Transcript Ortho SSI Prevention - OSW

Presenter
Jette R Hogenmiller, PhD, MN, FNPc, APRN, CDE, TNCCc
Current Position: Chief Nursing Officer, Haxtun Hospital
District; Haxtun, Colorado
Background: Infection Preventionist , Family Nurse
Practitioner & Oncology Clinical Nurse Specialist
Disclosures: Health, Innovation & Research, LLC
3M sponsored speaker
 The impact of surgical site infection (SSI) on
Orthopedic joint surgery outcomes (e.g. patient,
financial)
 Potential sources of Orthopedic joint surgery SSI’s
 Scientifically based SSI prevention strategies &
application to Orthopedic joint surgery
 Strategies that might be implemented in your setting to
further reduce Orthopedic joint surgery SSI’s
 Significance of SSI in Orthopedic joint surgeries
 Is it time for a “SSI Prevention Bundle” in Orthopedics?
 How does the APIC “Guide to the Elimination of
Orthopedic Surgical Site Infections” provide us direction
as Infection Preventionist’s? =
What is the evidence that guides us in SSI prevention?
 Review of a bundle used to reduce Orthopedic surgeries
& evidence for impact on outcomes
 Next steps, what are they… on our journey to zero for
SSI’s?
This is the
face of our
patients…
health care
consumer.
This is why we have
a passion about
being an Infection
Preventionist….we
want to protect
those who enter our
doors… they are
innocent, no matter
their age.
They & their families
entrust their lives in
our care.
 SSI account for ~ 15% of healthcare associated
infections (HAI’s)
 ~ 500K SSI annually among 44M inpatient surgical
procedures
 Mortality of infected vs. uninfected cases
(7.8% vs. 3.5%)
ICHE 1999; 20:725
 Risk factors: age, gender, nutritional status,
diabetes, & obesity
ICHE 1999; 20:250
 Skin preparation of patient/surgical team
 CDC category IB
Am J Inf Dis 2007; 3:51
What does having an SSI mean
to a person & society?
 $38,000 vs. $11,255 –> infected vs. non-infected fixation or hemi-
arthroplasty (Pollard, et. al, 2006)
 $50,000 to tx SSI (Lentino, 2003)

MRSA infections more costly than non-MRSA. (Pollard et al.)
 $250 million total knee & hip replacement SSIs, annual US cost of total
joint replacement infections (Kuper, 2008)

2.8 time higher costs for revision of a total joint due to infection than cost
of revision for aseptic loosening &

4.8 times higher than costs associated with primary total hip arthroplasty
(Kuper, 2008)
“Total hip arthroplasty revision due to infection results in significantly
-
more hospitalizations
-
increased total length of stay; # of operative procedures; and outpatient visits &
charges
-
additional complications than revision due to aseptic loosening of the
prosthesis“ (APIC, 2010)
_____________________________________________________________
“… increased median initial length of stay
- total # of hospitalizations
- # of surgical procedures,
- total length of stay, &
- cost
- substantial reduction in quality of life 1 yr later
Whitehouse, et. al (2002) [orthopedic procedures, incl. open reduction of fracture,
fusion, laminectomy & joint replacement; pairwise matched (1:1) case-control
study within a cohort (n=59 cases, 11/19% had joint replacement surgery)
 increased length of stay, including readmission within 90
days of surgery (13 vs 4 days)
 mean of 9.31 days of hospitalization attributable to infection
higher 1-year postoperative mortality (17% vs 4%) for
infected vs non-infected
Lee et al. (2006) [Sample > 64 years of age, nested-case control; 15,218 -> hip & knee
replacement, open reduction of fracture, other joint replacement, spinal fusion &
laminectomy]
Procedure
Index
Category
#
Procedures
# of
SSI’s
Pooled
Mean
Hip
prosthesis
0
49,576
334
0.67
Hip
prosthesis
1
65,046
938
1.44
Hip
prosthesis
2,3
15,769
379
2.4
Knee
prosthesis
0
70,675
409
0.58
Knee
prosthesis
1
79,653
786
0.99
Knee
prosthesis
2,3
20,855
333
1.60
Incidence SSI
Pooled means of
SSI rates by
operative inpatient
procedure & risk
index categories,
2006 through 2008
“…NHSN report, a large
U.S. database for HAI
aggregation &
comparison report titled:
“Data Summary for
2006 through 2008,”
issued December 2009,
SSI rates for hip
replacement & knee
replacement”
APIC, 2010 Guide to
the Elimination of
Orthopedic Surgical
Site Infections
 “Operation lasting more than the duration cut point hours, where the
duration cut point is the approximate 75th percentile of the duration of
surgery in minutes for the operative procedure, rounded to the
nearest whole number of hours.
 Contaminated (Class 3) or Dirty/infected (Class 4) wound class.
 ASA classification of 3, 4, or 5.
 The patient’s SSI risk category is simply the number of these factors
present at the time of the operation.”
Significant “pain” provides for
ability to take bold action!
Getting
to Zero
Is there a
SSI Ortho
prevention
bundle/path
to get us to
zero?
YES
Surgical Site Infection
Allan Morrison, Jr, MD, MSC, FACP, FIDSA, FSHEA
Surgery/Orthopedic SSI’s?
 Endogenous microorganisms
 Skin-dwelling microorganisms
 Most common source
 S aureus most common isolate
 Exogenous microorganisms
 Surgical personnel
 OR environment
 All tools, instruments, and materials
Mangram AJ, et al. The hospital infection control practices advisory committee. Guidelines for
prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
Glucose control
Preoperative CHG shower
Appropriate hair removal
Hand hygiene
Skin antisepsis
Antimicrobial prophylaxis
Normothermia
Mangram AJ, et al. The hospital infection control practices advisory committee.
Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol.
1999;20(4):250-278.
5 Million lives. Institute for Healthcare Improvement. Available at:
http://ihi.org/IHI/Programs/Campaign/Campaign.htm. Accessed on February 8, 2007.
System Processes
- Antibiotic usage & timing
- Air system/HVAC
- Blood glucose control
- Cleaning of OR
- Instrument/case opening
- MRSA colonization
- OR apparel
- Patient temperature, pre, intra & postoperative
- Skin preparation
- Sterilization
-Team work
- Other
Client history/behaviors
- Diabetes
- Demographics
- Preop preparation/education - Smoking
- Other
Clinical Experience
-For-profit, joint venture Orthopedic hospital (~5500+ cases
annually & ~30 surgeons
-Multi-state, multiple hospital system
-Inner-city, safety-net, level I trauma center, multi-hospital
system
Conferences – local, state, national & international
- APIC – IDSA – SHEA & others
-E Patchen Dellinger, MD. University of Washington
- Laura Prokuski, MD, University of Wisconsin
-Others
Research Review/Professional Society Guidelines
APIC “Guide
to the
Elimination
of
Orthopedic
SSI’s”
Providing
guidance for
Infection
Preventionists.
SHEA Practice
Recommendations
“Strategies to prevent surgical
site infections in acute care
hospital”
ICHE October 2008, vol. 29, supplement 1
Hair removal
Surgical Instrument Table
Anesthesia work space
Equipment (e.g. Tourniquets)
Agent
Grampositive
bacteria
Chlorhexidine
E
Alcohol
E
Iodine/iodophors
E
PCMX
G
Triclosan
G
Gram- Mtb
negative
bacteria
G
P
E
G
G
G
F
F
G
G
Fungi
Virus
F
G
G
F
P
G
G
G
F
U
E = excellent; F = fair; G = good; P = poor; U = unknown
Am J Infect Dis 2007; 3(1):51-61

Orthopaedic procedures rely on strict sterilization techniques to prevent SSI

Surgical instrument trays are wrapped for sterilization & these wraps routinely are inspected
by OR personnel to evaluate for breaches before use

Method: 90 sterilization wraps divided into groups with no defect & with 6 sizes of defects
ranging from 1.1 to 10.0 mm in diameter.

Puncture-type defects were created using nails of known diameter. All wraps were evaluated
by medical personnel for evidence of a breach. Detection rates ranged from 6.7% to
96.7% from the smallest to largest defects, respectively. The potential for bacterial
transmission thru wrap defects also was evaluated & contaminated nails of the smallest size
transmitted bacterial contaminants thru the wrap during the creation of puncture defects.
Thus, substantial perforations in sterilization wraps frequently are missed when evaluated
with commonly used techniques.

Defects with a diameter approximately that of a pencil (6.7 mm) were missed 18% of
the time, although contamination can be transmitted by a nail with the diameter of a
pin (1.1 mm). These results raise questions about a common screening method.
 Routinely sterilized surgical instruments were divided
into two groups and put on the same instrument
table, one group was covered with dressing and the
other was exposed to the air. The samples were
collected at 30 min, 60 min, and 90 min respectively
after operation began and bacterium culture was
done. The results showed that the general air
contamination rate of the exposed group was
1.18 times higher than that of the covered one
19 definable surfaces were sampled in 22 operating
rooms.
 33% of surfaces were contaminated with blood.
Contaminated equipment included surfaces that are in
continuous contact with patients, e.g., blood
pressure cuffs and pulse oximeter probes. Visual
inspection was not a reliable means of detecting
blood contamination.
RESULTS: Bacterial contamination of the anesthesia work
area increased significantly at the case conclusion, with a
mean difference of 115 colonies per surface area
sampled (95% CI: 62-169; P < 0.001). Transmission of
bacterial organisms, including VRE to IV stopcock sets
occurred in 32% (95% CI, 20.6-44.9%) of cases.
CONCLUSION: Potentially pathogenic, multidrug-resistant
bacterial organisms are transmitted during the practice of
general anesthesia to both the anesthesia work area and
intravenous stopcock sets.
 Purpose: Determine amount of microbial growth that develops on
the anesthesia machine after a full day's use in OR.
 Descriptive bacteriology study relevant to anesthesia practice
given proximity of the oropharynx & multiple body fluids to
anesthesia equipment & potential for cross-contamination to
patients & staff.
 P value of 0.12 indicated that the observed CFU increase was not
statistically significant at the .05 level.
 Organisms found on anesthesia machine tabletop: coagulasenegative Staphylococcus, Bacillus, alpha Streptococcus,
Acinetobacter, Staphylococcus aureus, and gram-negative
rods.
 Several were expected to be found; however, alpha
Streptococcus, Acinetobacter, S aureus, & gram-negative rods are
pathogenic organisms causing respiratory infections &
bacteremia, especially in patients with compromised conditions.
Study analyzed tourniquets used for orthopedic surgery
Group A tourniquets main OR
Group B tourniquets ambulatory surgicenter,
Group C tourniquets unused, prepackaged, sterile tourniquets from main
OR &
 Group D tourniquets were sterilely packed tourniquets from ambulatory
surgicenter.
 Tourniquets from Groups A, B, C, and D had 100%, 40%, 0%, and 0%
microbial growth, respectively.
 Group A tourniquets, coagulase-negative staphylococci, Bacillus &
Staphylococcus aureus were present in 100%, 60%, and 20% of
tourniquets, respectively. 20% contaminated either with Streptococcus
sanguis, Aerococcus viridans, or Cornyebacterium species.




 Coagulase-negative staphylococci & Bacillus were present in 40% and
30% of Group B tourniquets, respectively. Tourniquet contamination
may be a risk factor for the development of SSI in orthopedic surgery.
 BACKGROUND:. The purpose of the present study was to compare the infection
rates following joint replacement procedures performed by 1 orthopaedic surgeon
with & without the use of ultraviolet lighting.

METHODS: July 1986 to July 2005, 1 surgeon performed 5980 total joint
replacements at 1 facility. In September 1991, ultraviolet lighting was installed in
the operating rooms.
 RESULTS: The odds of infection were 3.1 times greater for procedures
performed without ultraviolet lighting (& with laminar airflow) as compared
with those performed with only ultraviolet lighting (p < 0.0001). The infection
rate associated with total hip replacement decreased from 1.03% to 0.72% (p =
0.5407), and the infection rate associated with total knee replacement decreased
from 2.20% to 0.50% (p < 0.0001).





Effect of different head coverings on air-borne transmission of bacteria & particles in the surgical area studied during 30 strictly standardized sham operations performed in a horizontal laminar air flow (LAF)
unit.
The OR team wore disposable gowns plus either a 1) non-sterile head covering consisting of a squire
type disposable hood & triple laminar face mask, 2) a sterilized helmet aspirator system or 3) no head
cover at all. In the wound area both types of head cover resulted in low and comparable air (means
of 8 and 4cfu/m(3)) and surface contamination (means of 69 and 126cfu/m(2)/h) rates.
Omission of head-gear resulted in a three- to five-fold increase (P > or = 0.01- 0.001), depending on
site sampled air contamination rate (mean of 22cfu/m(3)) whereas the bacterial sedimentation rate
in the wound area increased about 60-fold ( P > or = 0.0001). A proper head cover minimized the
emission of apparently heavy particles that were not removed by the horizontal LAF & contained mainly
streptococci, presumably of respiratory tract origin. Dust particle counts revealed no differences
between the three experimental situations. No correlation between air and surface contamination
rates or between air contamination and air particle counts was found
From a bacteriological point of view, disposable hoods of squire type and face masks are equally
as efficient as a helmet aspirator system & both will efficiently contain the substantial emission of
bacteria-carrying droplets from the respiratory tract occurring when head cover is omitted.
Finally, the use of bacterial air counts to assess surgical site surface contamination in horizontal LAF units
must be seriously questioned.
What is the evidence?
Are we using the evidence
we have?
“Excellence is a moving target”
Review of a
bundle used to
reduce
Orthopedic SSI &
evidence
supporting
potential for
positive impact
on outcomes
Bundle:
Preoperative:
•2% CHG Sage® Cloths
•3MTM Skin & Nasal
Antiseptic
•Warming with 3MTM Bair
Paws
•Huddle - checklist
TOPIC
ACTION
ACTION STATUS*
Yes
Medical
Dental
Education
2% CHG
Clinic
Has medical clearance been obtained?
Has dental clearance been obtained?
Preoperative education provided
Preoperative shower CHG pack & instructions given
PAT Visit
Laboratory
PAT
7-10 day prior to surgery
Complete laboratory tests, assure results support surgery OK
2% CHG
Preoperative Call
Reinforce & importance of preop 2% CHG showers
Education
Surgery Day - Preoperative Area
Verify OR room terminally cleaned prior to Ortho implant surgery
Laboratory
Labs drawn by 7AM & verify standards met to proceed with surgery
2% CHG
Nares
Verify showers completed (#1soap/H20; #2 PM; #3pre-op area);
Y=all done
Apply 3M product to nares, if pt not allergic to iodine. Use protocol.
Warming
Warming 30 min in advance of surgery; time Bear Paws applied
Dose of Antibx
Verify dosing based on current protocol
Antibiotic
Antibiotic infusion begun for 8 AM surgery

Vancomycin @
- infused by time of incision

Clindamycin @
- done 10 min. before incision

Ancef
- done 10 min before incision
Instruments
Coordinate time start for table/instrument prep - doc open time
Incision
Temp
Date
Time
Orthopedic Total
Joint Surgery
Checklist
PATIENT STICKER
(NOT for explants or
spacer revision)
Surgery Date:
____/____/______
Remind patient to be NPO after midnight, NO gum or mints, Meds
with a sip of water. Ask about recent illness
Terminal Clean
Team
No
COMMENTS
Team huddle - SCOAP/WHO
Intraoperative
Surgery incision time
Patient temperature maintained at 36.0
Circle which done
*Place initials of the
individual verifying
completion of the
action in the
appropriate "yes" or
"no" location, and
place the date and
time the action
occurred, where
appropriate, in
respective locations
& include AM or PM.
BACKGROUND: Chlorhexidine gluconate (CHG) skin concentrations were determined after preoperative
showering/skin cleansing using 4% CHG soap or 2% CHG-impregnated polyester cloth.
STUDY DESIGN: Subjects were randomized to 1 of 3 shower (4% soap)/skin cleansing (2% cloth) groups (n = 20 per group):
Group 1 A/B evening,
Group 2 A/B morning, or
Group 3 A/B evening & morning.
After showering or skin cleansing, volunteers returned to the investigator's laboratory where CHG skin surface concentrations
were determined at five separate skin sites. CHG concentrations were compared with CHG minimal inhibitory concentration
that inhibits 90% (MIC(90)) of staphylococcal skin isolates.
RESULTS:CHG MIC(90) for 61 skin isolates was 4.8 parts per million (ppm).
Evening only

17.2 – 31.6 ppm Group 1A, 4% CHG skin concentrations &

361.5 to 589.5 ppm Group 1B, 2% CHG. (p < 0.0001)
Morning only

51.6 to 119.6 ppm Group 2A, 4% CHG

848.1 to 1,049.6 ppm in group 2B, 2% CHG (p < 0.0001).
Evening & morning

101.4 to 149.4 ppm Group 3A, 4% CHG

1,484.6 to 2,031.3 ppm Group 3B 2% CHG cloth (p < 0.0001).
Effective CHG levels were not detected in the 4% CHG group in selected sites in seven (35%) subjects in group 1A, three
(15%) in group 2A, and five (25%) in group 3A.
Page #1
Night before
instructions on
use of 2% Sage
cloths.
Tested in inner-city
sample after
revised by
ambulatory care
nurses
Clean bed linens &
pajamas also
required.
Page # 2
1&2
packages
night before
1 package
AM of
surgery
Evidence & interventions
used to address these as sources of SSI
Population Location
Year % Staph %MRSA
IHS clinics 1
WA State
2004
27.3
1.9
Hosp admit 2
Atlanta
2003
21.0
2.7
Homeless 3
San Francisco
2002
22.8
2.8
Peds clinic 3
Chicago
2000
22.4
0.6
Adult*/Peds 3
New York
2000
28*/34
0*/0.4
Students 3
Minneapolis
2000
36.2
7.4
Peds ER 3
Chicago
2000
26.4
2.2
Hosp admit 3
Charlottesville
1999
NA
0.98
Hosp admit 3
Peds clinic4
Boston
Nashville
1998
2004
24.8
36.4
2.6
9.2
1) Leman R. Infect Control Hosp Epidemiol; 2004. 2) Jernigan JA. Infect Control Hosp Epidemiol; 2003.
Creech CB. Peds ID 2005
3) Salgado CD. Clin Infect Dis; 2003. 4)
Treatment: Pts received perioperative prophylaxis with:

nasal mupirocin for 5 days & a

bath or shower with 2% triclosan the day before
surgery.
The control group consisted of patients undergoing
similar procedures in the 6 months before the
mupirocin/triclosan regimen was started.
Both groups received intravenous cephradine for
24 hours perioperatively.
There was a marked decrease in the incidence of
MRSA nasal carriage in the group treated with
mupirocin & triclosan. After introduction of the
mupirocin/triclosan protocol, MRSA SSIs decreased from

23 per 1,000 to

3.3 to 4 per 1,000
Of the 11 MRSA SSIs that occurred in
the mupirocin/triclosan group, only
one patient received the intervention
correctly.
The number of SSIs caused by other pathogens
was not affected by the intervention. The relative
contributions of mupirocin & triclosan could not
be determined.
Nevertheless, the authors stated that their results
justify empirical, as opposed to targeted, usage
of mupirocin prophylaxis because current health
care practice makes it almost impossible to
preoperatively assess for MRSA carriage and
subsequently treat all patients undergoing
orthopaedic surgery.[this is an inappropriate
conclusion]
It is of concern that
Rotger found that 27%
of MRSA isolates
causing hip or knee
prosthetic joint infection
were resistant to
mupirocin.
 Rotger M, Trampuz A,
Piper KE, Steckelberg
JM, Patel R.
Phenotypic &
genotypic mupirocin
resistance among
staphylococci causing
prosthetic joint
infection. J Clin
Microbiol 2005;
43:4266-4268.
3M Skin &
Nasal
Antiseptic
http://solutions.3m.com/wps/portal/3M/en_US/infection-preventionsolutions/home/products/?PC_7_RJH9U52308DUB0IIL8TMGN3013000000_nid=5612BP15
V7be1ZB8J079ZXgl&WT.mc_id=www.3M.com/takecharge
Why is it important?
&
What method did we chose & Why?
CMS Core Measures – postoperative measure
 N = 200 randomized “normothermia” vs.
hypothermia
 SSI developed in 6% vs. 19% (p = 0.009)
 Length of Stay (LOS)  2.6 days for hypothermia
group (p = 0.001)
Intra-operative normo-thermia can be maintained by
blankets, warmed IV fluids
NEJM 1996;334:1209
 Hypothermia reduces
tissue oxygen tension by
vasoconstriction
 Hypothermia increases
duration of hospital
stay even in uninfected
patients
 Hypothermia reduces
leukocyte superoxide
production
 Melling. Lancet 2001;358:876
 Kurz. NEJM 1996;334:1209
 Hypothermia increases
bleeding & transfusion
requirement
 Rabkin. Arch Surg
1987;122:221
 INTRODUCTION: Use of the Bair Hugger forced-air patient
warming system during prolonged abdominal vascular
surgery may lead to increased bacterial contamination of the
surgical field by mobilization of the patient's skin flora.
 METHODS: Bacterial content analyzed in air & wound
specimens collected during surgery in 16 patients
undergoing abdominal vascular prosthetic graft insertion
procedure, using the Bair Hugger patient warming system.
Bacterial colony counts from the beginning & the end of
surgery were compared.
 RESULTS: No increase in bacterial counts at the study sites,
but also that there was a decrease (P < 0.01) in air
bacterial content around the patient & in the operating
theatre after prolonged use of the patient warmer. No
wound or graft infections occurred.
Antibiotics
& SSI
Prevention
Medication
Dosing
Timing
Are there opportunities beyond
the accepted timing?
J Am Acad Orthop Surg 2008;
16:283-293
Variety of Surgical Checklist exist:
 SCOAP
 WHO
 Others
BACKGROUND: The OR is a complex work environment with a high potential for adverse events. We
assessed personnel attitudes to a pre-operative checklist ('time out') immediately before
start of the operative procedure.
METHODS: 'Time out' was implemented in December 2007 as an additional safety barrier in two Swedish
hospitals. One year later, in order to assess how the checklist was perceived, a questionnaire was sent by
e-mail to 704 persons in the operating departments, including surgeons, anesthesiologists, operation and
anesthetic nurses and nurse assistants.
RESULTS: The questionnaire was answered by 331 (47%) persons
 93% responded that 'time out' contributes to increased patient safety.
 83% thought that 'time out' gave an opportunity to identify and solve problems.
Confirmation of patient identity, correct procedure, correct side and checking of
allergies or contagious diseases were considered 'very important' by 78-84% of
the responders. Attitudes to checking of patient positioning, allergies and review
of potential critical moments were positive but differed significantly between the professions.
Attitudes to a similar checklist at the end of surgery were positive and 72-99% agreed to the different
elements.
CONCLUSION: Staff attitudes toward a surgical checklist were mostly positive
1 year after their introduction in two large hospitals in central Sweden.
Chuckanut
Drive
Washington State
Ortho SSI
Prevention
Next steps,
what are
they… on our
journey to
zero for
SSI’s?
APIC (2010) . Guide to the Elimination of Orthopedic Surgical
Site Infections. APIC.
Kuper M, Rosenstein A. (2008) Infection prevention in total knee
and total hip arthroplasties. Am J Orthop, 37(1):E2–E5.
Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M,
Kaye KS. (2006) Surgical site infection in the elderly following
orthopaedic surgery. Risk Factors and Outcomes. J Bone Joint
Surg, 88(8):1705–1712.
Lentino JR. (2003) Prosthetic joint infections: bane of
orthopedists, challenge for infectious disease specialists. Clin
Infect Dis, 36:1157-1161.
Partanen J, Syrjala H, Vahanikkila H, Jalovaara P. (2006) Impact of deep infection after
hip fracture surgery on function and mortality. J Hosp Infect, 62(1):44-49.15.
Pollard TC, Newman JE, Barlow NJ, Price JD, Willett KM. (2006) Deep wound infection
after proximal femoral fracture: consequences and costs. J Hosp Infect, 63:133-139.
Rabkin. Arch Surg 1987;122:221
Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. (2002). The
impact of surgical site infections following Orthopedic surgery at a community hospital
and a university hospital: Adverse quality of life, excess length of stay, and extra cost.
Infect Control Hosp Epidemiol, 23:183-189.
Wilson J, Charlett A, Leong G, McDougall C, Duckworth G. (2008) Rates of surgical site
infection after hip replacement as a hospital performance indicator: Analysis of data
from the English mandatory surveillance system. Infect Control Hosp Epidemiol
Mar;29(3):219-226.
SSI related – additional slides & abstracts for ‘abbreviated’
evidence slides

OBJECTIVE: To ascertain the microbial load and type of organisms on used surgical instruments following standard cleaning,
which consisted of the use of a washer sterilizer followed by sonic cleaning.

DESIGN: In this prospective experimental study, used surgical instruments were immersed in Peptamin Tween broth, the
broth agitated, and then filtered through a 0.45 microm filter. Quantitative cultures were performed, and all microbes were
identified by using standard techniques.

SETTING: This study was conducted at a 660-bed university hospital.

RESULTS: The microbial load remaining on used surgical instruments after cleaning was as follows: 36 (72%) instruments 0
to 10 colony-forming units (CFU), 7 (14%) instruments 11 to 100 CFU, and 7 (14%) instruments > 100 CFU. Organisms
contaminating the instruments included coagulase-negative staphylococcus (56%) followed by Bacillus (22%) and
diphtheroids (14%). No other microbes were isolated from more than 4% of the instruments.

CONCLUSION: Most used nonlumen surgical instruments contain less than 100 CFU of relatively nonpathogenic
microorganisms after cleaning. This suggests that new low-temperature sterilization technologies are likely to be highly
effective in preventing cross-transmission of infection via nonlumen medical instruments.
BACKGROUND: The current prevalence of hospital-acquired infections and evolving amplification of bacterial resistance are
major public health concerns. A heightened awareness of intraoperative transmission of potentially pathogenic bacterial
organisms may lead to implementation of effective preventative measures.
METHODS: Sixty-one operative suites were randomly selected for analysis. Sterile intravenous stopcock sets and two sites on
the anesthesia machine were decontaminated and cultured aseptically at baseline and at case completion. The primary
outcome was the presence of a positive culture on the previously sterile patient stopcock set. Secondary outcomes were
the number of colonies per surface area sampled on the anesthesia machine, species identification, and antibiotic
susceptibility of isolated organisms. R
RESULTS: Bacterial contamination of the anesthesia work area increased significantly at the case conclusion, with a mean
difference of 115 colonies per surface area sampled (95% confidence interval [CI], 62-169; P < 0.001). Transmission of
bacterial organisms, including vancomycin-resistant enterococcus, to intravenous stopcock sets occurred in 32% (95% CI,
20.6-44.9%) of cases. Highly contaminated work areas increased the odds of stopcock contamination by 4.7 (95% CI,
1.42-15.42; P = 0.011). Contaminated intravenous tubing was associated with a trend toward increased nosocomial
infection rates (odds ratio, 3.08; 95% CI, 0.56-17.5; P = 0.11) and with an increase in mortality (95% CI odds ratio, 1.11infinity; P = 0.0395).
CONCLUSION: Potentially pathogenic, multidrug-resistant bacterial organisms are transmitted during the practice of
general anesthesia to both the anesthesia work area and intravenous stopcock sets. Implementation of infection
control measures in this area may help to reduce both the evolving problem of increasing bacterial resistance and the
development of life-threatening infectious complications.
This study analyzed tourniquets used for orthopedic surgery in our hospital to
 Group A tourniquets were from our main operating room,
 Group B tourniquets were from our ambulatory surgicenter,
 Group C tourniquets were unused, prepackaged, sterile tourniquets from our
main operating room, and
 Group D tourniquets were sterilely packed tourniquets from our ambulatory
surgicenter.
Tourniquets from Groups A, B, C, and D had 100%, 40%, 0%, and 0% microbial
growth, respectively. For Group A tourniquets, coagulase-negative staphylococci,
Bacillus, and Staphylococcus aureus were present in 100%, 60%, and 20% of
tourniquets, respectively.
Twenty percent were contaminated either with Streptococcus sanguis, Aerococcus
viridans, or Cornyebacterium species. Coagulase-negative staphylococci and
Bacillus were present in 40% and 30% of Group B tourniquets, respectively.
Tourniquet contamination may be a risk factor for the development of surgical site
infection in orthopedic surgery.
Routinely sterilized surgical instruments were divided into two
groups and put on the same instrument table, one group was
covered with dressing and the other was exposed to the air.
The samples were collected at 30 min, 60 min, and 90 min
respectively after operation began and bacterium culture was
done.
The results showed that the general air contamination rate
of the exposed group was 1.18 times higher than that of
the covered one. The exposure time had a positive
correlation with bacterium contamination rate. This study
gave the laboratory evidence for controlling the infection in
the operation room.
STUDY DESIGN: A cadaver study to evaluate contamination in the operating room through the use of a
high-speed bone cutter.
OBJECTIVES: To determine the grade of contamination of animate and inanimate objects through an
aerosol intraoperatively, produced by a high-speed cutter during lumbar laminectomy.
SUMMARY OF BACKGROUND: In spinal surgery, high-speed cutters are used that produce an aerosol
consisting of a mixture of irrigation solution, blood, and tissue debris. Such aerosols can be
contaminated with potential pathogens. The surgical personnel and the environment are therefore
exposed to a contamination risk.
METHODS: Laminectomies at three points (L2-L4) were performed on a human cadaver using a high-speed
cutting device. The aerosol produced by the irrigation solution was contaminated with Staphylococcus
aureus ATCC 12600. To detect the contamination of the environment and of the surgical team,
surveillance cultures were used.
RESULTS: By air sampling, staphylococci were detected in the operating room at an extension of 5 by 7 m.
The surgical team showed extensive face and body contamination with S. aureus. Despite protection by
a barrier drape, similar contamination was observed on both the cadaver's head and the
anesthesiologist.
CONCLUSIONS: The use of high-speed cutters in spinal surgery produces an aerosol that can be
contaminated with blood-borne pathogens from infected patients. This aerosol is spread over the whole
surgical room and contaminates the room and all personnel present. It is therefore critical to ensure that
effective infection control measures are performed, not only by the surgeons but by everyone present in
the operating room. The room itself must be sufficiently disinfected after such procedures.
 The purpose of this study was to determine the amount of microbial
growth that develops on the anesthesia machine after a full day's use
in the operating room. This descriptive bacteriology study is relevant to
anesthesia practice because of the proximity of the oropharynx and multiple
body fluids to anesthesia equipment and the potential for crosscontamination to patients and staff. The Wilcoxon signed rank test was used
to evaluate the change in colony-forming units (CFUs) before and after use
of equipment. The resulting P value of 0.12 indicated that the observed CFU
increase was not statistically significant at the .05 level. The study identified
many organisms that survive on the anesthesia machine tabletop, namely,
coagulase-negative Staphylococcus, Bacillus, alpha Streptococcus,
Acinetobacter, Staphylococcus aureus, and gram-negative rods.
Several were expected to be found; however, alpha Streptococcus,
Acinetobacter, S aureus, and gram-negative rods are pathogenic organisms
causing respiratory infections and bacteremia, especially in patients with
compromised conditions. Terminal cleaning methods may have changed
during the course of the study, thereby contributing to the volume of
microbes present before use and distorting the change in the number of
CFUs before and after use.
This study was conducted to determine the extent of blood
contamination of anesthesia equipment and monitoring equipment in
clinical use in operating rooms. The study employed a catalytic-test
method, which is used in forensic medicine, to detect blood
contamination of anesthesia equipment and monitoring equipment.
Nineteen definable surfaces were sampled in 22 operating rooms.
Thirty-three percent of surfaces were contaminated with blood.
Contaminated equipment included surfaces that are in continuous
contact with patients, e.g., blood pressure cuffs and pulse oximeter
probes. Visual inspection was not a reliable means of detecting blood
contamination. Whether this blood contamination represents an
infection risk was not determined. Nevertheless, improved cleaning
and disinfection procedures are probably needed. Equipment design
needs to focus on reducing the potential for blood contamination and
enhancing capability for cleaning and disinfection.

The effect of different head coverings on air-borne transmission of bacteria and particles in the
surgical area was studied during 30 strictly standardized sham operations performed in a horizontal
laminar air flow (LAF) unit. The operating team members wore disposable gowns plus either a nonsterile head covering consisting of a squire type disposable hood and triple laminar face mask, a
sterilized helmet aspirator system or no head cover at all. In the wound area both types of head
cover resulted in low and comparable air (means of 8 and 4cfu/m(3)) and surface contamination
(means of 69 and 126cfu/m(2)/h) rates. Omission of head-gear resulted in a three- to five-fold
increase (P > or = 0.01- 0.001), depending on site sampled air contamination rate (mean of
22cfu/m(3)) whereas the bacterial sedimentation rate in the wound area increased about 60-fold (
P > or = 0.0001). A proper head cover minimized the emission of apparently heavy particles that
were not removed by the horizontal LAF and contained mainly streptococci, presumably of
respiratory tract origin. Dust particle counts revealed no differences between the three
experimental situations. No correlation between air and surface contamination rates or between air
contamination and air particle counts was found. We conclude that, from a bacteriological point of
view, disposable hoods of squire type and face masks are equally as efficient as a helmet aspirator
system and both will efficiently contain the substantial emission of bacteria-carrying droplets from
the respiratory tract occurring when head cover is omitted. Finally, the use of bacterial air counts to
assess surgical site surface contamination in horizontal LAF units must be seriously questioned.
Copyright 2001 The Hospital Infection Society.
BACKGROUND: Ultraviolet lighting is an alternative to laminar airflow in the operating room that may be as
effective for lowering the number of environmental bacteria and possibly lowering infection rates by
killing the bacteria rather than simply reducing the number at the operative site. The purpose of the
present study was to compare the infection rates following joint replacement procedures performed by
one orthopaedic surgeon with and without the use of ultraviolet lighting.
METHODS: From July 1986 to July 2005, one surgeon performed 5980 total joint replacements at one
facility. In September 1991, ultraviolet lighting was installed in the operating rooms. All procedures that
were performed before the installation of the ultraviolet lighting utilized horizontal laminar airflow,
whereas all procedures that were performed after that date utilized ultraviolet lighting without laminar
airflow. Factors associated with the rate of infection were analyzed.
RESULTS: Over a nineteen-year period, forty-seven infections occurred following 5980 joint replacements.
The infection rate without ultraviolet lighting (and with laminar airflow) was 1.77%, and the infection rate
with ultraviolet lighting was 0.57% (p < 0.0001). The odds of infection were 3.1 times greater for
procedures performed without ultraviolet lighting (and with laminar airflow) as compared with
those performed with only ultraviolet lighting (p < 0.0001). The infection rate associated with total hip
replacement decreased from 1.03% to 0.72% (p = 0.5407), and the infection rate associated with total
knee replacement decreased from 2.20% to 0.50% (p < 0.0001). Revision surgery, previous infection,
age, total body mass index, use of cement, disease, and diagnosis were not associated with an elevated
infection rate.
CONCLUSION: When appropriate safety precautions are taken, ultraviolet lighting appears to be an
effective way to lower the risk of infection in the operating room during total joint replacement surgery.
 INTRODUCTION: Use of the Bair Hugger forced-air patient warming
system during prolonged abdominal vascular surgery may lead to
increased bacterial contamination of the surgical field by mobilization of
the patient's skin flora.
 METHODS: This possibility was studied by analyzing bacterial content in
air and wound specimens collected during surgery in 16 patients
undergoing abdominal vascular prosthetic graft insertion procedure, using
the Bair Hugger patient warming system. The bacterial colony counts
from the beginning and the end of surgery were compared, and the data
analyzed using the Wilcoxon matched pairs test.
 RESULTS: The results showed not only that there was no increase in
bacterial counts at the study sites, but also that there was a decrease (P <
0.01) in air bacterial content around the patient and in the operating
theatre after prolonged use of the patient warmer. No wound or graft
infections occurred.
 CONCLUSION: The use of this warming system does not lead to
increased bacterial contamination of the operating theatre atmosphere,
and it is unlikely to affect the surgical field adversely.
 Orthopaedic procedures rely on strict sterilization techniques to prevent
surgical site infections. Surgical instrument trays are wrapped for
sterilization, and these wraps routinely are inspected by operating room
personnel to evaluate for breaches before using the contained instruments.
The sensitivity of this practice for detecting wrap defects has not been
established. We divided 90 sterilization wraps into groups with no defect and
with six sizes of defects ranging from 1.1 to 10.0 mm in diameter. Puncturetype defects were created using nails of known diameter. All wraps were
evaluated by medical personnel for evidence of a breach. Detection rates
ranged from 6.7% to 96.7% from the smallest to largest defects, respectively.
The potential for bacterial transmission through wrap defects also was
evaluated, and contaminated nails of the smallest size transmitted bacterial
contaminants through the wrap during the creation of puncture defects.
Thus, substantial perforations in sterilization wraps frequently are missed
when evaluated with commonly used techniques. Defects with a diameter
approximately that of a pencil (6.7 mm) were missed 18% of the time,
although contamination can be transmitted by a nail with the diameter
of a pin (1.1 mm). These results raise questions about a common
screening method.
BACKGROUND: SKIN asepsis is a sentinel strategy for reducing risk of surgical site infections. In this study, chlorhexidine
gluconate (CHG) skin concentrations were determined after preoperative showering/skin cleansing using 4% CHG soap or 2%
CHG-impregnated polyester cloth.
STUDY DESIGN: Subjects were randomized to one of three shower (4% soap)/skin cleansing (2% cloth) groups (n = 20 per group):
Group 1 A/B evening,
Group 2 A/B morning, or
Group 3 A/B evening and morning.
After showering or skin cleansing, volunteers returned to the investigator's laboratory where CHG skin surface concentrations
were determined at five separate skin sites. CHG concentrations were compared with CHG minimal inhibitory concentration
that inhibits 90% (MIC(90)) of staphylococcal skin isolates.
RESULTS:CHG MIC(90) for 61 skin isolates was 4.8 parts per million (ppm).
Group 1A, 4% CHG skin oncentrations ranged from 17.2 to 31.6 ppm, and CHG concentrations were 361.5 to 589.5 ppm (p < 0.0001) in
Group 1B (2%). In group 2A (4%), CHG levels ranged from 51.6 to 119.6 ppm and 848.1 to 1,049.6 ppm in group 2B (2%), respectively (p < 0.0001).
CHG levels ranged from 101.4 to 149.4 ppm in the 4% CHG group (group 3A) compared with 1,484.6 to 2,031.3 ppm in 2% CHG cloth (group 3B)
group (p < 0.0001). Effective CHG levels were not detected in the 4% CHG group in selected sites in seven (35%) subjects in group 1A, three
(15%) in group 2A, and five (25%) in group 3A.
CONCLUSIONS: EFFECTIVE CHG levels were achieved on most skin sites after using 4% CHG; gaps in antiseptic coverage were noted at selective
sites even after repeated application. Use of the 2% CHG polyester cloth resulted in considerably higher skin concentrations with no gaps in
antiseptic coverage. Effective decolonization of the skin before hospital admission can play an important role in reducing risk of surgical site
infections.
Despite the use of ultraclean air, there are still cases of infection in total
joint arthroplasty. One possible route by which bacteria may enter the
wound is indirectly by contamination of instruments during skin
preparation and draping. We found that bacterial air counts were 4.4
times higher during preparation and draping for hip or knee
arthroplasty using an unscrubbed, ungowned leg holder than during
the operation itself. With the leg holder scrubbed and gowned during
preparation and draping, the air counts were reduced but were still
2.4 fold greater than intraoperatively. On some occasions, the air
counts during preparation and draping exceeded the standards for
ultraclean air irrespective of the attire of the leg holder. We
recommend that the leg is held by a scrubbed and gowned member
of the team. More importantly, we consider that instrument packs
should be opened only after skin preparation and draping have been
completed.
INTRODUCTION: Operating department staff are usually required to wear dedicated theatre
shoes whilst in the theatre area but there is little evidence to support the beneficial use of
theatre shoes.
 PATIENTS & METHODS: We performed a study to assess the level of bacterial
contamination of theatre shoes at the beginning and end of a working day, and compared
the results with outdoor footwear.
 RESULTS: We found the presence of pathogenic bacterial species responsible for
postoperative wound infection on all shoe groups, with outdoor shoes being the most
heavily contaminated. Samples taken from theatre shoes at the end of duty were less
contaminated than those taken at the beginning of the day with the greatest reduction being
in the number of coagulase-negative staphylococcal species grown. Studies have
demonstrated that floor bacteria may contribute up to 15% of airborne bacterial
colony forming units in operating rooms. The pathogenic bacteria we isolated have also
been demonstrated as contaminants in water droplets spilt onto sterile gloves after surgical
scrubbing.
 CONCLUSIONS: Theatre shoes and floors present a potential source for postoperative
infection. A combination of dedicated theatre shoe use and a good floor washing protocol
controls the level of shoe contamination by coagulase-negative staphylococci in particular.
This finding is significant given the importance of staphylococcal species in postoperative
wound infection.


BACKGROUND: The operating room is a complex work environment with a high potential for adverse
events. Protocols for perioperative verification processes have increasingly been recommended by
professional organizations during the last few years. We assessed personnel attitudes to a pre-
operative checklist ('time out') immediately before start of the operative procedure.
METHODS: 'Time out' was implemented in December 2007 as an additional safety barrier in two Swedish
hospitals. One year later, in order to assess how the checklist was perceived, a questionnaire was sent by
e-mail to 704 persons in the operating departments, including surgeons, anesthesiologists, operation and
anesthetic nurses and nurse assistants. In order to identify differences in response between professions,
each alternative in the questionnaire was assigned a numerical value.

RESULTS: The questionnaire was answered by 331 (47%) persons and 93%
responded that 'time
out' contributes to increased patient safety. Eighty-six percent thought that 'time
out' gave an opportunity to identify and solve problems. Confirmation of patient
identity, correct procedure, correct side and checking of allergies or contagious
diseases were considered 'very important' by 78-84% of the responders. Attitudes
to checking of patient positioning, allergies and review of potential critical
moments were positive but differed significantly between the professions. Attitudes to a similar
checklist at the end of surgery were positive and 72-99% agreed to the different elements.
 CONCLUSION: Staff attitudes toward a surgical checklist were mostly
positive 1 year after their introduction in two large hospitals in central
Sweden.
Addressing the rising concern about surgical site infections caused by Staphylococcus aureus (S. aureus),
including methicillin resistant Staphylococcus aureus (MRSA), 3M today announced the launch of the 3M™
Skin and Nasal Antiseptic (Povidone-Iodine Solution 5% w/w (0.5% available iodine) USP) Patient
Preoperative Skin Preparation. This is the first product designed to reduce S. aureus in the nasal
passages or nares, and is applied in the healthcare setting prior to surgery. Clinical studies show
that the antiseptic kills 99.5% of S. aureus in the nares in one hour and maintains that level for at
least twelve hours, an important benefit for patients undergoing surgery who may be at risk for
infection.1
“Staphylococcus aureus is the leading cause of surgical site infections with approximately 80
percent of S. aureus infections caused by the patient’s own nasal flora2,” said Matt Scholz,
corporate scientist, Infection Prevention Division at 3M. “As a patient preoperative skin preparation, 3M Skin
and Nasal Antiseptic helps reduce the risk of S. aureus surgical site infection, including MRSA, which
provides healthcare providers with confidence and control.”
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