Focusing on processes and compliance to prevent hospital-acquired infections

by Lorri Downs, RN, BSN, MS, CIC

When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection. In regard to preventing hospital-acquired infections (HAIs), the CDC, IDSA and SHEA have developed a compendium of the various best practices available, so we know the information is out there. However, more often than not, surveys show that the world of clinical practice falls short when it comes to implementing these evidenced-based guidelines.

For example, studies have shown that the most effective way to prevent the most common HAI urinary tract infections is to avoid catheterization, yet data indicates that approximately one quarter of patients admitted to hospitals have urinary catheters inserted. In 30 percent to 50 percent of those patients, a urinary catheter was not medically indicated, but was inserted for either an unclear or inappropriate indication, such as urinary incontinence.

Likewise, hand hygiene, the number one defense against healthcare-acquired infections, has been proven to have an important role in prevention. The CDC estimates that adherence to handwashing procedures alone could prevent the deaths of 20,000 patients each year. Studies have shown, however, that despite being a proven effective practice, hand hygiene compliance among healthcare workers is poor, with the World Health Organization reporting an average compliance rate of 40 percent.

The CMS reimbursement changes that took effect in October 2008 helped to bring the issue to the forefront somewhat, as healthcare professionals dealt with the mandate that they eliminate certain HAIs and improve patient safety or risk losing Medicare reimbursement dollars. However, the Health and Human Services department’s 2009 quality report to Congress “found very little progress” on eliminating hospital-acquired infections. Of five major types of serious hospital-related infections, rates of illnesses increased for three and one showed no progress.

Such data and findings leads to a simple conclusion. Preventing hospital-acquired infection is not all about policies and procedures—it has a lot to do with processes and building in compliance.

Let’s take a look at an example of a HAI prevention process—surgical skin preparation—followed by some ideas on how to reinforce compliance to aseptic technique. Of course, it goes without saying that these ideas can be applied to measuring and validating skill and competencies for sterile techniques related to most best practices for preventing HAIs.

Surgical site infections (SSIs) are the third most frequent hospital-acquired infection. Twenty-seven million people undergo surgery each year, and approximately 500,000 will acquire an SSI. Fifteen percent of elective surgery patients and 30 percent of patients receiving contaminated or dirty surgery are estimated to develop a postoperative wound infection. SSIs continue to occur despite advances in infection control practices such as improved operating room ventilation, sterilization, surgical technique, and availability of antimicrobial prophylaxis.

We know that bacteria commonly found on the skin are a frequent cause of SSIs. Thus, effective preoperative skin preparation is our first line of defense against postoperative wound infection. According to the CDC, effective skin preparation depends on three key factors: preoperative antiseptic showers, preoperative hair removal and immediate surgical site preparation in the operating room.

Preoperative Showers

The Centers for Disease Control and Prevention (CDC) “strongly recommends” (Category 1B) that healthcare facilities “require patients to shower or bathe with an antiseptic agent on at least the night before the operative day.” A preoperative antiseptic shower or bath decreases microbial colony counts on the skin. Products containing chlorhexidine gluconate have been shown to decrease bacterial colony counts nine-fold but require several applications to attain maximum antimicrobial benefit. Therefore, repeated antiseptic showers are usually indicated.

Preoperative Hair Removal

What is the “best practice” for hair removal? Here is what current evidence suggests:

• Refrain from hair removal unless it interferes with the surgical procedure or wound closure.
• If hair is removed, it should be done with a clipper or depilatory cream in an area outside the room where the procedure will be performed.
• Razors have no place in the operating room. In one study, SSI rates were 5.6 percent in patients who had their hair removed by razor shave, compared to a 0.6 percent rate among those who had their hair removed by depilatory or who had no hair removed. Clipping hair immediately before an operation has also been associated with a lower risk of SSI than shaving or clipping the night before an operation; results are 1.8 percent compared to 4.0 percent. Although the use of depilatories has been associated with a lower chance of SSI than clipping or shaving, depilatories can produce hypersensitivity reactions.

Surgical Site Preparation

According to AORN Recommended Practices, preoperative skin preparation should be performed only minutes before the start of the procedure. But, first AORN states that:

• The condition of the skin at the surgical site should be assessed prior to preparation for rashes, skin eruptions, and abrasions.
• The skin should be free of gross contamination, such as dirt or soil, or any other debris before skin preparation is initiated.

Immediate surgical site preparation can be performed with a variety of antiseptic agents at the actual incision site. Most common are iodophors, alcohol-containing products, and chlorhexidine gluconate (CHG). The U.S. Food and Drug Administration (FDA) has long recognized alcohol as the most effective and rapid-acting skin antiseptic. Few surgical professionals would dismiss the proven efficacy of alcohol; however, the debate continues about the superiority of surgical preps containing CHG and alcohol versus surgical preps containing iodine and alcohol. In a recent study, the efficacy of three different surgical skin preps was compared. Results varied for a variety of reasons, such as differences in application method and patient risk factors. But overall results clearly pointed to the combination solutions with alcohol as the most effective in reducing bacterial counts.

The Question of Compliance

Now that we’ve established best-practice standards for surgical skin preparation, we need to take a look at compliance. There are three main challenges:

• Assuring “best practice” when greater than 90 percent of all surgical patients arrive on the morning of surgery and must be relied upon to properly perform a preoperative shower when they were instructed either in a physician office visit or in a preadmission telephone call or interview;
• Addressing surgeons that provide physician orders contrary to best practice;
• Measuring competency and validating skills of perioperative staff members to assure that standards are adhered to on every surgical procedure.

Patient Compliance

From a patient’s perspective, perioperative care begins in the surgeon’s office, progresses to the surgical facility, continues with discharge to home and ends in the surgeon’s office. The patient is typically given oral instructions, preprinted forms and educational materials that explain the surgeon’s orders prior to and the day of surgery. These instructions should teach the patient four essential things:

1. What to expect;
2. When and how it will happen;
3. Where it will take place;
4. Why it is necessary.

In other words, it is important to anticipate and answer the patient’s questions before they arise. The most effective way to establish an effective preoperative education program is to develop a standardized approach that is adopted by the perioperative staff, including the surgeon.

Surgeon Compliance

As mentioned, the surgeon’s sound judgment and proper technique have a great impact on the prevention of surgical site infections. What influences surgeons to change their opinion and subsequently their technique? It typically occurs in one of two ways:

• Through the presentation of overwhelming, substantial data;
• Through peer pressure to change.

A third influencer might be reimbursement pressure resulting from negative outcome data. In our data-driven world, tracking, measurement, and reporting of healthcare outcomes are becoming more common. Web sites such as www.healthgrades.com, www.RateMDs.com, and www.physicianreports.com make it easy to find physician data; this can and is influencing physician compliance with best-practice policies and procedures. While these data sources are not always considered reliable, objective clinical data can be tracked by hospitals through third-party companies that contract with a facility to obtain and monitor data trends. Two such companies that provide these services are MedMined (www.medmined.com) and Cereplex (www.cereplex.com).

Staff Compliance

In the final parallel, the patient encounters an assortment of perioperative team members at each location with varied roles and responsibilities. To provide consistency throughout the continuum, AORN offers two suggestions:

1. Use the AORN recommended practices for skin preparation as guidelines for developing policies and procedures in the practice setting;
2. Include an introduction to (or review of) policies and procedures in the orientation and ongoing education of staff members to assist in the development of knowledge, skills, and attitudes that affect patient outcomes.

For clinicians, aseptic principles and techniques are the cornerstone of infection control efforts. Aseptic techniques are the practices that restrict microorganisms in the environment and on equipment and supplies, and that prevent normal body flora from contaminating patients. Although the principles appear to be basic, logical and intuitive, non adherence to one or more is common for a multitude of reasons. Time factors, staffing issues, expectations from coworkers, pressure from surgeons or anesthesiologists, poor traffic control, and inefficient supply logistics are some of the most common influencers. Even fear of reprisal can interfere with the maintenance of a sterile field.

Seven Principles of Asepsis

Proper adherence to aseptic technique minimizes and often eliminates modes and sources of contamination. Consistent observance of the boundaries established in the principles by each member of the team still provides the best way to ensure that aseptic technique is followed. How can we all be reminded to comply? Here are a few suggestions that can help satisfy this basic need, simply and effectively.

Annual Review

Annual review can take place in the form of a scheduled inservice to review principles, policies, and procedures. Consider developing skits and scenarios that depict proper and improper practices and techniques. These can be entertaining while pointing out the common breaches in aseptic technique that can and do occur in every facility. Traditional methods include modular study guides followed by a multiple-choice test.

Skills Validation

Validation of competency follows training and is typically accomplished through clinical observations in the operating room setting by a trained observer, and through written tests that are conducted annually and recorded in the employee’s permanent record. An alternative form of written validation or testing can be conducted using pictures and/or actual clinical staging. A sketch or picture of a healthcare setting that includes both obvious and subtle breaches in aseptic technique can be presented to a clinician, who would be asked to identify the breaches and correct the situation according to recommended practices and standards. Additionally, a simulation can be staged in a vacant room; clinicians would be asked to enter the room, identify and correct all breaches in aseptic technique, and document their findings on the testing form provided. Either of these tests could be graded and placed in a personnel record.

Visual Reminders

Posters, signs, and stickers can serve as effective prompts when placed appropriately within the healthcare setting. Because these tools will be viewed by the public, they should look as professional as possible; they should also be durable enough to withstand normal wear and tear. It is important to follow facility protocols regarding the use of visual reminders. Some facilities are adding specially designed stickers to the outside of commonly used supplies within the OR to remind personnel of important procedures and processes. For educational materials on hand washing and aseptic technique that can be printed and posted in your facility, check out www.engenderhealth.org/ip/miw/index.html.

Clinical Documentation

A separate form or checklist including the principles of asepsis can be incorporated into the perioperative record. Adherence to aseptic technique can be documented by having the nursing circulators sign the perioperative record. A sample patient record from AORN includes an outcome statement in the Postprocedure Assessment and Evaluation section stating, “Patient’s surgery performed using aseptic technique and in a manner to prevent cross-contamination.” This not only serves as a consistent and frequent reminder to adhere to these principles, but also provides a review each time the circulator performs his or her duties. Most often, a separate form is not needed unless there have been unrelenting issues with following the principles of asepsis without improvement over time in a given facility. Typically, the incorporation of a checklist, signature, or outcome statement attesting to adherence of the principles is sufficient.

Review of Departmental Infection Rates

Infection rates should be shared with the clinical staff on a routine basis. The decision to share this data with staff may be controversial for fear that the data would be misinterpreted. Through trending and coding of sensitive data, both by specialty and discipline, satisfactory methods of data analysis and presentation can be developed, making it possible to share information that will improve overall patient care.

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Patient and operation characteristics that may influence the risk of surgical site infection development

Patient

• Age
• Nutritional status
• Diabetes
• Smoking
• Obesity
• Coexistent infections at a remote body site
• Colonization with microorganisms
• Altered immune response
• Length of preoperative stay

Operation

• Duration of surgical scrub
• Skin antisepsis
• Preoperative shaving
• Preoperative skin prep
• Duration of operation
• Antimicrobial prophylaxis
• Operating room ventilation
• Inadequate sterilization of instruments
• Foreign material in the surgical site
• Surgical drains
• Surgical technique

-         Poor hemostasis

-         Failure to obliterate dead space

-         Tissue trauma

Source: CDC’s Guideline for Prevention of Surgical Site Infection, 1999

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Lorri Downs, RN, BSN, MS, CIC is a board certified infection preventionist and vice president of Infection Prevention at Medline Industries Inc. Ms. Downs possesses a diverse portfolio of more than 25 years in the nursing profession. Her expertise has focused on infection prevention surveillance at large acute care organizations, plus ambulatory and public health settings. Ms. Downs has crafted hospital infection control programs, local emergency preparedness plans as well as lectured on various infection prevention topics.