Improving the Operating Room Environment to Drive Down

Infections

Prepared by:Sarah Simmons and Maria Rodriguez

MPH CIC RN BSN CIC

Requirements for successful completion

Attendance of entire presentation

Completion/submission of EvaluationOnce successful completion has been verified, a “Certificate of Successful Completion” will be rewarded for 1 Contact Hour. This continuing nursing education activity was approved by the Texas Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Conflicts of interest - No conflicts of interest exist

No Sponsorship or commercial support was provided

No endorsement of products will be done

Activity Disclosures

Purpose Of Activity

The purpose of this education activity is to enhance the knowledge base and skills of Registered Nurses working as infection prevention nurses and surgical nurses in the area of hospital associated infections by addressing how the environment can be a contributor and by reviewing current environmental disinfection options in an effort to decrease risk of an infection.This will result in improved attention to cleaning and a new perspective for adding environmental disinfection in the operating room cleaning process which will promote safer patient environments as evidenced by Evaluation results and/or Comments.

Define the role the environment plays in postop surgical site infections

Describe the impact of hospital associated infections (HAIs) on patient outcomes and hospitals

Discuss environmental disinfection

Describe two types of environmental disinfection

Learning Objectives

1.7 million hospital acquired infections (HAIs) annually

99,000 of these infections lead to death

8,000 deaths related to surgical site infections

Hospital Acquired Infections

Doubles the risk of death after surgery

Five-fold increased risk for readmission

60% more likely to require ICU care

Length of stay increases 6 days

Consequences of SSI

Increased cost of care

Total Knee/Total Hip Replacement (TKR/THR): $17,708

Coronary Artery Bypass Graft Risk 1 (CABG) ,

C-section, Bariatrics, Hysterectomy: $20,000

Coronary Artery Bypass Graft Risk 2 ( CABG): $31,597

Mandatory reporting of infections

HCAHPS - Hospital Consumer Assessment of Healthcare Providers and Systems

Liability

The Cost of SSIs

CMS – Center for Medicare and Medicaid ServicesFor payment from CMS, hospitals are required to report data about certain infections to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN).

Current CMS reporting through NHSN are central line-associated bloodstream infections, catheter-associated urinary tract infections, surgical site infections and healthcare worker influenza vaccination coverage. Future reporting will include multidrug-resistant organisms and more.

The public reporting of these data is part of a movement by the Department of Health and Human Services to make healthcare safer. http://www.medicare.gov/hospitalcompare/Data/Healthcare-Associated-Infections.html

Mandatory Public Reporting

State HAI Reporting Laws

Federal regulations are not reflected on the map, even though the national regulations require that hospitals in all states that receive Medicare

reimbursement now have Hospital Acquired Infection (HAI) reporting requirements whether or not state law requires it.

Permission received to use legislative map from APIC website-http://www.apic.org/Resource_/TinyMceFileManager/Advocacy-PDFs/Advocacy_Updates/Static_map_-_HAI_revised_7-6-11.gif

27 state laws require public reporting of

hospital-acquired infection rates.

2 state laws allow confidential reporting of

infection rates to state agencies (NE NV).

3 states have voluntary public reporting of

infection information (AR, AZ, WI).

5 states have study laws on public reporting

(AK, GA, IN, NM, NC).

13 states and D.C. have no laws on public

reporting of hospital infections, though

some have bills pending on the matterhttp://www.health.ny.gov/statistics/facilities/hospital/h

ospital_acquired_infections/2011/docs/hospital_acq

uired_infection.pdf

National Health Safety Network -NHSNConduit for facilities to comply with Centers for Medicare and Medicaid Services (CMS) infection reporting requirements.Provides healthcare facilities data collection abilities in order to see their data in real-time and to share with facility leaders and other external partners.

For PatientsPatients can use NHSN data posted publicly on the Hospital Compare site. Patients are encouraged to visit the website to see how their local facilities are doing and discuss concerns with their healthcare providers. Many patients are choosing their hospital after checking the Hospital Compare website. http://www.cdc.gov/nhsn/about.html

CDC’s National Healthcare Safety

Network (NHSN)

.

As of Federal Fiscal Year 2013 (Oct. 1 2012), hospitals are paid on how well they perform.

Hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions must collect and submit HCAHPS data in order to receive their full annual payment update. The Hospital Value-Based Purchasing (Hospital VBP) program links a portion of IPPS hospitals' payment from CMS to performance on a set of quality measures.

The Hospital VBP Total Performance Score (TPS) for FY 2013 has two components: the Clinical Process of Care Domain, which accounts for 70% of the TPS; and the Patient Experience of Care Domain, 30% of the TPS. The HCAHPS Survey is the basis of the Patient Experience of Care Domain.

The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), further strengthened the incentive for IPPS hospitals to improve patient experience of care by providing the public with access to HCAHPS scores on the Hospital Compare website.

HCAHPS

http://www.medicare.gov/hospitalcompare/data/hospital-vbp.html; http://www.medicare.gov/HospitalCompare/Data/Patient-Experience-Domain.html

HCAHPS cont.

Patient Experience Measures• Nursing Communication• Doctor Communication• Hospital Cleanliness and

Quietness• Hospital Staff Responsiveness• Pain Management• Medicine Communication• Discharge Information• Overall Hospital Rating

http://www.medicare.gov/hospitalcompare/data/hospital-vbp.html

http://www.medicare.gov/HospitalCompare/Data/Patient-Experience-domain.html

CMS Hospital Compare

Hospital Compare example

Required adherence to the NHSN Surgical Site Infection definitions/criteria

Superficial Incisional SSI:Infection occurs within 30 days after any NHSN operative procedure and involves only skin and subcutaneous tissue

of the incision and the patient has at least one of the following: Purulent drainage from the superficial incision Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision Superficial incision is deliberately opened by a surgeon, and is culture positive or not cultured and at

least one of the following signs and symptoms : Pain/tenderness; Localized swelling; Redness, or Heat. A culture negative finding does not meet this criterion.

Diagnosis of superficial incisional SSI by the surgeon or attending physician.

Deep Incisional SSI:Infection occurs within 30 or 90 days after the NHSN operative procedure and involves deep soft tissues of the

incision (e.g., fascial and muscle layers) and patient has at least one of the following: Purulent drainage form the deep incision A deep incision that spontaneously dehisces or is deliberately opened by a surgeon and is culture

positive or not cultured and the patient has at least one of the following signs or symptoms: Fever (>38ºC) or Localized pain or tenderness

An abscess or other evidence of infection involving the deep incision is found on direct examination, during invasive procedure, or by histopathologic examination or imaging test.

Diagnosis of a deep incisional SSI by a surgeon or attending physician

Organ/Space SSI:Infection occurs within 30 or 90 days after the NHSN operative procedure and the incision involves any part of the

body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure:

Purulent drainage from a drain that is placed into the organ space Organisms isolated from an aseptically obtained culture of fluid/ tissue in the organ/space An abscess or other evidence of infection involving the organ/space is found on direct examination,

during invasive procedure, or by histopathologic exam. or imaging test Diagnosis of an organ/space SSI by a surgeon or attending physician

AND meets the criteria for a specific infection location

Infection Identification--NHSN

Bacteria!

Skin vs. Environment

Causes of SSIs

Organism % of infections reported

Staphylococcus aureus 20%

Coagulase-negative Staphylococci 14%

Enterococcus spp. 12%

Escherichia coli, Pseudomonas aeruginosa 8% each

Enterobacter spp. 7%

Proteus mirabilis, Klebsiella pneumoniae, other Streptococcus spp.

3% each

Group D Streptococci, Bacteroides fragilis, other gram positive anaerobes

2% each

Common Organisms for SSI

Known issues with cleaning:The best cleaning still doesn’t thoroughly clean all

of today’s new types of surfaces

Climbing infection rates

Inadequate staffing

Pressure on housekeeping staff to turn over rooms quickly

The Problem

Overall cleaning compliance is only 47%:

Anesthesia medication cart 38%

Anesthesia knobs 25%

IV poles 55%

Bed controls 64%

Floors 93%

Cleaning Practices

73% of surfaces positive for bacterial growth after cleaning, including:

Pseudomonas spp.

Enterococcus spp.

Methicillin-resistant Staphylococcus aureus (MRSA)

Acinetobacter spp.

Klebsiella pneumoniae

Escherichia coli

Cleaning Compliance

Bacteria Survival Time

Acinetobacter baumannii 26 days

Pseudomonas aeruginosa 5 weeks

Vancomycin resistant Enterococcus(VRE)

4 months

Clostridium difficile 5 months

Methicillin-resistant Staphylococcus aureus (MRSA)

7 months

Escherichia coli 16 months

Environmental Survival

Research linking the role of the environment to the development of health care associated infections and transmission of multi drug-resistant organisms is causing Perioperative leaders to actively partner with environmental services and infection prevention colleagues to help identify cleaning strategies.

Wood cites a 2011 study in which researchers observed a mean cleaning rate of 25% for objects monitored in the operating room setting in 6 acute care hospitals. “It’s studies like this that show us the concept of clean is still evolving in the perioperative setting.”

(Source – Perioperative Insider Weekly Newsletter 5 High Touch Surfaces to Clean Better July 10 2013)

Amber Wood, AORN Perioperative Nursing Specialist MSN, RN, CNOR, CIC, CPN.

OR Environmental cleaning - an important strategy in

preventing infection.“Research shows that ORs may

not be as clean as they could or should be…”

Wood’s concern:“Organisms such as MRSA(Methicillin-resistant Staphylococcus aureus )

and CRE(carbapenem-resistant Enterobacteriaceae) are colonized on a

patient and health care providers are touching a patient and then

touching the environment … creating reservoirs of these pathogens.”

Wood advises, “Identifying high-touch objects in each procedural setting and thoroughly cleaning these areas in collaboration with environmental services can help decrease contamination and transmission.”

Five high-touch objects common in all procedural settings:

1. Anesthesia cart and equipment (including IV pole)2. Anesthesia machine3. Patient4. OR bed5. Table strap

6. monitors

(Source – Perioperative Insider Weekly Newsletter 5 High Touch Surfaces to Clean Better July 10 2013)

OR Environmental cleaning cont.

Workspace becomes highly contaminated during cases with bacteria such as:

Enterococcus spp.

Micrococcus spp.

Staphylococcus spp.

MRSA

VRE

Bacteria recovered from IV administration sets after surgery

Anesthesia Equipment

Improper practices can increase apatient’s risk for acquiring an infection.

http://www.7sbundle.com/uploads/4/6/4/2/4642325/implementing_aorn

_surgical_attire_recommendations_2012.ppt

Are you contributing to your patient’s risk?

http://www.7sbundle.com/uploads/4/6/4/2/4642325/implem

enting_aorn_surgical_attire_recommendations_2012.ppt

Comments Score

1

Gather equipment. Wash hands and put on appropriate personal

protective equipment. Leave cleaning cart/supplies outside OR.

Keep OR door closed while cleaning.

2

Collect all linen, dispose of in appropriate hamper bags for the

laundry. Dispose of linen from open packs, whether soiled or not,

in the proper linen hamper. If linen is wet or heavily soiled, double

the bag.

3

Discard any soiled sponges, suction canisters, tubing, and other

waste as infectious waste as per local SOP.

4 Gather all litter from floor and deposit in waste containers.

5 Remove all trash/linen from room.

6 Clean/Disinfect waste can and replace bag.

7 Clean/Disinfect hampers and replace linen hamper bags.

8

Clean/ Disinfect OR Lights and high touch areas. Clean/disinfect

fixed & ceiling-mounted equipment to include hoses, cabinets and

shelves. Clean/disinfect surgical lights & external tracks. Start at

the highest point and work down. Wipe down high touch areas

with disinfectant.

9

Clean/ Disinfect equipment. Clean/disinfect horizontal surfaces

(counter tops, open shelves). Damp wipe all furniture, back table,

Mayo stands, ring stands, X-ray view boxes, suction bovie, kick

buckets, and scrub sinks.

10

Damp wipe the operating table with disinfectant solution,

removing all blood and soiled materials. Remove all pads, and

disinfect all surfaces, pads and table stand down to the casters.

Remake the operating table. Let disinfectant stand for 10 minutes

of contact time.

11

Clean/disinfect handles of cabinets, push plates, telephones, light

switches and all glass surfaces

12

Mop ceiling surfaces and walls with micro fiber mop.

Clean/disinfect ventilation faceplates/grills. Dust Vents.

13 Low dust ledges, counter tops, hard surface floors, & baseboards.

14 Clean/disinfect utility areas.

15 Clean/disinfect sub sterile areas.

16 Clean storage & supply areas.

17

Clean/Disinfect OR Floor. Move all equipment and furniture to one

side of room. Flood floor w/ disinfectant solution, machine scrub &

pick up solution w/ wet-vac. Roll casters and wheels of furniture

through disinfectant solution on the floor. Move all

equipment/furniture and mop other side of room.

18 Return all furniture & equipment when floor is dry.

19

Replace empty soap dispensers & waterless-hand sanitizers, clean

foot pump & tubing.

20 Review checklist to ensure all areas have been cleaned.

21 Notify circulator that OR is ready.

22

Remove all personal protective equipment and thoroughly wash

hands, being careful to avoid self contamination.

1. Number of Applicable Items

2. Minus number of Unsatisfactory Items

3. Equals Number of Satisfactory Items

Multiply Line 3 by 100 then divide by Line 1

Total Score for Area

Operating Room Terminal Cleaning

Technician Comments/Maintenance Issues:

Technician: Check each number when complete/cross out non applicable areas.

Quality Assurance Checklist

UNIT/ROOM:

DATE/TIME:

“Never Events”

Surgical site infections (SSIs) after coronary artery bypass graft (CABG), bariatric and orthopedic procedures

Litigation against facilities

Litigation against staff/physicians

Patients and family members are becoming more aware of their patient rights.

Litigation

Hydrogen Peroxide Vapor

Ultraviolet Germicidal Irradiation

Enhanced Disinfection Methods

Produces and disperses a vapor of hydrogen peroxide (H2O2)

Creates oxygen radicals that react with cell walls

Room must be sealed during the process

Hydrogen Peroxide Vapor

-OHO2

-

HO2

HO2HO2

O2-

O2-

-OH

-OH

O2-

HO2

-OH

Ultraviolet Germicidal Irradiation (UVGI)

Mercury UV (Hg UV) Pulsed Xenon (PX-UV)

Continuous Light Pulsed Light

253.7 nm 200-280 nm

Photodimerization PhotodimerizationPhotohydrationPhotosplittingPhotocrosslinking

Medicaire/Quality InitiativesPatient Assessment retrieved August 8 2013 from CMS website https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment.html

Committee to Reduce Infection Deaths. State Laws on Reporting HAIs retrieved Sept. 11 2013 from Hospital Infections website http://www.hospitalinfection.org/legislation.html

Hospital Compare retrieved August 8 2013 from Medicaire website http://www.medicare.gov/hospitalcompare/data/hospital-vbp.html

Hospital Compare Data Patient Experience retrieved August 8 2013 from CMS website http://www.medicare.gov/HospitalCompare/Data/Patient-Experience-Domain.html

http://www.cdc.gov/HAI/ssi/ssi.html A.Wood. OR Environmental Cleaning- an important strategy in preventing infection. Perioperative Insider Weekly

Newsletter. July 10 2013 L Munoz-Price, et al. Decreasing Operating Room Environmental Pathogen Contamination through Improved Cleaning

Practice. Infection Control and Hospital Epidemiology. 2012;33(9): 897-904 W Truscott. Patients, Particles, Pathology and Pathogens: The Infection Connection. Operating Room & Infection

Control. April 2009 Pg 42-50. R Loftus, et al. Transmission of Pathogenic Bacterial Organisms in the Anesthesia Work Area. Anesthesiology 2008;

109(3):399-407. C Owens, K Stoessel. Surgical Site Infections: epidemiology, microbiology and prevention. Journal of Hospital Infection.

2008; 70(S2):3-10. A Kramer, I Schwebke, G Kampf. How long do nosocomial pathogens persist on inanimate surfaces? A systematic

review. BMC Infectious Diseases 2006, 6:130 C Edminston, et al. Molecular Epidemiology of Microbial Contamination in the Operating Room Environment: Is there a

risk of infection? Surgery. 2005;138(4):573-582 To Err is Human: Building a Safer Health System (2000) Institutes of Medicine.

http://www.nap.edu/openbook.php?isbn=0309068371 A Jawad, H Seifert, A Snelling, J Heritage, P Hawkey. Survival of Acinetobacter baumannii on Dry Surfaces: Comparison

on Outbreak and Sporadic Isolates. J. Clin. Microbiol. July 1998 vol. 36 no. 7 1938-1941 C Wendt, B Wiesenthal, E Dietz, H Rüden. Survival of Vancomycin-Resistant and Vancomycin-Susceptible Enterococci on

Dry Surfaces. J. Clin. Microbiol. December 1998 vol. 36 no. 12 3734-3736

References

Questions?

Thank You