Like a detective called to a crime scene, a surgery center recently summoned me to investigate a mysterious surgical site infection. How, they wanted to know, did a routine ACL repair on a 32-year-old male result in a Staphylococcus aureus infection? After retracing every step in the case and looking beyond the usual SSI suspects, we identified several breaches in practice that likely caused this infection. I first suspected a skin contamination, but all evidence pointed to the reprocessing room, where both the cleaning and the high-level disinfection practices were inadequate.

Case history
Ten days after undergoing an arthroscopic anterior cruciate ligament repair, the patient presented to the orthopedic surgeon's office with the telltale signs of an infection: a 101 ?F temperature, pain, redness and swelling of the knee. The surgeon reported that he aspirated purulent fluid from the site. I reviewed the surgeon's notes from the patient's office visit and found that a culture revealed S. aureus (sensitive to methicillin). The patient was admitted to the hospital for irrigation and lavage with subsequent IV antibiotic administration.

Upon identifying the infection, we took the following steps to identify the cause:

• We reviewed the operative notes for possible notation of breaches in technique or practice. None were noted.
• We interviewed the administrator and pertinent nursing staff, including the nurse manager, relating to practices, procedures and protocols.
• We conducted a walk-through of the facility and observed practices. We questioned additional staff members, including the nurses who prep patients, the scrub nurse, surgeons, and the technician responsible for cleaning and reprocessing equipment. Alarms went off after we interviewed the reprocessing tech.

In addition to these steps, we reviewed the literature relating to arthroscopic procedures and noted the following infection risk factors associated with ACL repairs: foreign bodies, including staples and grafts; tourniquet time; use of intraoperative intra-articular steroids (not widely used); and longer duration of surgery for complicated procedures. None of these factors would come into play with our case, however.

What the pathology report suggested
The organism cultured is key in the investigation as the result will give the infection preventionist a clue as to the possible origin of the organism. S. aureus is found mainly on the skin and in nasal passages and suggests the following:

• One of the causes could have been from inadequate pre-op skin preparation.
• S. aureus could be transmitted in various other ways, such as inadequate hand antisepsis, hand or glove contamination, or inadequate cleaning, disinfection or sterilization of equipment.
• The environment plays a key role in transmission of organisms in any healthcare setting.

The culprits
After a thorough investigation and numerous discussions and observations, we identified a few breaches in practice and attributed them as the probable cause of this infection.

• Inadequate cleaning. The tech responsible for the cleaning and disinfection of equipment failed to clean the arthroscope before disinfecting it. Cleaning can be done manually or with mechanical units — ultrasonic cleaners or washer-disinfectors, for example — for fragile or difficult-to-clean instruments. This facility performs only manual cleaning; they do not use mechanical units. With manual cleaning, the 2 essential components are friction and fluidics. Friction (rubbing and scrubbing the soiled area with a brush) is an old and dependable method. Fluidics (fluids under pressure) is used to remove soil and debris from internal channels after brushing and when the design doesn't allow passage of a brush through a channel.

Cleaning is the removal of such foreign material as soil and organic matter from objects and is normally accomplished using water with detergents or enzymatic products. Thorough cleaning is required before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes. Also, if soiled materials dry or bake onto the instruments, the removal process becomes more difficult and the disinfection or sterilization process less effective or ineffective. Surgical instruments should be presoaked or rinsed to prevent drying of blood and to soften or remove blood from the instruments.

CDC guidelines (www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf) recommend that laparoscopes, arthroscopes and other scopes that enter normally sterile tissue should be sterilized before each use; if this is not feasible, they should receive at least high-level disinfection.

• Shortened soak time. In addition and to further suggest that the reprocessing practices were to blame, the high-level disinfection procedure revealed that the scopes weren't soaked for the correct length of time as per the manufacturer's instructions. The facility uses an OPA product with a recommended soak time of 12 minutes. The technician was soaking the scopes for a total of 5 minutes, thereby creating a breach in practice as per instructions. The technician informed us that the high volume of procedures didn't allow for 12-minute soak times. He decreased it to 5 minutes to cope with the demand for "sterilized" scopes.

Prevention strategies
Inadequate cleaning and high-level disinfection practices at this ASC more than likely contributed to this previously healthy 32-year-old male's surgical site infection with subsequent morbidity as revealed during an on-site visit and in-depth review of practices, policies and procedures. Appropriate policies were in place, yes, but so were breaches in practice. Be sure not to overlook these overall best practices to prevent occurrences of surgical site infections in same-day surgery patients:

• Meticulous hand hygiene for all patients, from pre-operative holding until the patient is discharged.
• Pre-operative hair removal if ordered by the surgeon should be carried out preferably with electric clippers right before surgery, avoiding shaving.
• Cleaning and low-level disinfection of the clippers according to the manufacturer's instructions.
• Administration of pre-operative antibiotics if ordered by the surgeon.
• Standardized patient skin prep procedures, based upon manufacturers' written instructions, that are specific to the antimicrobial agent to be used and according to healthcare facility policies and procedures. See details at www.ast.org/pdf/Standards_of_Practice/RSOP_Skin_Prep.pdf.
• Appropriate surgical hand scrub procedures per facility policy, including types of hand scrub products and procedures for conducting the process.
• Appropriate draping/preparation of the patient and handling of instruments to ensure a completely sterile field at all times.
• Keeping the patient's body at the optimal temperature to prevent hypothermia.
• Thorough cleaning of the environment after the patient leaves the OR suite, which includes all equipment and items that have come into contact with the patient. Proper chemical dwell times are important to achieving optimum disinfection.
• Strict adherence to cleaning and disinfection/sterilization guidelines with supervision of staff responsible for such. Staff competencies should be conducted to ensure that procedures are understood and undertaken.
• Conduct overall education relating to prevention of infections on a regular basis.