Infection Prevention: Playing Zone Defense Against Superbugs

There's always the possibility that a patient with an active infection will arrive at your facility for surgery. To prevent SSIs and stop the spread of multi-drug resistant organisms, those of us in the OR tend to focus exclusively on the patient and not as much on what's happening around the patient. That's why our ORs have embraced the concept of the Risk Zone, which we define as the isolation of the patient's immediate environment. Any equipment, instruments or people within arm's reach of, or in actual contact with, a patient are inside the zone. The idea is to contain all contamination risk within that immediate area by establishing clear-cut guidelines such as these:

• In pre-op. Make sure a note identifying the patient as a carrier is easily visible on the chart or in the EMR. Place the patient in a designated isolation room or bay with door signage. Keep the chart in an attached ante room. In the isolation area, have the patient perform hand hygiene and sign consent forms. Wipe down or throw away the pen they use. Place the forms in the patient's chart.
• During transport to surgery. Slide the chart in a clean yellow bag or pillowcase. The nurse transporting the patient should wear a yellow gown and gloves to signify the patient is in contact isolation. To open the OR door, the nurse should not use her hands, but rather her elbows or back. If the door requires a badge scan, the nurse should lean over the sensor with her badge.
• Inside the OR. The anesthesia provider should don a yellow gown and gloves before the patient enters. The circulator should also wear yellow PPE and stay with the patient inside the Risk Zone for transfer to the bed, positioning and anesthesia induction. Anyone assisting with positioning must be gowned and gloved.

It's extremely helpful to find another RN or tech who always stays outside of the Risk Zone to assist as a staff resource. This person enters the patient's in-room time on the computer, and is subsequently available to open supplies, grab blankets out of the warmer, make phone calls and so on.

After the patient has been moved to the surgical table, wipe down the transport bed or stretcher in the OR before moving it to the hallway. Once the patient is draped and the surgery starts, the circulator should ungown and perform hand hygiene, so as not to potentially contaminate the entire room.

One other thing: If you need supplies or instruments that aren't in the OR, lean on your core techs outside of the room to track them down.

• After surgery. When the procedure is complete, the circulator prepares to transport the patient to the PACU. She wipes down the chart and places it in a yellow bag or pillowcase. The circulator and anesthesia provider must don fresh yellow gowns and gloves before moving the patient to recovery. A scrub tech should stay by the patient's side while the circulator retrieves the transport bed or stretcher from the hallway. A PACU nurse should also be in a yellow gown and gloves, ready to receive the patient in an isolation room or bay. Remove the patient's chart from the yellow bag, wipe it down and place it in an ante room. Staff who cared for the patient in PACU should remove their yellow gowns and gloves, perform hand hygiene and change their scrubs.

To implement the Risk Zone system, we presented at staff meetings and developed a poster that we showed to perioperative staff at our annual skills fair. We encouraged every nurse and tech to advocate for their patients and make sure to speak up when the protocol is violated ?— such as when a surgeon walks into the OR and positions the patient without donning gowns and gloves.

We continue to evaluate and audit for compliance. Over the last year and a half since we began the program, we've seen much improvement. It was a big project to implement. I needed input and buy-in from the entire perioperative team. All of us — pre-op, post-op, anesthesia providers, surgeons, surgical techs, circulating nurses and ancillary members like physician assistants, vendors and radiology techs — were accountable.

As a result, it took a couple years for me to successfully engage everyone and get all relevant units and personnel on board to fully implement this process. It was a significant challenge, but worth the effort as we found one more way we protect our patients from multi-drug resistant organisms. Remember, infection prevention isn't solely about focusing on the patient in front of you. It also demands putting care plans in place for the patients who are next in line to enter the OR.

Increasing awareness among your team about how to properly prevent cross contamination of microorganisms in the isolated surgical patient's immediate environment decreases SSI risk and environmental exposure to drug-resistant bacteria for healthcare providers and OR staff. OSM