The pressure to turn rooms over quickly can sometimes overshadow the importance of infection prevention in cataract surgery. Here are 7 tips to help you get your cataract infection rate to 0% (and keep it there).

1. Fine-tune your pre-op protocols.
One of the steps the Jervey Eye Center in Greenville, S.C., took to address a small cluster of endophthalmitis cases several years ago was adjusting its pre-op antibiotic and eye prep protocols. The 3-OR facility initially gave patients 1 drop of the antibiotic Zymar in the pre-op area and a 0.5% betadine drop once the patient was in the OR. Soon after the center opened, "we had more infections than we were comfortable with, so that made us start looking at some of our practices," says Nurse Director Cheryl R. Berrios, RN. They added 2 more drops to the antibiotic protocol (patients now get 3 Zymar drops in pre-op) and an initial 0.5% betadine drop before they enter the OR to give it "just another few minutes to kill any bacteria that might be in the eye." Patients still get another betadine drop in the OR during prepping. The center has seen a drop in endophthalmitis cases since instituting the new protocol.

2. Monitor the air in your ORs.
Cataract surgery is "normally a very clean surgery," notes Gina Stancel, HCRM, CST, COA, of the Eye Centers of Florida, but "you still have contaminants that build up in the air, and you've got to monitor that." You should be maintaining positive pressure in your ORs at all times. Here are some other steps your colleagues recommend you take to prevent exposure of instruments and the surgical site to potential air contaminants:

• Keep OR doors closed and limit traffic in and out of rooms.
• Trash bins should have lids that stay closed during cases; take out the trash between cases.
• Use sterile drapes and covers on equipment and supply carts.
• Keep instrument trays covered when transporting them from sterilizers to the OR (see "CMS Issues New Flash Sterilization Guidelines for ASCs" on page 10).
• Prep and drape patients in the OR immediately before the procedure, not in a pre-op holding area. Even if they don't have far to go, "anything can happen" while moving the patient from one room to another, warns Ms. Stancel.

3. Use an automated flushing system for instruments.
Skipping steps is not an option when you're cleaning eye instruments before sterilization. Two and a half years ago, Jody Looker, RN, CNOR, clinical director of the Winchester (Va.) Eye Surgery System, invested about $1,700 in an automatic flushing system that's preset to flush phaco handpieces and cannulated instrumentation with 120cc of fluid and then flush them with air at the push of a button (actually 2 pushes — Ms. Looker has her techs run the system twice just to be safe). Staff can also adjust the machine to manually flush other types of instruments that require different amounts of fluid, per manufacturers' instructions. Ms. Looker calls the system an "efficiency saver"; instead of measuring fluids and using syringes to flush cannulas — a messy process — the automated system frees up staff to concentrate on other tasks, like hand-washing instruments, removing debris and wiping down tables. It also ensures that cannulated instruments are properly flushed according to manufacturers' instructions every time.

4. Remove barriers to patient cooperation.
Effective communication between your staff and your patients is particularly crucial in preventing infections. Make sure your patients understand their pre- and post-op instructions and can properly care for themselves once they leave your facility. One problem you should look out for in this economy is patients not being able to afford their medications, says Linda Spraley, RN, CNOR, head of the Ohio chapter of the American Society of Ophthalmic Nurses. "Pre- and post-op medications, especially the antibiotics, are so expensive," she says. Your surgeons can dispense sample medications or prescribe less-expensive alternatives, she says.

At the Phoenix (Ariz.) Eye Surgical Center, the admitting nurse asks patients if they used their pre-op drops. "If this has not been done per surgeons' orders, the case is cancelled," says Administrator Sharon Sjulstad, RN, CNOR, CRNO, CASC. Staff go over the instructions for post-op drops with both patients and their family members verbally, give written instructions to patients and follow up by phone either that evening or the next day. The Pacific Eye Institute in Upland, Calif., includes color photographs of each medication bottle with specific instructions printed beneath each one. "It's harder for patients to get the instructions confused when they can associate it with a picture," says Surgical Administrator Dayel Griffith, COA.

5. When it comes to cleaning, think outside the OR.
The staff at the Dulaney Eye Institute in Towson, Md., take a very methodical approach to maintaining a sterile environment in their ORs. "We clean all horizontal and vertical surfaces at the beginning of the day, and all horizontal surfaces are cleaned between cases" with a sodium hypochlorite (bleach) solution, says Administrator Andrea M. Hyatt, CASC. At the end of the day, staff perform terminal cleaning in the ORs, "starting at the ceiling and working their way down." But the facility's commitment to cleanliness doesn't stop at the OR doors. At the beginning of each day, staff also wipe down all horizontal surfaces in the center's business offices and personal workspaces with the same cleaning solution used in the ORs. The facility maintains a sterile corridor and limits traffic in and out of recovery areas to 1 family member or support person per patient. Hand sanitizers placed throughout the facility encourage proper hand hygiene among patients and their visitors, and masks are made available for anyone with a significant cough, says Ms. Hyatt.

6. Send patients to the showers (or the salon).
The Alberta Eye Institute in Edmon-ton, Canada, counsels patients not to wash their hair in the tub or sink for 2 weeks after cataract surgery. "We're quite strict," says facility President Heather Climenhaga, MSA. "We tell them to shower with their head back and wear goggles, and if they're not going to do that, to treat themselves and go to the hairdresser." It may sound like a strange addition to the usual instructions — administer eye drops and medications as directed, avoid touching or rubbing the eye — but Ms. Climenhaga says it's not so strange when you consider that the bulk of your cataract patients are elderly, and many elderly people bathe in the tub rather than the shower. "Some of the ladies don't think anything about soaking in the tub water, then splashing it on their face." She says she knows of at least 1 patient who ended up with enteric bacteria growth in the eye post-op, likely caused by washing the hair or face with dirty bath water.

7. Be proactive about tracking infections.
Do you actively monitor post-operative complications or infections originating from your facility, or do you wait for your surgeons to call when there's a problem? CMS' new infection control condition for coverage requires ambulatory surgery centers to have "a system to actively identify infections that may have been related to procedures" performed there. The Winchester Eye Surgery System takes a 2-pronged approach, reaching out to both surgeons and patients. Each physician gets a monthly post-op complication survey that lists all the patients and surgeries performed that month and asks physicians to report any complications associated with those patients, says Ms. Looker. Mean-while, the facility's patient satisfaction survey includes 2 questions designed to help detect any problems: "Do you have any complications from your surgery?" and "After your discharge from our facility, were you admitted to a hospital?"

In addition to gathering infection information from patients and physicians, Ms. Stancel says it's important to keep thorough documentation of everything that went into the case — every staff and surgical team member who touched the patient, what bed they were in, what instruments were used and the sterilization parameters for that set — so you can track the origin of any reported infection and take steps to address the potential problems that may have caused it. Also be sure to keep detailed records of all chemical and biological indicators used on sterilization loads and all the system maintenance performed on your sterilizers.