After reading this article, the learner will be able to:
1. Recognize the transmission of surgical site related infections
2. Understand the importance of proper use of personal protective equipment
3. Describe the mechanisms to prevent the transmission of organisms
Surgical patients are at particular risk for developing surgical site infections (SSIs) due to compromise of the body's first line of defense: the skin.1 Thirty-six percent of all hospital-associated infections (HAIs) are SSIs.1 Between 2% and 5% (approximately 500,000) of all U.S. patients who undergo surgery in inpatient facilities develop an SSI.2 These infections are costing healthcare systems up to $10 billion annually.2 The Association of periOperative Registered Nurses (AORN) recommends that perioperative personnel take definitive action to prevent the transmission of HAIs.2
Infection prevention in the postoperative setting requires good communication, knowledge of recommended prevention practices, and adherence to prevention guidelines. Transmission of communicable diseases can occur through contact with high-touch surfaces, because the organisms travel on the hands of healthcare workers.3 The CDC has issued guidelines for preventing the spread of HAIs using transmission-based precautions. The basic infection prevention and control principles of hand hygiene and the correct donning and doffing of personal protective equipment are recognized as a best practice to prevent the spread of communicable disease among patients.3
The CDC guidelines for isolation precautions were last updated in 2007; however, addendums for Ebola virus and measles were made more recently. CDC isolation precaution guidelines should guide interactions between healthcare providers and patients.3 They provide evidence-based recommendations based on clinical presentation and the likely pathogen.3
Expanding upon the recommendations set forth in the CDC guidelines, AORN's 2016 Guidelines for Perioperative Practice include a section on the prevention of transmissible infections. It states that:
Healthcare workers should use standard precautions in the perioperative setting.
Contact precautions should be used when providing care to patients who are known or suspected to be infected or colonized with microorganisms transmitted by direct or indirect contact.
Droplet precautions should be used in the preoperative, intraoperative and postoperative phases when providing care to patients who are known or suspected to be infected with microorganisms that can be transmitted by large droplets.
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.
Healthcare personnel must follow the OSHA bloodborne pathogens standard when risk of exposure to blood or other potentially infectious materials exists.4
It is not enough to simply implement transmission-based precautions; staff members must then inform all other healthcare workers who will encounter the patient. Between 2% and 24% of personnel caring for patients colonized with multidrug-resistant bacteria or Clostridium difficile infection acquired the pathogens on their hands after glove removal.5 Incorrect technique for donning and doffing of personal protective equipment (PPE) is common.5
Direct observations were performed in a 2015 study that collected data on PPE removal practices by healthcare workers.6 Thirty healthcare workers were observed, and only 43% removed their equipment in the correct order.6 In addition, only 17% removed their equipment in the correct order and disposed of it in the patient room.6
Proper removal of PPE is important to prevent contamination. When healthcare workers become contaminated during removal of PPE, this can contribute to transmission of pathogens in the hospital.7 Between 2% and 5% of healthcare personnel who care for patients with multi-drug resistant organisms (MDROs) acquire the pathogen on their hands after glove removal.7 When CDC guidelines for donning and doffing PPE are followed, less frequent hand and clothing contamination occur. Contamination of the skin and clothing of personnel contributes to the transmission of organisms.7
The CDC guidelines for isolation precautions provide clear instruction for donning and doffing of PPE (outlined below). Hand hygiene should be performed immediately after removing all PPE.1
Fully cover torso from neck to knees, arms to end of wrist, and wrap the gown around the back.
Fasten in back at neck and waist.
Mask or respirator:
Secure ties or elastic band at middle of head and neck.
Fit the flexible band to the nose bridge.
Fit the device snugly to the face and below the chin.
Fit-check the respirator.
Use nonsterile gloves for isolation.
Select gloves according to hand size.
Gloves should extend to cover the wrists of the isolation gown.
Remove PPE at the doorway, before leaving the patient room, or in the anteroom, in this order.
Grasp the outside of one glove with the opposite gloved hand; peel off.
Hold the removed glove in the gloved hand.
Slide the fingers of the ungloved hand under the remaining glove at the wrist.
Touch the "clean" head band or ear pieces; the exterior of the goggles of shield is contaminated.
Place the PPE in a designated receptacle for reprocessing, or in a waste container.
Unfasten the neck, followed by the waist ties.
Remove the gown using a peeling motion; pull the gown from each shoulder toward the same hand; the gown will turn inside out.
Hold the removed gown away from body, roll it into a bundle, and discard it in a waste or linen receptacle.
Mask or Respirator:
Do not touch the front of a mask or respirator that is contaminated.
Grasp ONLY the bottom, followed by the top ties/elastics, to remove it.
Discard it in a waste container.
Of the more dangerous organisms in circulation today is carbapenem-resistant Klebsiella pneumoniae. A systematic review of outbreak transmission found that 10% of K pneumoniae isolates were derived from surgical site wounds.8 Within the hospitals that reported outbreaks, the intervention most commonly used to contain them was the establishment of contact precautions (used by all).8 Carriers, or colonizers, of these organisms can act as reservoirs and contribute to the spread of these organisms in the hospital environment.8 According to AORN recommendations, a clean environment should be maintained.4
Bacteria, viruses and fungi can persist on environmental surfaces and be passed on via the hands of healthcare workers to cause HAIs.9 One study found that bacteria such as Acinetobacter, Clostridium difficile, vancomycin-resistant Enterococcus, Pseudomonas aeruginosa, Serratia marcescens and methicillin-resistant Staphylococcus aureus survived for months on inanimate surfaces.9 Gram-negative bacteria, such as Klebsiella and Pseudomonas, may persist on surfaces longer than gram-positive bacteria.9 Adenovirus is the only virus that had a range of 3 months' persistence on inanimate surfaces.9 The longest persistence was 150 days.9 Surfaces that are disinfected before immediate contact with the patient can reduce HAI transmission.9
In the postoperative setting, surgical patients are being monitored for vital signs and stability. Monitoring these patients requires the use of medical devices that may be used between patients. Reusable medical devices and equipment raise HAI concerns, since they can serve as a reservoir for pathogens if not cleaned properly between uses.10
Examining the design of a surface can also help determine the cleanliness status of that surface.10 In a 2013 review, researchers observed that smoother bedrail surfaces were easier to clean and disinfect than surfaces that had higher surface roughness values.10 They also found pathogenic microorganisms on monitors, blood gas analyzers, ventilator knobs, and radiant warmer control buttons.10
The same study also found variability in the cleaning ability of disinfecting wipes used to clean the equipment. The researchers tested six types of disinfecting wipes containing similar and distinct chemicals.10 All of the wipes exhibited differences in how well they actually performed, even though they all left less than 6.4 mcg/cm2 of protein on the test surface.10 Each manufacturer has its own instructions for use and contact time.10 When disinfecting a surface, it is important to follow the manufacturer's instructions. The surface contact time is the amount of time the surface must remain wet in order to kill organisms.10
Strategies to contain environmental surface contamination include reducing and containing shedding and improving cleaning and disinfection.11 Each cleaning and disinfection product relies heavily on the end user to ensure proper selection and contact times.11 Monitoring the cleaning process with fluorescent light markers or adenosine triphosphate testing is recommended.11 Feedback to departments responsible for cleaning is vital to maintaining clean surfaces.11
An enhancement to the cleaning and disinfection process is a "no-touch" automated room disinfection system.11 Such systems distribute hydrogen peroxide vapor, aerosolized hydrogen peroxide, ultraviolet C and pulsed-xenon ultraviolet radiation.11 These systems reduce reliance on an operator to achieve adequate disinfection.11 The systems must be used in conjunction with typical surface cleaning.
To reduce and contain shedding, improved hand hygiene-both after contact with the patient environment and before and after direct contact with the patient-is vital.11 The timely identification of patients with MDROs is the key to contamination containment.11 Patient room assignments can be challenging when single patient rooms are unavailable.11 Patients then need to be placed with other patients who share the same resistant organisms. This process can hamper the proper isolation of patients.11
Proper Hand Hygiene
The pathogens that contribute most often to surgical site infections include S aureus, coagulase-negative Staphylococci, Enterococcus species and E coli.2 Microbes can be spread via the hands of healthcare workers due to lapses in hand hygiene.12 In one study, hand hygiene adherence was only 30% to 40% in intensive care units.12 Transmission to the hands of healthcare workers was most successful with E coli, Salmonella, S aureus, Candida albicans, rhinovirus, hepatitis A and rotavirus.9 Healthcare workers with contaminated hands can then contaminate five more surfaces or 14 other subjects.9
Hand hygiene is the single most important tool to prevent the spread of infections.13 It is cheap, easy and does not cost the healthcare worker anything. Hand hygiene can be performed as hand washing or hand sanitizing. Both methods are effective for cleaning the hands, but one is more appropriate depending on circumstances. Alcohol-based hand sanitizers are not an effective means of killing C difficile spores, so hand washing is the recommended method of hand hygiene for patients infected with this organism.15 Products containing sodium hypochlorite and a hydrogen peroxide/peracetic acid product are currently the only Environmental Protection Agency-approved disinfectants for environmental surfaces contaminated with C difficile.14
Hand hygiene alone can significantly reduce the risk of infection transmission in healthcare settings if implemented properly.13 The indications for hand hygiene while performing patient care are:
Soap and water:
V When visibly dirty or contaminated with proteinaceous material, blood or other body fluids
V After using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water
V Before and after eating food
When hands are not visibly soiled, an alcohol-based hand rub should be used routinely for decontaminating hands:13
V Before having direct contact with patients
V Before donning sterile gloves when inserting a central intravascular catheter
V Before inserting indwelling urinary catheters, peripheral vascular catheters or other invasive devices that do not require a surgical procedure
V After contact with a patient's intact skin
V After contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings if hands are not visibly soiled
V After contact with inanimate objects in the immediate vicinity of the patient
V After removing gloves
V When moving from a contaminated body site to a clean body site during patient care.
Although healthcare workers understand the need to perform hand hygiene, in one review in an intensive care unit, adherence only reached 30% to 40%.12 Some factors that affect hand hygiene adherence include wearing gloves instead of performing hand hygiene; skin irritation from cleansers; lack of availability of sinks or cleaning products; belief that the risk of acquiring infections from patients is low; lack of knowledge of protocols; and skepticism about the value of hand hygiene.13
At the Forefront
Healthcare workers are at the forefront of infection prevention. They literally are what stand between a patient going home after a procedure in good health and a longer length of stay due to an HAI. Implementing good infection prevention practices will lead to infection-free patients. Simple processes such as appropriate PPE use, environmental surface cleaning and proper hand hygiene are important steps to preventing the spread of HAIs among postoperative patients.
1. Link T, et al. Determining high touch areas in the operating room with levels of contamination. Am J Infect Control. 2016; doi: 10.1016/j.ajic.2016.03.013.
2. Burlingame B, et al. Transmissible Infections. In: Guidelines for Perioperative Practice. 2016 edition. Association of Perioperative Nurses; 2016: 482-483.
3. Siegel JD, et al, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings; 2007:14. http://www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf
4. Burlingame B, et al. Transmissible Infections. In: Guidelines for Perioperative Practice. 2016 edition. Association of Perioperative Nurses; 2016: 472-482. http://www.aornstandards.org/
5. John A, et al. Are healthcare personnel trained in correct use of personal protective equipment? Am J Infect Control. 2016;44(7):840-847.
6. Tomas M, et al. Contamination of healthcare personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.
7. Zellmer C, et al. Variation in healthcare worker removal of personal protective equipment. Am J Infect Control. 2015;43(7):750-751.
8. Campos A, et al. Outbreak of Klebsiella pneumonia carbapenemase-producing K pneumonia: A systematic review. Am J Infect Control. 2016; doi: 10.1016/j.ajic.2016.03.022.
9. Kramer A, et al. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006;6:130.
10. Gold K, et al. Cleaning assessment of disinfectant cleaning wipes on an external surface of a medical device contaminated with artificial blood or Streptococcus pneumonia. Am J Infect Control. 2013;41(10):901-907.
11. Otter J, et al. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control. 2013;41(5 Suppl):S6-S11.
12. Neo J, et al. Evidence-based practices to increase hand hygiene compliance in healthcare facilities: An integrated review. Am J Infect Control. 2016;44:691-704.
13. Mathur P. Hand hygiene: Back to the basics of infection control. Indian J Med Res. 2011;134(5):611-620.
14. EPA's Registered Antimicrobial Products Effective against Clostridium difficile Spores https://www.epa.gov/pesticide-registration/list-k-epas-registered-antimicrobial-products-effective-against-clostridium
15. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16): 16-17.
Kelly Romano is the director of infection control and patient safety at Einstein Medical Center Montgomery in East Norriton, Pa.