysis, interpreta-tion, and dissemination of data based on infec-tions occurring in the health care facility.1

Recommendation XII

Policies and procedures for the prevention and control of trans-missible infections and MDROs should be developed, reviewed periodically, revised as necessary, and readily available within the practice setting.

Policies and procedures assist in the development of patient safety, quality assessment, and performance improvement activities. Policies and procedures estab-lish authority, responsibility, and accountability within the facility. They also serve as operational guidelines that are used to minimize patient risk factors for com-plications, standardize practice, direct perioperative personnel, and establish continuous performance improvement programs.

XII.a. Policies and procedures should be developed to guide, support, and monitor adherence to stan-dard and transmission-based precautions, including systems that should be used to col-lect, analyze, and communicate information re la ted to t r ansmiss ib le in fec t ions . 1 [Recommended for Practice]

Definitive policies and procedures as part of an overall administrative strategy can demon-strate a commitment to preventing transmissible infections by incorporating infection control into the organizational objectives for patient and occupational safety.1 Policies and proce-dures that guide and support patient care, treat-ment, and services are an accreditation require-ment for both hospitals and ambulatory settings.1,161,162,170-173

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Figure 1. Surgical Wound Classification Decision Tree

Copyright © AORN, Inc., 2011

Is this an old wound (ie, greater than 4 to 6 hours) with• retained devitalized tissue (eg, gangrene, necrosis); or• existing clinical infection (eg, purulence); or• perforated viscera?

NO

Is the wound• clean (ie, not infected or inflamed); or• did the incision follow non-penetrating, blunt trauma?

Was the procedure free from entry into respiratory, alimentary, or genitourinary tract?

Was the wound primarily closed or drained with closed drainage (eg, chest tubes)?

YES

Is there a wound? NO No Wound Classification

Class IClean YES

Was the respiratory, alimentary, or genitourinary tract entered under controlled conditions without

• evidence of infection or contamination; or• major break in technique (eg, spillage from gastrointestinal tract)?

NO

Is the wound• fresh, open, or accidental; or• is there gross (ie, visible) spillage from GI tract; or• is there non-purulent inflammation present?

Was there a major break in technique (eg, unsterile instruments used) during the procedure?

NO

Class IIClean -

ContaminatedYES

Class IIIContaminatedYES

Class IVDirty, Infected

YES

NO

YES

Is there a wound? NO No Wound Classification

Class IClean YES

NO

NO

Class IIClean -

ContaminatedYES

Class IIIContaminatedYES

Class IVDirty, Infected

YESIs this an old wound (ie, greater than 4 to 6 hours) with

• retained devitalized tissue (eg, gangrene, necrosis), or• existing clinical infection (eg, purulence), or• perforated viscera?

Is the wound• clean (ie, not infected or inflamed) or• the result of a non-penetrating, blunt trauma?

Was the procedure free from entry into the respiratory, alimentary, or genitourinary tract?

Was the wound primarily closed or drained with closed drainage (eg, bulb drain)?

Was the respiratory, alimentary, or genitourinary tract entered under controlled conditions without

• evidence of infection or contamination or• major break in technique (eg, spillage from the gastrointestinal tract)?

Is the wound• fresh, open, or accidental; or• is there gross (ie, visible) spillage from the gastrointestinal tract; or• is there non-purulent inflammation present?

Was there a major break in sterile technique (eg, unsterile instruments used) during the procedure?

REFERENCES1. Mangram AJ, Horan TC, Pearson ML; Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical

site infection, 1999. Am J Infect Control. 1999;27(2):97-132.2. Garner, JS. CDC guideline for prevention of surgical wound infections, 1985. Supercedes guideline for prevention of surgical wound

infections published in 1982. (Originally published in 1985). Revised. Infect Control. 1986;7(3):193-200. http://wonder.cdc.gov/wonder/prevguid/p0000420/p0000420.asp. Accessed July 31, 2011.

3. Altemeier WA. Surgical infections: incisional wounds. In: Bennett JV, Brachman PS, eds. Hospital Infections. Boston, MA: Little, Brown and Co; 1979:287-306.

4. Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: the influence of ultraviolet irradiation of the operating room and various other factors. Ann Surg. 1964;160(Suppl2):1-192.

NOTE: These are the original source documents for development of the CDC surgical wound classification system.

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RP: Transmissible InfectionsXII.a.1. Policies and procedures should be devel-

oped and implemented to address specific perioperative interventions to prevent SSIs, MDROs, central line-associated blood stream infections, and catheter-associated urinary tract infections.

XII.b. Policies and procedures designed to eliminate or minimize health care personnel exposure to blood and other potentially infectious materials must be developed and implemented.4

A written exposure control plan that is con-sistent with federal, state, and local rules and regulations and that governs occupational expo-sure to bloodborne pathogens, is reviewed peri-odically, and is readily available in the practice setting promotes safety with medical devices and blood and body fluids.4 [Recommended for Practice]

XII.c. Policies should be developed in accordance with federal and state guidelines and should be consistent with existing impaired-provider and disability guidelines to define work restrictions for health care providers who have infections, exudative lesions, and nonintact skin. The poli-cies should include whether the employee

has a viral burden above the recommended threshold for the relevant virus, has a medical condition or conditions that result in an inability to perform assigned tasks, has documented untoward events (eg, having transmitted hepatitis B, hepatitis C, or HIV), refuses or is unable to follow recommended guidelines to prevent transmission of infec-tious diseases, oris unable to perform regular duties, assuming that reasonable accommodation has been offered for the disability.50


XII.d. A comprehensive vaccination policy for all health care personnel should be developed and implemented.50 The vaccination policy should include a method to ensure that

all health care personnel are up to date with recommended vaccines,health care personnel vaccination and immu-nity status is reviewed at the time of hire and at least annually thereafter, andnecessary vaccines are offered to employees in conjunction with routine annual disease-prevention measures (eg, influenza vaccina-tion, TB testing).


XII.e. Policies and procedures should be developed based on federal and state guidelines to define emergency response to threats of intentionally released pathogens (eg, anthrax, botulism, plague, smallpox).

Establishing policies and procedures for emergency preparedness guides health care pro-

viders in responding to intentionally released pathogens and treating patients who are exposed to biological agents.165 [Recommended for Practice]

XII.f. Policies and procedures should include pro-cesses for initial education, training, ongoing competency validation, and annual review of issues dealing with infection transmission.

Policies and procedures assist in the develop-ment of activities that support patient safety, quality assessment, and the establishment of guidelines for continuous performance improvement. Standardizing processes for per-formance expectations between perioperative settings facilitates continuity of care and reduces the risk of error when personnel rotate between areas. [Effectiveness Not Established]

Recommendation XIII

Perioperative team members should participate in a variety of quality assurance and performance improvement activities to monitor and improve the prevention of infections and MDROs.

Quality assurance and performance improvement pro-grams assist in evaluating the quality of patient care and the formulation of plans for corrective actions. These programs provide data that may be used to determine whether an individual organization is within benchmark goals and, if not, identify areas that may require corrective actions.

XIII.a. Process monitoring should be a part of every perioperative setting as part of an overall infec-tion prevention program. Process monitoring should include174

hand hygiene compliance,standard and transmissible infection precau-tion compliance,influenza vaccinations for personnel and patients,environmental cleaning practices, andcentral line and urinary catheter insertion practices.

[Effectiveness Not Established]

XIII.a.1. Perioperative nurses should assess and monitor cleaning and disinfection practices.

Monitoring cleaning and disinfection practices to ensure adherence can help con-trol transmission of MDROs and other pathogens that may be residing in the envi-ronment.11,175 The information obtained from assessments can be used to develop focused administrative and educational interventions that incorporate ongoing feed-back to the environmental services person-nel, to improve cleaning and disinfection practices in health care institutions.10

Compliance and adjunct monitoring after terminal cleaning can help prevent cross-contamination of areas that have or have had patients with MDROs.27,175

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RP: Transmissible InfectionsXIII.a.2. Perioperative nurses should participate in

quality improvement initiatives that pro-mote understanding of and adherence to the principles of sterile technique.73

XIII.a.3. A quality improvement program for the use of indwelling urinary catheters and central l i n e s s h o u l d b e d e v e l o p e d a n d implemented.

Monitoring the use of indwelling cathe-ters can reduce catheter-associated urinary tract infections.146

Quality improvement initiatives in which various strategies are ‘‘bundled’’ together may improve compliance with evidence-based recommended practices and reduce the incidence of central line- associated blood stream infections.143

XIII.a.4. A quality improvement program for the use of indwelling catheters should be devel-oped and implemented.143

XIII.b. Quality indicators should be developed to mea-sure improvement in the control and transmis-sion of infectious diseases, including MDROs. Quality indicators for measuring the provision of safe patient care with regard to transmissible infections in the perioperative setting should include

the rate of SSIs,the selection of antibiotics that are appropri-ate for surgery,the timing of antibiotic administration, andimmunization rates of patients and personnel.

[Likely to be Effective]Quality indicators are measurable and dem-

onstrate that facilities are using specific inter-ventions to provide safe patient care.176 Accord-ing to the Agency for Healthcare Research and Quality, “An adequate quality indicator must have a sound clinical or empirical rationale for its use. It should measure an important aspect of quality that is subject to provider or health care system control.”176(p3) Quality indicators are one response to the need for multidimensional, accessible quality measures that can be used to gauge performance in health care. The quality indicators are evidence-based and can be used to identify variations in the quality of care pro-vided on both an inpatient and outpatient basis.

XIII.b.1. Perioperative personnel who contract an infection or have a communicable disease should report it to the designated responsi-ble person.

Prompt reporting enables employers to provide timely and confidential evaluation, intervention, and testing, or appropriate prophylaxis.1,28

XIII.b.2. All exposure incidents (eg, needlesticks, blood exposures) must be reported accord-ing to health care organization policy and

based on the OSHA bloodborne pathogens standard.4

Documenting all exposure incidents pro-vides the employer with feedback regarding the circumstances of employee exposures. This information can be used to focus efforts on decreasing or eliminating specific circumstances or routes of exposures.60

XIII.b.3. Perioperative nurses should contribute to ongoing surveillance of proper use of PPE.

By monitoring the proper use of PPE, perioperative nurses can contribute to com-munity safety by helping limit take-home transmissions of infectious and toxic agents.66 To gather data on take-home trans-missions, NIOSH has recommended expanding current surveillance programs, such as building on the existing NIOSH Sentinel Event Notification Surveillance for Occupational Risks programs for lead and pesticides, which would require prioritizing toxic agents and targeting surveillance in areas where workplace exposure is rela-tively common.

The NIOSH Task Force recommends, at a minimum,• develop surveillance programs to docu-

ment the effectiveness of control mea-sures being used, including an assess-ment of the feasibility and effectiveness of alternative measures;

• assess the performance of existing pro-tective clothing (eg, single-use disposable clothing, clothing that can be laundered) as barriers for chemical, biological, ther-mal, and physical hazards;

• assess the use and acceptance of PPE by workers;

• research and develop new types of mate-rials for protective clothing and gloves, including evaluating performance and characteristics; and

• ensure that protective clothing is made available and designed to fit all workers.

XIII.c. Rates of transmissible infections and MDROs should be monitored, documented, and reported to the designated infection prevention-ist and quality assurance improvement manager and any other personnel deemed appropriate by the health care organization. Surveillance should include monitoring

use of standard precautions, contact precau-tions, droplet precautions, and airborne precautions; outbreak-speci f ic pathogens (eg , N meningitides); isolation precautions for MDROs, surveil-l a n c e p r a c t i c e s , a n d p r a c t i t i o n e r adherence177;bloodborne pathogen exposures;use of PPE; and

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RP: Transmissible Infectionshealth care personnel immunization rates.

[Recommended for Practice]Surveillance is a critical component of any

MDRO control program because it allows for the detection of newly emerging pathogens, helps identify epidemiologic trends (eg, single patient, clusters of patients), and measures the effectiveness of interventions.27 Surveillance is important for follow-up with health care per-sonnel who may have an infection or be colonized.1

XIII.d. Perioperative nurses should participate in sur-veillance programs for SSI. [Recommended for Practice]

Routine review and interpretation of SSI rates may help detect significant increases or outbreaks and identify areas where additional resources might be needed to improve SSI rates.105

A successful surveillance program includes using epidemiologically sound infection defini-tions, surveillance methods, stratification of SSI rates according to risk factors associated with SSI development, and data feedback.97 Using consistent definitions as part of an SSI surveil-lance program helps ensure accurate interpreta-tion and reporting. The CDC’s National Nosoco-mial Infections Surveillance system has developed standardized surveillance criteria for defining SSIs.97

Knowing what patient and surgery character-istics may influence the risk of SSI allows the surveillance team to stratify surgeries, makes surveillance data more comprehensible, and allows for targeted prevention measures.97 According to the Hospital Infection Control Practices Advisory Committee, patient charac-teristics that may be associated with an increased risk of SSI include diabetes, cigarette smoking, systemic steroid use, obesity (ie, > 20% ideal body weight), extremes of age, poor nutritional status, and perioperative transfusion of certain blood products. Surgery characteris-tics that affect SSI incidence include preopera-tive antiseptic showering, preoperative hair removal, skin prep practices, preoperative hand and forearm antisepsis, management of infected or colonized perioperative team members, and antimicrobial prophylaxis.

XIII.d.1. Perioperative nurses should implement and record the measures related to Surgical Care Improvement Project (SCIP) initiatives according to health care organization policy.

As a national quality improvement initia-tive, SCIP is supported by more than 10 national organizations with the goal of improving surgical outcomes and signifi-cantly reducing surgical complications. Sur-gical Care Improvement Project measures

are part of the Joint Commission’s account-ability measures.178

One study that involved Surgical Care Improvement Project initiatives showed the importance of following these standard guidelines to decrease the number of patients who experience an SSI.179 Perioper-ative nurses can take an active role in implementing Surgical Care Improvement Project measures and reporting data to iden-tify areas where improvements can be made.

XIII.d.2. The choice of which procedures to monitor should be made jointly by surgeons and infection prevention personnel. SSI surveil-lance should target high-risk procedures.97

XIII.d.3. When a cluster of SSIs involves an unusual organism, a formal epidemiologic investiga-tion should be conducted.97

Outbreaks and clusters of SSIs that involved unusual organisms (eg, Clostrid-ium perfringens, Legionella pneumophila, Legionelle dumoffii, Nocardia farcinica, Pseudomonas multivorans, Rhizopus ory-zae, Rhodococcus bronchialis) have been attributed to contaminated adhesive dress-ings, elastic bandages, colonized surgical personnel, tap water, and disinfectant solutions.97

XIII.e. Perioperative nurses should contribute to creat-ing a culture of safety. [Likely to be Effective]

A culture of safety is created throughmanagement initiatives that improve patient and health care personnel safety,health care personnel participation in safety planning,the availability of appropriate PPE for the identified tasks,the influence of group norms regarding appropriate safety practices, andthe facility’s socialization process for new hires.1

A culture of safety has a direct effect on pre-venting transmissible infections.1

Glossary

Airborne infection isolation: The isolation of patients infected with organisms spread via airborne droplet nuclei < 5 µm in diameter.

Airborne precautions: Precautions that reduce the risk of an airborne transmission of infectious airborne droplet nuclei (ie, small particle residue 5 microns or smaller). Airborne transmission refers to contact with infectious airborne droplet nuclei that can remain sus-pended in the air for extended periods of time or infec-tious dust particles that can be circulated by air currents.

Contact precautions: Precautions designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact.

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RP: Transmissible InfectionsDirect contact: Person-to-person contact resulting in

physical transfer of infectious microorganisms between an infected or colonized person and a susceptible host.

Droplet precautions: Precautions that reduce the risk of large particle droplet (ie, 5 microns or larger) transmission of infectious agents.

Enhanced environmental cleaning: Environmental cleaning practices implemented to prevent the spread of infections or outbreaks, enhanced cleaning practices promote consistent and standardized cleaning proce-dures that extend beyond routine cleaning.

Exposure incident: A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral con-tact with blood or other potentially infectious materi-als that results from the performance of an employee’s duties.

Indirect contact: Contact of a susceptible host with a contaminated object (eg, instruments, hands).

Infection preventionist: A health care professional specializing in leading and directing infection preven-tion and control programs.

Isolation precautions: Special precautionary mea-sures, practices, and procedures used in the care of patients with contagious or communicable diseases.

Personal protective equipment (PPE): Specialized equipment or clothing for eyes, face, head, body, and extremities; protective clothing; respiratory devices; and protective shields and barriers designed to protect the worker from injury or exposure to a patient’s blood, tissue, or body fluids. Used by health care workers and others whenever necessary to protect themselves from the hazards of processes or environments, chemical hazards, or mechanical irritants encountered in a man-ner capable of causing injury or impairment in the function of any part of the body through absorption, inhalation, or physical contact.

Powered air-purifying respirator: A respirator that uses a battery-powered blower to move the air flow through the filters.

Procedure mask: A mask that covers the nose and mouth and is intended for use in general patient care situations. These masks generally attach to the face with ear loops rather than ties or elastic. Unlike surgi-cal masks, procedure masks are not regulated by the US Food and Drug Administration.

Respirator: A personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling haz-ardous airborne particles (including dust particles and infectious agents), gases, or vapors. Source: What is a respirator? NIOSH. http://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/RespSource1.html. Accessed October 2, 2012.

Standard precautions: The primary strategy for suc-cessful infection control and reduction of worker expo-sure. Precautions used for care of all patients regard-less of their diagnosis or presumed infectious status.

Surgical mask: A device worn over the mouth and nose by perioperative team members during surgical procedures to protect both the surgical patient and perioperative team members from transfer of microor-ganisms and body fluids. Surgical masks are also used

to protect health care providers from contact with large infectious droplets (>5 mcm in size). According to draft guidance issued by the US Food and Drug Administration on May 15, 2003, surgical masks are evaluated using standardized testing procedures for fluid resistance, bacterial filtration efficiency, differen-tial pressure (air exchange), and flammability to miti-gate the risks to health associated with the use of surgi-cal masks. These specifications apply to any masks that are labeled surgical, laser, isolation, or dental or medical procedure.

Transmission-based precautions: Precautions designed to be used with patients known or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmis-sion in the practice setting.

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Acknowledgments

Lead author

Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNORDirector of Evidence-based Perioperative PracticeAORN Nursing DepartmentDenver, Colorado

Contributing authors

Ramona Conner, MSN, RN, CNORManager, Standards and Recommended PracticesAORN Nursing DepartmentDenver, Colorado

Kimberly J. RetzlaffManaging EditorAORN Publications DepartmentDenver, Colorado

The authors and AORN thank George Allen, PhD, MS, RN, CNOR, CIC, Director Infection Control, Downstate Medical Center and Clinical Assistant Professor, SUNY College of Health Related Professions, Brooklyn, New York; Hudson Garret, Jr., PhD, MSN, MPH, FNP-BC, Senior Director, Clinical Affairs, PDI Healthcare, Atlanta, Georgia; Marcia R. Patrick, MSN, RN, CIC, Association for Professionals in Infection Control and Epidemiology liaison to the AORN Recommended Practices Advisory Board and Independent Consultant, Tacoma, Washington; and Rebecca Saxton, PhD, RN, CNOR, CNE, Associate Professor, Research College of Nursing, Director, Center for Nursing Research and Innovation, Kansas City, Missouri, for their assistance in developing this recommended practices document.

Publication HistoRy

Originally published February 1993, AORN Journal, as “Recommended practices for universal precautions in the perioperative practice setting.”

Revised November 1998 as “Recommended prac-tices for standard and transmission-based precautions in the perioperative practice setting”; published Febru-ary 1999, AORN Journal. Reformatted July 2000.

Approved June 2006, AORN Board of Directors, as “Recommended practices for prevention of transmissi-ble infections in perioperative practice settings.” Pub-lished in Standards, Recommended Practices, and Guidelines, 2007 edition.

Revised and reformatted December 2012 for online publication in Perioperative Standards and Recom-mended Practices.

http://www.hhs.gov/ash/initiatives/hai/actionplan/

http://www.hhs.gov/ash/initiatives/hai/actionplan/

http://purl.access.gpo.gov/GPO/LPS93676

http://purl.access.gpo.gov/GPO/LPS93676

http://www.jointcommission.org/accountability_measures.aspx

http://www.jointcommission.org/accountability_measures.aspx

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section 2.18 - recommended practices for prevention of...

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