Infection Prevention: A Patient Safety Imperative For The Perioperative Setting

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Date Published
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Batican, Kryza Dale B.

May 2015
GEORGE ALLEN, PhD, RN, CNOR, CIC
http://www.aornjournal.org/article/S0001-2092(15)00252-5/pdf
Infection Prevention: A Patient Safety Imperative for the

Perioperative Setting
I am delighted to serve as the AORN Journal Guest Editor for this special focus issue on
infection prevention. I am an infection preventionist (IP) with more than 20 years of
experience managing the infection prevention and control program at a university-affiliated
acute care hospital in Brooklyn, New York. In addition, I am a perioperative RN who continues
to scrub and circulate in the OR on a per diem basis. Ensuring the safety of personnel related
to the transmission of infections in the workplace is one aspect of the IPs role. Just as
important is the role of ensuring the safety of patients as they interact with the perioperative
environmentdany venue in which surgical and other invasive procedures are performed,
including traditional ORs, interventional radiology suites, and outpatient facilities, including
ambulatory surgical centers. THE BURDEN OF HEALTH CAREeASSOCIATED INFECTIONS
Health careeassociated infections (HAIs) are a major patient safety issue, resulting in a
significant level of morbidity and mortality in the United States each year. A prevalence survey
conducted by the Centers for Disease Control and Prevention (CDC) in 2011 to provide a
national annual estimate of HAIs in acute care hospitals in the United States found that one in
25 patients developed at least one HAI, for an estimated 722,000 HAIs.1 These infections
resulted in approximately 75,000 deaths during hospitalization.2 Surgical site infections (SSIs)
and pneumonia were the most prevalent HAIs (ie, an estimated 157,500 infections of each
type).1,2 Table 1 provides estimates of the different types of HAIs. Gastrointestinal infections,
including Clostridium difficile infections; urinary tract infections; and primary bloodstream
infections are other HAIs prevalent in the United States. A study conducted by Umscheid et
al3 found that between 55% and 70% of HAIs could be prevented using evidencebased
strategies. A 2009 report estimated that preventing 70% of HAIs could result in cost savings
between $25 and $31.5 billion annually, in 2007 dollars.4 This represents the most current
cost data available. SURGICAL SITE INFECTIONS In the perioperative setting, the major
patient safety concern of perioperative nurses and IPs is to prevent the development of SSIs.
An SSI is an infection that occurs after surgery at the site of the body where the surgery was
performed. It can be a superficial infection involving the skin only or a more serious infection
involving tissue under the skin, organs, or implanted materials, such as prostheses used in
hip and knee replacement surgeries. Numerous risk factors for SSIs have been described.
Generally, they fall into three main categories: patient-centered characteristics, such as age,
obesity, malnutrition, diabetes mellitus, and other comorbidities;
characteristics of the
surgical procedure, including the wound classification, length of the surgery, skill of the
surgeon, timeliness, appropriate use of antibiotic prophylaxis, and maintenance of
normothermia throughout the perioperative experience; and the OR environment relating to
sanitation, temperature and humidity, ventilation, and traffic patterns.5 Infection prevention
efforts begin in the preoperative phase and continue through the intraoperative and
postoperative phases of care. The prevention of SSIs is of critical importance and can only be
achieved through implementation of nd consistent and rigid adherence to infection prevention
standards. These standards address all potential risk factors for the development of SSIs
beginning with the patient, encompassing the personnel who may come in contact with the
patient, and ending with the environment. The most basic standard is compliance with hand
hygiene by all health care personnel as they interact with the patient and the patients
environment. Hand hygiene involves cleansing with soap and water or using an alcohol-based
waterless product. Cleansing with soap and water, using friction for at least 20 seconds, must
be performed when hands are visibly soiled or after care of a patient with spore-forming
pathogens such as C difficile. An alcohol-based waterless product can be used when the
hands are not visibly soiled. To prevent the transmission of infection, hand hygiene must be
performed before and after every patient contact and whenever hands are visibly soiled.6
MANDATORY REPORTING OF SSIs Sone states now require the reporting of SSIs using
criteria from the CDCs National Healthcare Safety Network (NHSN).7 In addition, since 2012,
the Centers for Medicare & Medicaid Services (CMS) under the Hospital Inpatient Quality
Reporting Program requirements for 2012 has mandated the reporting of SSIs in patients who
have undergone inpatient abdominal hysterectomy and inpatient colon procedures.7 The
SSIs to be reported to the CMS related to these procedures include deep incisional primary
and organ/space infections detected during the surgical hospitalization, on re-admission to
the hospital where the surgery was performed or on admission to another hospital, or through
post-discharge surveillance within 30 days of the procedure.7 Ambulatory surgical centers
have also come under regulatory scrutiny from the CMS, which requires that ASCs have an
infection control program that seeks to minimize infections and communicable diseases as a
Condition for Coverage.8 Surgical site infection data from individual hospitals are made
available to the public.9 Consequently, health care institutions have an added incentive to
increase patient safety by reducing SSIs in their patients. FOCUS ON INFECTION
PREVENTION This special focus issue of the Journal explores infection prevention and
control strategies employed in the perioperative environment to facilitate patient safety and
prevent SSIs. Sue Barnes, BSN, RN, CIC, notes in Infection prevention: the surgical care
continuum 10 that surgical procedures are being performed in a number of settings outside
of the traditional OR, but the basics of infection prevention remain the same. Based on the
surgical setting, the IP should be informed about the infection risks and should collaborate
with other team members to optimize infection prevention practices. In To bathe or not to
bathe with chlorhexidine gluconate: is it time to take a stand for preadmission bathing and
cleansing?, 11 Charles E. Edmiston Jr, PhD, MS, BS, CIC, SM-ASCP, and colleagues offer a
discussion of why facilities should not stop requiring a preoperative bath or shower with
chlorhexidine gluconate (CHG) despite new recommendations from both the CDC and AORN
that have been expanded to include the use of other cleansing products (eg, antimicrobial or
nonantimicrobial soap, other unspecified skin antiseptics). The authors note that because
SSIs are expensive in terms of resource use, they require an investment in focused evidencebased interventional strategies. They point out that historically, the preadmission shower
using an antiseptic solution has been endorsed by a number of national and international
organizations as a strategy for reducing the risk of SSI. However, they conclude that the
effectiveness of a preadmission shower with CHG requires a rigid standardized approach,
maximizing skin-surface concentrations of CHG, and also requires efforts to improve patient
compliance.
Reflection:
One of our main responsibility inside the operating room is to maintain its sterility to avoid
introducing infection to our patint, and this is what this article tackles about. It emphasizes the
importance of hand hygiene as a basic compliance as we interact with the patient and other
healthcare members and the author has appoint because our hands are one of the basic
carrier of cross contamination. In short this articles emphasize the critical importance of
infection prevention as it relates to the safety of both personnel and patients in the
perioperative . Collaboration between perioperative nurses and IPs is a critical step in
reducing SSIs.

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