Without proper precautions, health care workers can easily pass micro-organisms to patients. In Michigan, 16 Pseudomonas infections were traced back to a nurse with a severe fungal infection under a fingernail; organisms from infectious cosmetics had colonized the wound. In California, seven patients contracted Serratia infections and one died apparently due to a Serratia colony on the artificial nails of a scrub nurse. Because workers can be such potent vectors for microorganisms, it's critical that they understand the principles that will help prevent being the source of a nosocomial outbreak. Here is an overview.
Keep infected workers out of the OR
Numerous studies have linked surgical site infection outbreaks back to infected health care workers. For this reason, the Centers for Disease Control recommends that all facilities institute policies that encourage workers to report illness and that do not penalize them with loss of wages, benefits or job status. The CDC recommends always excusing workers with draining skin lesions from operating room duty until the lesion has healed.
Keep extraneous items off the hands
Exogenous organisms that cannot colonize human skin can colonize artificial nails and jewelry, and some studies show that hands can be more heavily colonized in areas under jewelry. Scrubbing may not remove these. Prohibit artificial nail wear and jewelry, and ask surgical personnel to keep nails short. Although there is little evidence to link surgical site infections with long fingernails, long nails can puncture surgical gloves.
Re-evaluate your hand scrubbing policy
There is a lot of evidence that supports thorough hand scrubs prior to surgery. However, health care workers are notoriously non-compliant with accepted scrubbing techniques.
The Centers for Disease Control is preparing to release a new guideline on this critical topic. If the final guideline resembles the draft version, the agency will be strongly recommending waterless, alcohol-based scrubs as an effective and compliance-friendly alternative to the traditional versions. The draft guidelines also recommend against brushing, except for brushing under the fingernails. For more detailed information, see p. 25.
Wear gloves properly
Although little direct research proves their effectiveness in preventing infection of the surgical patient, virtually every medical guideline or authority accepts the use of gloves as an important standard in infection control. The Centers for Disease Control says "a strong theoretical rationale exists" for gloves and "several studies provide evidence that gloves can help reduce transmission of pathogens in a healthcare setting." "The use of gloves in surgery is so ingrained to protect the surgical site and patient, no one questions it," says Jan Schultz, MSN, a consultant in Roswell, Ga., and an expert in aseptic practices in the perioperative setting.
Three tips on effective glove wear:
- Be sure your staff understands that gloves are not a replacement for hand hygiene. "Gloves are a useful additional means of reducing nosocomial infection, but they supplement rather than replace hand washing," explains H. Saloojee, MD, an international infection control author from South Africa. "Possible microbial contamination of hands and transmission of infection has been reported despite gloves being worn."
Adds Ms. Schultz, "Wash your hands, wash your hands, wash your hands. Gloves only work when the hands are clean to start with."
- Wear two gloves when indicated. Studies show surgical perforation rates ranging from zero to over 30 percent, depending on the procedure, with many perforations undetected by the surgeons or staff. A British study found the overall perforation rate was 4.8 percent, with a perforation rate of zero for endoscopy to a rate of 28.5 percent for major head and neck resections.3 Another study showed a 35 percent perforation rate for surgeons wearing single gloves, compared to a 3.8 percent rate of dual perforation when wearing double gloves. The study notes that longer operations were associated with increased risk of glove perforation.
Several studies have shown that many surgical glove perforations go undetected. Says Denise Korniewicz, DNSc, RN, an expert on medical-glove issues at the University of Maryland. "Perioperative staff members frequently are unaware that their surgical gloves have failed until they find blood on their hands after surgery."
Double-glove systems have been developed that use a colored inner glove to indicate to the wearer that the outer glove is perforated. A study published in 2001 compared double-glove systems with single gloves. In 885 surgeries, the overall glove perforation rate was 18 percent. Just over a third of surgeons wearing single gloves detected perforation during surgery, while 86 percent of surgeons wearing a double-glove system detected perforations.
Pat Metcalf, BSN, CIC, a specialist in neurosurgical IC and Director of Infection Control for Children's Medical Center of Dallas, says all neurosurgeons there wear double gloves: "Small holes will occur in gloves, and there's much less of a chance of holes occurring in two gloves at exactly the same place."
"Today, during laparascopic procedures and orthopedics, surgeons routinely double glove, as well as the first assistant holding the retractor or participating directly within the wound," notes Ms. Schultz. "If there's nothing in the procedure that would damage a glove, however, double gloving isn't necessary. A single glove is an adequate barrier for these procedures."
- Be sure your staff discards disposable gloves between patients, advises Terri Goodman, PhD, of the Infection Control Education Institute: "Some healthcare workers have gotten into the habit of putting on gloves and leaving them on as they go from activity to activity. This practice negates the glove's effectiveness and provides a false sense of security for the worker."
During talking, sneezing and coughing, the mouth expels microorganism droplets. A tightly worn mask can help reduce the load of microorganisms placed into the air.
The Association of periOperative Nurses (AORN) provides the following guidelines for masks:
- Change them between uses and whenever they become moist;
- Do not reuse masks. Do not hang them from the neck or tuck them into a pocket for future use;
- Do not touch the filter of the mask when removing it in order to prevent contamination of hands;
- Wear the mask according to the manufacturer's directions, which are based on the design. Tie strings tightly, with the upper string around the back of the head and the lower strings around the neck. Do not cross the strings because it will cause a gap around the cheeks. Contour the metallic strip around the bridge of the nose.
It may be that there is no benefit to the wearing of masks by nonscrubbed staff working outside the sterile field. One review of controlled studies of surgical face masks (1,453 patients) found that in one small trial, wearing masks was associated with fewer infections; in a large trial there was no difference in infection rates between the masked and unmasked group. However, AORN recommends that such personnel continue wearing masks until we know more.
"It's too early to do away with masks. If the data continue to develop, it may change our thinking. It's a work in progress regarding infection control, but masks will remain an important aspect of personal protection," says Ms. Schultz.
Gowns, aprons, and other protective body clothing.
These items provide physical barriers between surgical workers and the patient, but there is little evidence that they help prevent transmission of organisms from health care workers to the patient. Their principle role is to protect staff from splashed bodily fluids. As for the use of cover gowns or lab coats outside the OR, AORN says, "Although they provide a professional appearance, they add significant cost but have not been shown to improve patient care or affect the rate of surgical wound infection."
Disposable shoe covers are commonplace in the OR, but infection control experts say they serve no real purpose.
"The waterproof booties should be used for procedures with fluids. The other ones don't serve any purpose. The floor is dirty, and shoes are dirty, and there's not much we can do about it," says Ms. Schultz.
1. Lipp A, Edwards P. "Disposable surgical face masks for preventing surgical wound infection in clean surgery." Cochrane Database Syst Rev. 2002;(1):CD002929.
2. Boyce, JM, et al. proposed "Guideline for Hand Hygiene in Healthcare Settings." Centers for Disease Control and Prevention, 2001.