Recommended Practice for the Prevention of Transmissible

InfectionsLisa Spruce, DNP, RN, ACNP, ACNS, ANP, CNOR

Director, Evidence-Based Perioperative Practice

Transmissible InfectionsRP Highlights

• Some new elements for standard precautions.

Standard Precautions

Standard Precautions

Environmental Control

• Environmental contamination was the major determinant of transmission to healthcare workers’ gloves or gowns. Compliance with contact precautions and more aggressive environmental cleaning may decrease transmission.

• ~Morgan (2012)

Respiratory hygiene/Cough etiquette

• Covering the mouth or nose with a tissue or sleeve.

• Wear a surgical mask if able.

• Stay at least 3 feet away from others

• Posting signs and providing instructions to patients and visitors.

• Single syringe, single needle, one time.

• Outbreaks of Hep C and B have been attributed to unsafe injection practices in multiple states.

• Health care textiles: change and launder after each patient use or when soiled.

• Launder in a health care-accredited laundry facility.

Standard Precautions

Contact Precautions

Contact with infected patients or contaminated surfaces leads to pathogen transmission 45% of the time.

Perioperative personnel should don PPE and:

• Wear gloves whenever touching a patient’s skin or items 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.

Make sure to discard PPE upon exiting the room!

Droplet/Airborne Precautions

Droplet• Place patient in a single

patient room before and after surgery.

• Special air handling and ventilation IS NOT required.

• Place at least 3 feet away from other patients.

• Place a mask on patient for transport.

Airborne• Patients should be placed in an

airborne infection isolation room.

• Special air handling and ventilation IS required.

• Do not place in the same room with other patients.

• Personnel should don a surgical mask or N95 respirator.

• Place a mask on patient for transport.

Intubation/extubation is a cough producing procedure!

After such procedures are performed, sufficient time should be allowed for 99% of airborne contaminants to be expelled before sterile supplies are opened for subsequent patients.

The OR doors are to remain closed.

Recovery should take place in an AIIR.

• If there is not AIIR- use a HEPA.

• Position near patient’s breathing zone.

• Switch the portable unit off during the surgical procedure.

• Provide fresh air according to ventilation standards for the OR.

HEPA filters

Environmental Cleaning

• Standard cleaning and disinfection procedures should be followed.

• Only perform after the appropriate amount of time for air ventilation.

• If room cleaning begins before the appropriate time has elapsed, cleaning personnel should wear N95 respirators or powered air-purifying respirators.

OSHA

Bloodborne Pathogen Standard

• PPE including surgical caps, hoods, shoe covers, or boots when gross contamination is anticipated.

• No eating or drinking in the semi-restricted or restricted areas.

• Gowns, gloves, masks, eye protection.

• Anticipate exposures!!

Prevention of Exposure

Controls

Engineering• Needleless systems

• Self-sheathing needles

• Sharps storage and disposal containers.

Work Practice• Prohibit risky handling of needles

and sharps.

• Prohibit recapping of needles by a two-handed technique.

• Using a neutral zone or hands free technique for passing sharps.

• Double glove for all surgical procedures.

Periop Actions

To prevent the transmission of health care-acquired infections

Surgical Site Infections

CDC: Atlanta, GA

SSI Statistics

• 500,000 annual SSIs

• 1.7 million HAIs

Sterile TechniqueThis is the foundation of infection prevention!

• Maintain a clean environment

• Wear clean surgical attire

• Perioperative skin antisepsis

• Hand hygiene

• Minimize traffic

• Adequate sterilization

Actions to Prevent SSI

Decolonization

• Collaborate with medical colleagues.

• Staph aureus has been found to be “the most powerful independent risk factor for SSI” in patients undergoing cardiothoracic surgery.

• Mupirocin ointment

• CHG

Antimicrobial Prophylaxis

Administer according to health care organization policy.

Critically timed adjunct therapy intended to reduce the microbial burden of surgical contamination to a level that cannot overwhelm the patient’s defenses.

• Improve hand hygiene practices

• Contact precautions until patient culture negative

• Managing vascular and urinary catheters

• Preventing lower resp tract infection in intubated patients

• Following the CDC Campaign to Prevent Antimicrobial Resistance

• Limiting and carefully selecting antimicrobial agents

MDROs

CLABSI

• Implement CDC Guidelines – Sterile technique

– Maximal sterile barrier• Hair covering

• Mask

• Sterile gown

• Sterile gloves

• Sterile full body drape

• Follow CDC guidelines– Insert only for medically indicated conditions

– Use only as necessary for surgical patients

– Document date and time of insertion

– Remove asap post-op (preferably within 24 hours)

– Strict aseptic technique

– Only allow trained persons to insert

CAUTI

Immunizations

CDC Recommendations

HCWs who get a flu shot decrease:

•transmission of influenza•staff illness and absenteeism•influenza-related illness and death, especially among patients

who are at increased risk

Health care personnel with Transmissible Infections

Restrict Activities

• Viral infections (flu)

• Purulent conjunctivitis

• Acute GI illness

• Asymptomatic carrier of diptheria

• Exudative lesions that cannot be contained

• Herpes simplex infections of the fingers or hands

• Pediculosis

• Scabies

• Meningococcal infection

• Work restrictions depend on several factors– Circulating viral burden

– Category of clinical activities

Consult with infection preventionist!

Bloodborne Infections

• AORN Surgical Wound Classification Decision Tree

• Helps perioperative nurses accurately identify surgical wounds

Surgical Wound Classification

AORN Decision Tree

AORN Decision Tree

Table