Transmissible Infections

Get clinical answers to frequently asked questions about Transmissible Infections.

  • What is Zika and what precautions should be taken for suspected or confirmed cases in the perioperative setting?

    Zika is a mosquito-borne disease that primarily spreads through the bite of an infected Aedes species mosquito, although it can be transmitted sexually or from a pregnant woman to her fetus, which can result in serious birth defects. Workers who are exposed to mosquitoes, or the blood or other body fluids of an infected person, are at risk for Zika.

    Guidance from the CDC and OSHA on Zika is rapidly evolving. Healthcare providers should evaluate patients for Zika infection according to CDC recommendations. Many people infected with Zika won’t have symptoms or will only have mild symptoms. The most common symptoms are fever, rash, joint pain, and red eyes. Other symptoms include muscle pain and headache. Symptoms can last for several days to a week.

    Surgical interventions are not typically indicated for treatment of Zika. Elective surgery for patients with suspected or confirmed Zika should be decided on a case-by-case basis by the provider and local health department.

    Perioperative team members caring for patients with Zika should follow standard precautions, which include following best practices for hand hygiene and wearing personal protective equipment (PPE) (eg, gown, gloves, mask, eye protection) whenever the possibility exists for exposure to blood and other potentially infectious materials.

    Consider enhanced precautions in situations where workers are at increased risk of exposure to Zika virus. While there is no evidence of Zika transmission through aerosol exposure, minimizing the aerosolization of blood or body fluids as much as possible during patient care may help prevent workers from being exposed. Additional protections, including engineering controls or enhanced PPE to prevent or reduce exposure, may be necessary during any aerosol-generating procedures.

    Resources:


    Updated August 24, 2016

  • What is strikethrough?

    Answer:

    Strikethrough is the passage of liquid that could contain microorganisms through a barrier product, such as a surgical gown or drape, including its seams and points of attachment.1

    In the United States, surgical gowns and drapes are considered to be Class II medical devices2,3 and as such, they are subject to regulation by the US Food and Drug Administration (FDA).4 Failure of these devices is subject to medical device reporting requirements according to the Safe Medical Devices Act of 1990 as amended in March 2000.5 Any incidents of strikethrough of surgical gowns or drapes should be reported, investigated, and corrective action taken. These incidents should be reported to the healthcare facility management and to MedWatch: The FDA Safety Information and Adverse Event Reporting Program at http://www.fda.gov/Safety/MedWatch/.6

    References:

    1. ANSI/AAMI PB70: Liquid barrier performance and classification of protective apparel and drapes intended for use in health care facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2012.
    2. Surgical devices, Surgical apparel, 21 §878.4040 (2012). https://www.gpo.gov/fdsys/granule/CFR-2012-title21-vol8/CFR-2012-title21-vol8-sec878-4040. Accessed May 3, 2016.
    3. Surgical devices, Surgical drapes and drape accessories, 21 §878.4370 (2012). https://www.gpo.gov/fdsys/granule/CFR-2012-title21-vol8/CFR-2012-title21-vol8-sec878-4370. Accessed May 3, 2016.
    4. Medical Devices, General and Plastic Surgery Devices, 21 CFR §878 (2014). https://www.gpo.gov/fdsys/granule/CFR-2014-title21-vol8/CFR-2014-title21-vol8-part878. Accessed May 4, 2016.
    5. Medical Device Reporting, 21 CFR §803 (2012). https://www.gpo.gov/fdsys/pkg/CFR-2012-title21-vol8/pdf/CFR-2012-title21-vol8-part803.pdf. Accessed May 4, 2016.
    6. MedWatch: the FDA safety information and adverse event reporting program. US Food and Drug Administration. http://www.fda.gov/Safety/MedWatch/. Accessed May 4, 2016.

    Updated May 4, 2016

  • What should I do if I am exposed to strikethrough of blood or body fluids?

    Answer:

    You must wash your hands and skin with soap and water or flush your mucous membranes with water immediately or as soon as possible after coming into direct contact with blood or other potentially infectious materials. You also must replace PPE and clothing as soon as possible after exposure to blood or other potentially infectious materials. You should report exposures to your health care organization as soon as they occur and infections as soon as the disease process is noted. Early self-reporting of exposures and infections helps prevent transmission to patients and other health care providers.

    Resources:

    • Guideline for prevention of transmissible infections. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:471-503.
    • Occupational Safety and Health Standards, Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR §1910.1030 (2012). Occupational Safety and Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051. Accessed May 4, 2016.
    • Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1998;19(6):407–463.

    Updated May 4, 2016

  • As a manager, what should I do if personnel report exposure to strikethrough of blood or body fluids?

    Answer:

    You must follow your health care organization’s established, written exposure control plan, which should be consistent with federal, state, and local rules and regulations. All exposure incidents (eg, needlesticks, blood exposures) must be reported according to health care organization policy and based on the OSHA bloodborne pathogens standard.

    All incidents of occupational exposure to blood or other potentially infectious materials must be documented. Documentation should include:

    • the route of exposure;
    • the circumstances associated with the exposure;
    • the source individual’s serological status, if known;
    • the employee’s name and social security number;
    • the employee’s hepatitis B vaccination status and other relevant medical information for both individuals, including vaccination dates and any medical records related to the employee’s ability to receive vaccinations;
    • results of all related examinations, medical tests, and post-exposure evaluation and follow-up procedures;
    • a licensed health care professional’s written opinion; and
    • a copy of the information provided to the employee.

    Documenting all exposure incidents provides the employer with feedback regarding the circumstances of employee exposures. This information can be used to focus efforts on decreasing or eliminating specific circumstances or routes of exposures.

    Resources:

    • Guideline for prevention of transmissible infections. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:471-503.
    • Occupational Safety and Health Standards, Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR §1910.1030 (2012). Occupational Safety and Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051. Accessed May 4, 2016.
    • Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1998;19(6):407–463.

    Updated May 4, 2016

  • How should perioperative team members select surgical gowns?

    Answer:

    Perioperative personnel should select gowns, gloves, and drape products for the procedure according to the barrier performance class of the product as stated on the label and according to the anticipated degree of exposure to blood, body fluids, and other potentially infectious materials.1

    Surgical gowns and drapes are labeled by the manufacturer as Level 1, 2, 3, or 4 depending upon the barrier properties of the critical zone of the gown or drape (ie, the area where direct contact with blood, body fluids, or other potentially infectious materials is most likely to occur as shown in Figure 1).2 Notably, areas located outside the critical zones (eg, back of gown) may not be protective.2 The manufacturer defines which areas of the gown are critical zones and must label any areas that are not protective.2

    Other factors that should be considered by perioperative personnel when selecting surgical gowns, gloves, and drape products for surgical or other invasive procedures include the:

    • volume of irrigation fluid;
    • potential for splash, spray, pooling, or soaking;
    • duration of the procedure;
    • type of procedure (eg, minimally invasive versus open, superficial incision versus deep body cavity); and
    • team member’s role.1

    Surgical gowns and drape products used during operative and other invasive procedures must provide a barrier and should be resistant to tears, punctures, and abrasions.1 As well, they should be non-abrasive and non-toxic, lint-free, functional, and flexible.1 Surgical gowns, gloves, and drape products should be evaluated for these qualities by the appropriate facility committees and purchasing personnel before purchase.1

    Surgical gowns labeled to show critical zones where strikethrough is most likely to occur

    References:

    1. Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:65-93.
    2. ANSI/AAMI PB70: Liquid barrier performance and classification of protective apparel and drapes intended for use in health care facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2012.

    Updated May 4, 2016

  • What is the difference in barrier performance between gowns and drapes labeled Level 1, 2, 3, and 4?

    Answer:

    Barrier performance and classification of surgical gowns and drapes is established by the American National Standards Institute, Inc. (ANSI) and the Association for the Advancement of Medical Instrumentation (AAMI) in the ANSI/AAMI PB70: 2012, Liquid barrier performance and classification of protective apparel and drapes intended for use in health care facilities.1 This standard establishes classifications of barrier performance according to the hierarchy of risks associated with the anticipated exposure to blood, body fluids, or other potentially infectious materials, or other liquid volume involved in the type and duration of procedure or activity being performed.1 These classifications are:

    • Level 1: Surgical gowns, isolation gowns, and drapes demonstrating the ability to resist liquid penetration in a water resistance: impact penetration test.
    • Level 2: Surgical gowns, isolation gowns, and drapes demonstrating the ability to resist liquid penetration in a water resistance: impact penetration test, and a water resistance: hydrostatic pressure test.
    • Level 3: Surgical gowns, isolation gowns, and drapes demonstrating the ability to resist liquid penetration in a water resistance: impact penetration test, and a water resistance: hydrostatic pressure test set at a higher value than for Level 2.
    • Level 4:
      • Gowns—Surgical gowns and isolation gowns demonstrating the ability to resist liquid and viral penetration using a bacteriophage.
      • Drapes—Surgical drapes demonstrating the ability to resist liquid penetration using synthetic blood.1

    In the United States, surgical gowns and drapes are considered to be Class II medical devices2,3 and as such, they are subject to regulation by the US Food and Drug Administration.4

    Notably, in addition to the barrier performance level of the product as stated on the label, perioperative personnel should select gowns, gloves, and drape products for the procedure according to the anticipated degree of exposure to blood, body fluids, and other potentially infectious materials.4 Other factors that should be considered by perioperative personnel when selecting surgical gowns, gloves, and drape products for surgical or other invasive procedures include the:

    • volume of irrigation fluid;
    • potential for splash, spray, pooling, or soaking;
    • duration of the procedure;
    • type of procedure (eg, minimally invasive versus open, superficial incision versus deep body cavity); and
    • team member’s role.5

    For more specific information regarding test methods, the reader should refer to ANSI/AAMI PB70: 2012, Liquid barrier performance and classification of protective apparel and drapes intended for use in health care facilities.1

    References:

    1. ANSI/AAMI PB70: Liquid barrier performance and classification of protective apparel and drapes intended for use in health care facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2012.
    2. Surgical devices, Surgical apparel, 21 §878.4040 (2012). https://www.gpo.gov/fdsys/granule/CFR-2012-title21-vol8/CFR-2012-title21-vol8-sec878-4040. Accessed May 3, 2016.
    3. Surgical devices, Surgical drapes and drape accessories, 21 §878.4370 (2012). https://www.gpo.gov/fdsys/granule/CFR-2012-title21-vol8/CFR-2012-title21-vol8-sec878-4370. Accessed May 3, 2016.
    4. Medical Devices, General and Plastic Surgery Devices, 21 CFR §878 (2014). https://www.gpo.gov/fdsys/granule/CFR-2014-title21-vol8/CFR-2014-title21-vol8-part878. Accessed May 4, 2016.
    5. Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:65-93.

    Updated May 4, 2016

  • What is the critical zone of a gown or drape and how is this determined?

    Answer:

    The critical zone of a surgical gown is the area where direct contact with blood, body fluids, or other potentially infectious materials (OPIM) is most likely to occur.1 The critical zone of a surgical gown includes the front area of the gown from chest to knees and the sleeves from cuff to above the elbow; however, as shown in Figure 1, the exact dimensions of the critical zone are determined by the manufacturer.1 Critical zones may include the seams of the gown and other points of attachment.1 Because areas outside of the critical zone are also subject to contact with blood, body fluids, or OPIM, the entire front of a gown, including its seams and other components, is required to provide at least the minimum barrier performance (ie, Level 1).1 The back of the gown is expected to remain dry, and for this reason there is no liquid barrier performance requirement for that area.1 The materials used for the back of the gown may be made of lighter weight and more breathable materials.1

    The critical zone of a surgical drape is the area where direct contact with blood, body fluids, or OPIM is most likely to occur.1 Because areas outside of the critical zone are also subject to contact with blood, body fluids, and OPIM, and because of the variation in patient size, patient positioning, and draping technique, as well as the potential need to expand the surgical site during the procedure, the entire drape is required to provide the minimum barrier performance (ie. Level 1).1

    Surgical gowns labeled to show critical zones where strikethrough is most likely to occur

    References:

    1. ANSI/AAMI PB70: Liquid barrier performance and classification of protective apparel and drapes intended for use in health care facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2012.

    Updated May 4, 2016

  • When should perioperative team members change gloves during an invasive procedure?

    Surgical gloves worn during invasive surgical procedures should be changed:

    • after each patient procedure;
    • when suspected or actual contamination occurs;
    • after touching surgical helmet system hoods and visors;
    • after adjusting optic eyepieces on the operative microscope;
    • immediately after direct contact with methyl methacrylate;
    • when gloves begin to swell, expand, and become loose on the hands as a result of the material’s absorption of fluids and fats;
    • when a visible defect or perforation is noted or when a suspected or actual perforation from a needle, suture, bone, or other object occurs; and
    • every 90 to 150 minutes.

    Resource:

    • Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:65-93.

    Updated May 4, 2016

  • Why should perioperative team members double glove during invasive procedures?

    Answer:

    Perioperative team members should double glove (ie, wear two pairs of gloves, one over the other) during invasive procedures to:

    • reduce the risk of glove perforation,
    • reduce the risk of surgical site infection for the patient,
    • protect the wearer from exposure to bloodborne pathogens, and
    • minimize the amount of blood exposure during needlestick injuries.

    In addition, using glove perforation indicator systems (ie, a double gloving system comprising a colored pair of surgical gloves worn beneath a standard pair of surgical gloves) can assist the wearer in identifying glove perforations.

    Resources:

    • Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:65-93.
    • Guideline for prevention of transmissible infections. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:471-503.
    • Guideline for sharps safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:417-440.

    Updated May 4, 2016

  • What is MERS-CoV and what precautions should be taken for suspected or confirmed cases in the perioperative setting?

    Answer:

    Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is a respiratory illness caused by coronavirus. It was first reported in Saudi Arabia in 2012 and has since spread to several other countries, including the United States. Most patients with MERS-CoV have developed severe acute respiratory illness with symptoms of fever, cough and shortness of breath. Healthcare providers should evaluate patients for MERS-CoV infection according to CDC recommendations. Guidance from the CDC on MERS is rapidly evolving due to the current lack of a safe and effective vaccine and chemoprophylaxis, a possible high rate of morbidity and mortality among infected patients, and incompletely defined modes of transmission of MERS-CoV.

    Because MERS-CoV affects the respiratory system, surgical interventions are not typically indicated for treatment. Elective surgery for patients with suspected or confirmed MERS-CoV should be decided on a case-by-case basis by the provider and local health department. Preoperative screening should include:

    • fever
    • symptoms of respiratory illness (eg, pneumonia, ARDS, cough, shortness of breath)
    • close contact with a confirmed MERS case while the case was ill
    • travel within 14 days to countries with ongoing MERS-CoV transmission (eg, Arabian Peninsula: Bahrain, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, the United Arab Emirates, and Yemen; Republic of Korea)

    Perioperative team members caring for patients with MERS-CoV should follow standard, contact, and airborne precautions (eg, gown, gloves, N95 respirator, and eye protection).

    Resources:

    • CDC MERS Information
    • CDC Healthcare Professional Guidance
    • CDC Infection Control Guidance
    • Guideline for Prevention of Transmissible Infections in the Perioperative Setting. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated June 16, 2015

  • Do observers in the OR have to meet immunization requirements?

    Answer:

    Yes, observers of operative or other invasive procedures (eg, students, visiting physicians) should be immunized according to the health care organization's policy for healthcare personnel.

    Resources:

    • Wood A. Immunization recommendations for perioperative observers. [Clinical Issues]. AORN J. 2013;97(5):587-589.

    Updated August 7, 2013

  • Do prescription eye glasses provide adequate eye protection for scrubbed team members?

    Answer:

    Standard prescription eye glasses are not considered eye protection by the CDC. Appropriate eye protection should fit snug on the brow and have solid side shields, in addition to having anti-fog properties. A face shield may also be worn to protect the eyes and face from splash or splatter.

    Resources:

    • Ogg M. Types of acceptable eye protection. [Clinical Issues]. AORN J. 2013;98(2):195-196.

    Updated August 7, 2013

  • How is the surgical wound classification determined?

    Surgical wound classification is determined using the wound classification scheme from the CDC described below. AORN has developed the Surgical Wound Classification Decision Tree (PDF) to assist in decision making for surgical wound classification. Perioperative nurses can use the Surgical Wound Classification Decision Tree as a tool to assist in decision making for surgical wound classification. The wound classification is subject to change; therefore, the wound classification should be assigned in consultation with the surgeon at the end of the procedure and documented in the perioperative record.

    The AORN Surgical Wound Classification Decision Tree is Copyright ©2014 AORN, Inc. All rights reserved. Except as noted herein, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without prior written permission from AORN, Inc. Users are not permitted to use this content for commercial purposes. Users are permitted to save or print the tree for use in their work settings. Permission for other uses may be sought directly from AORN, Inc., located in Denver, Colorado (USA), by contacting the AORN Publications Department.

    Resources:

    • Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;331-364.
    • Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012.
    • Mangram AJ , Horan TC , Pearson ML , Silver LC .Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;27(2):97-132.
    • Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and various other factors . Ann Surg. 1964;160(Suppl 2):1–192.
    • Simmons BP. Guideline for prevention of surgical wound infections. Infect Control. 1982;3:185-196.

    Updated January 28, 2013.

  • What is the purpose of documenting surgical wound classifications?

    The wound classification is a formula used for grading the extent of microbial contamination postoperatively, thereby indicating the likelihood that a patient will develop an infection at the surgical site. The classification also allows for comparison of wound infection rates associated with different surgical techniques, surgeons and facilities. The comparison may be useful for research and may also serve to alert infection prevention personnel to wounds at increased risk for infection, enabling appropriate surveillance and preventative measures to be taken

    Resources:

    • Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;331-364.
    • Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012.
    • Mangram AJ , Horan TC , Pearson ML , Silver LC .Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;27(2):97-132.
    • Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and various other factors . Ann Surg. 1964;160(Suppl 2):1–192.
    • Simmons BP. Guideline for prevention of surgical wound infections. Infect Control. 1982;3:185-196.

    Updated January 28, 2013.

  • What are the surgical wound classifications?

    The Center for Disease Control and Prevention uses an adaptation of the American College of Surgeons wound classification schema, which divides surgical wounds into four classes:

    CLASS I/CLEAN WOUNDS: an uninfected surgical wound in which no inflammation is encountered and the respiratory, alimentary, genital, or urinary tracts are not entered. Clean wounds are primarily closed and, if necessary, drained with closed drainage. Surgical wound incisions that are made after nonpenetrating (ie, blunt) trauma should be included in this category if they meet the criteria.

    CLASS II/CLEAN-CONTAMINATED WOUNDS: a surgical wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically included in this category are surgical procedures involving the biliary tract, appendix, vagina, and oropharynx, provided no evidence of infection is encountered and no major break in technique occurs.

    CLASS III/CONTAMINATED WOUNDS: open, fresh, accidental wounds. This typically involves surgical procedures in which a major break in sterile technique occurs (eg, emergency open cardiac massage) or when gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered.

    CLASS IV/DIRTY OR INFECTED WOUNDS: old traumatic wounds with retained or devitalized tissue, as well as wounds that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the wound before the surgical procedure.

    Resources:

    • Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;331-364.
    • Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012.
    • Mangram AJ , Horan TC , Pearson ML , Silver LC .Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;27(2):97-132.
    • Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and various other factors . Ann Surg. 1964;160(Suppl 2):1–192.
    • Simmons BP. Guideline for prevention of surgical wound infections. Infect Control. 1982;3:185-196.

    Updated January 28, 2013.