Looking to boost your infection prevention efforts? We surveyed 140 surgical facility managers on their top infection control products and spoke to Donna Nucci, RN, CIC, an infection preventionist at Yale-New Haven (Conn.) Hospital, on the best practices for each one. Straight from the front lines, here are 10 ways to win the war against SSIs.
Point-of-use cleaning and transportation trays
Pre-cleaning at the point of use should be the first step of reprocessing endoscopes, yet nearly one-third (31%) of our respondents say they aren't doing it. After use, staff should flush endoscopes with an enzymatic solution and remove organic material from the exterior of the scope, says Ms. Nucci. You can make the task easier with customizable single-use endoscope kits equipped with a brush, pre-moistened sponge and pre-measured enzymatic solution. "A custom pack takes the guesswork out and ensures consistent best practices," she says.
To reduce the risk of bioburden, keep all surgical instruments moist with an enzymatic solution, especially if the case is longer than an hour, says Ms. Nucci. Easy-to-use pre-cleaning enzymatic sprays, foams and gels prevent blood and organic matter from drying and impeding sterilization.
Safe transportation of dirty instruments and scopes to your reprocessing area in a rigid, covered container is also key, says Ms. Nucci. To help limit mix-ups, many survey respondents note that they like using color-coded tray liners that indicate whether instruments are contaminated or clean.
Manual cleaning aids
Manufacturers have developed several ways to make the tedious and error-ridden task of manual cleaning more standardized and easier for your techs. One favorite of our surveyed surgical leaders was automatic detergent dispensing systems, which add precisely the right amount of enzymatic solution and correct-temperature water for cleaning. For lumened instruments, several managers swear by independent flushing systems and pull-through brushes that allow for easier, more thorough cleaning inside tricky cannulas.
Ms. Nucci says high-volume endoscopy centers may want to invest in an independent scope leak tester or an automated endoscope reprocessor (AER) with a built-in leak tester, since these mechanical methods better catch the tiny holes where contaminants hide. "They're much more efficient and accurate than having a tech hold down a scope underwater to check for bubbles," she says. "Anything that streamlines and standardizes the process while decreasing the risk of human error is beneficial."
Reprocessing verification tests
You should already be following your devices' reprocessing verification methods listed in the instructions for use. But there are a few other ways to enhance your quality control efforts, says Ms. Nucci. These include devices like fiber-optic scopes that check for bioburden inside lumens or chemical analyses that swab and test instruments for leftover proteins. But before investing in any of these adjunct technologies, Ms. Nucci stresses that you must review any clinical studies supporting the tests, since some have limited evidence backing up their efficacy claims. You could also consider simpler options. One surveyed manager notes that his facility uses a magnifying glass "to assess and ensure that the tools are free from visible debris before packing for sterilization."
Verification also applies to your cleaning and sterilization equipment. While 72% of respondents say they include a biological indicator in every load to test the effectiveness of their autoclaves, 3% say they don't use one at all. However, Ms. Nucci notes that the Association for the Advancement of Medical Instrumentation (AAMI) recommends weekly, and preferably daily, sterilizer efficacy testing with a biological indicator, in addition to using an internal chemical indicator in every sterilization package.
Safer storage systems
Once your instruments are reprocessed, don't let your techs' hard work go to waste with poor storage. Keep instruments in an enclosed area designed for sterile supplies. "Some facilities put their instruments in a cabinet or an area not built for storing sterile equipment or endoscopes," says Ms. Nucci. "Some even leave sterile items out in the OR, exposed to multiple patient procedures. This is against AORN standards."
For endoscopes, consider updated cabinets that feature extra-long bays for hanging and filtered air vents. Some new systems even include tracking software to alert staff when safe scope storage time is exceeded. A few manufacturers also claim their storage has anti-microbial properties, which 24% of surveyed managers say they're currently using or considering. Ms. Nucci cautions, though, that evidence backing these claims is still limited.
Hand hygiene monitors
At the most basic level of infection control is hand hygiene, yet 45% of respondents say they don't have a way to monitor or encourage compliance among employees and physicians. "That was very surprising," says Ms. Nucci. "Governing bodies and regulatory agencies see hand hygiene as the cornerstone of infection prevention methods."
While high-tech hand hygiene tracking systems are available, our respondents listed "secret shopper" style monitoring as a top way they increase compliance. Many managers also like to periodically apply "fake germ" solutions to staffers' hands to show missed microbes. "That normally scares people into compliance," says Jennifer Churca, CRCST, CIS, MS, materials manager and CPD supervisor for Midtown Surgery Center in New York City. "People don't realize how much flora they're carrying around." But there's an even easier approach: Install more hand sanitizer dispensers at the point of care. "Many facilities have not asked staff where dispensers should be installed," says Ms. Nucci. "Non-compliance often occurs when there aren't enough hand hygiene opportunities for staff."
CHG shower kits/wipes
There's plenty of science on the benefits of pre-op showering, yet 52% of our respondents say their patients don't use a chlorhexidine gluconate (CHG) solution before surgery. Of those that do, just 7% say they start using it 2 or more days beforehand.
"The New England Journal of Medicine published recommendations in 2010 supporting the use of CHG soap and wipes to reduce SSIs," says Ms. Nucci. "Evidence shows that there's an SSI reduction in patients undergoing certain procedures who use CHG in the days before and on the day of surgery."
Patient compliance is often the biggest challenge of instituting a CHG pre-op program, she adds. Offering pre-made kits complete with a small bottle of CHG soap, disposable cloths and instructions, or individual pre-moistened wipes, make it more likely for patients to use the solution, according to the 21% of survey respondents who offer such options. It's especially helpful when you couple the CHG kits or wipes with phone call or text message reminders, several of our respondents say. One hospital manager notes that they increased compliance simply by giving patients CHG wipes during pre-admission testing and then calling them the day before surgery to remind them of their scheduled time and to use the wipes.
Single-use sterile skin preps
Respondents say skin preps are a priority in their infection control efforts. "We are trying to standardize surgical prepping by procedure rather than individual surgeon preference, and transition to the circulator doing the prepping," says Patricia A. McNamee, RN, BSN, MS, assistant vice president of perioperative services at Monmouth Medical Center in Long Branch N.J. While most facilities have shifted from aqueous preps to alcohol-based ones, Ms. Nucci says she doesn't see enough investing in products that prevent cross-contamination. "Facilities should use a sterile single-use prep every time," she says, "as well as mandate annual training and audits of staff members that perform surgical preps to ensure compliance with AORN standards and manufacturer instructions."
Surface cleaning wipes
Nearly 25% of respondents say they're still using a surface cleaning disinfectant that has a dry time of 5 minutes or longer.
"There's no need to use these when we have shorter dry times available," says Ms. Nucci. "If you have a solution with a 10-minute dwell time, your staffer is likely going to have to wipe that down every minute for 10 minutes. That's just not practical."
Also consider your employees' safety. More than one-third (35%) of respondents say they're using a liquid solution or a spray to clean their ORs, which Ms. Nucci notes could expose staffers to hazardous chemicals. Instead, she says regulatory bodies, including OSHA, encourage the use of wipes.
Germ-zapping robots are a new innovation in infection prevention. Eleven percent of our survey respondents say they're using ultraviolet (UV) or hydrogen peroxide whole-room disinfection units. While these robots may help boost terminal cleaning or turnover efforts after cases with a serious infection, evidence on their impact on SSIs is limited. Because of that, consider these only as an add-on to your meticulous cleaning efforts, says Ms. Nucci.
In an effort to save time and supply costs, staff may reuse medication vials on multiple patients, spreading bloodborne pathogens. Though not foolproof, Ms. Nucci recommends purchasing single-dose vials whenever possible, as well as mandating annual safe injection training for all staff. As with every new addition to your infection prevention efforts, the most important part is getting staff to use the products correctly. "Education is the key," says Beth Summerlin, MSN, RN, CNOR, manager of surgical service at Wellstar Windy Hill East Bobb Health Park OSC in Marietta, Ga. "All of the products are good, but if not used correctly, it defeats the effort."
When the Bon Secours St. Mary's Hospital in Richmond, Va., noticed an uptick in its infection rates for breast, joint and spine cases in 2013, it took action. "We saw the cases and knew that the commonality was that an implant was involved," says Jean Watling, RN, BSN, CNOR, perioperative nurse manager. "So we formed an SSI taskforce to look at every possible contributor to infection." The team reviewed literature and implemented several new initiatives, says Ms. Watling, including:
- Better skin prepping. Patients receive CHG wipes to use at home before the day of surgery. In pre-op, staff applies the CHG wipe again to the patient. Hair is removed with clippers in pre-op instead of in the OR. Finally, surgeons have moved from using aqueous preps in the OR to CHG-based ones.
- Updated environmental cleaning. In addition to increasing the education of housekeeping staff, the hospital also started using a touch-point cleaning checklist to ensure staffers hit every high-touch area between cases. The hospital also purchased a UV robot to disinfect the ORs overnight.
- Restructured employee actions. Leadership started monitoring staff and surgeon hand hygiene compliance, limiting traffic in the OR and enforcing a stricter dress code.
The changes worked. The flurry of initiatives and new products helped bring the hospital's SSI rate from 0.5% to 0.36% this past year.