Our hospital's surgical site infection rate began to rise as compliance with our infection control policies began to slip. Cause and effect? We certainly suspected so. Our infection control professionals sat down with representatives from each department, showed them our recommended practices and standards and said, "This is what we want, and this is what our standard is." We made it clear that our ultimate goal was to protect the patients and that the best way to do that was to increase OR personnel's knowledge of the basics of infection control in these four notoriously troublesome areas. Perhaps it's time for you to review these basics with your team.

Traffic control

• Limit the traffic in and out of ORs and the number of people who can occupy a suite.
• Close doors at all times, including when the room is being cleaned.
• Use inner doors for sterile supply delivery.
• Limit scrub relief on cases lasting shorter than two hours.
• Ban fabric bags and backpacks from the ORs (we set up a staging area for vendors' bags and materials).
• Eliminate all food and drink from sterile areas.

Surgical attire

• No scrubs worn outside the building are allowed in the OR suite or sterile processing department.
• Scrub tops and ties are to be tucked in at all times.
• Scrubs and scrub jackets are changed when soiled.
• Close and tie cloth gowns when worn as warm-ups.
• Hats are to cover all hair on head.
• Launder cloth hats daily and cover them with a disposable hat.
• Cover all facial hair with facemask or hood.
• Scrub personnel must wear protective eyewear (goggles or face shield) during all procedures.
• Sterile processing staff must wear personal protective equipment (apron, gloves, goggles or face shields) at all times.
• All shoes worn in the OR and sterile processing must be free of blood and dirt.
• Nail polish, if worn, must be free of chips and cracks. No artificial fingernails in the OR suite and sterile processing.
• Jewelry's limited to modest earrings (small post style is preferred; hoops no greater than 3/4 inch may be worn if fully contained in the cap), wedding rings and engagement rings, wristwatches and no more than one plain metal chain necklace. No bracelets or excessive jewelry allowed.

Instruments

• Check indicators in every sterile tray.
• Limit prevac sterilization of instrumentation in OR sterilizers.
• Implants must have a biological rapid read indicator.
• Wash blood from instruments with sterile water during and after all cases.
• Require that all loaner sets be delivered by 5 p.m. the night before surgery, and sets with more than 10 trays arrive 48 hours in advance so you have time to sterilize them.
• Replace peel packs in instrument trays with approved paper bags.

Proper hand hygiene

• Wash hands before starting work, when hands are visibly soiled, between patient contacts, after removing gloves, after using the restroom, after performing first hand scrub of the day with brush (use foam for sequential scrubs) and after cleaning under nails with nail pick.

Peer pressure not always bad
One of the early issues that our group addressed was how to handle staff members who weren't following the new guidelines. We worried that if we were too harsh on them, they'd become more resistant to changes.

Instead of instituting a disciplinary process, we decided to take a more positive approach. Whenever a staff member either didn't follow the protocols or was resistant to our changes, we always brought the focus back to how we were trying to make our facility safer for our patients. Sure, we encountered some resistance from our independent-minded employees, particularly the surgeons and anesthesia providers, but when it became clear we weren't judging them they usually came around. Since most of the staff agreed with our ideas, they were able to apply some constructive peer pressure to overcome the resistance.

Our sales reps were a bit of a challenge to deal with because they weren't our employees. We had to make sure they heard about our methods before they came into our ORs, and had to find a way for them to bring their supplies without compromising our other policies.

One idea that worked: hanging educational posters that reinforced our concepts, periodically replacing them with new ones so staff wouldn't ignore them as part of the background. Also, at least twice a year we clean air vents and light fixtures and power wash all movable equipment. We remove rust, repaint and replace excess "staff junk."

As a result of our initiatives, our infection rates have dropped sharply. Best of all, everyone is working together for our patients' safety. The key here is that we wanted to create a consistent message throughout perioperative services, including our OR staff, surgeons, anesthesia providers, sterile processing staff, and ancillary services such as housekeeping, radiology, biomedical and facilities engineering personnel. By getting everybody involved, no one could say, "That wasn't what I was told." Now everyone got the same message and everyone knew what we wanted.