Good hygiene practice in hospitals and in operating theatres is mandatory to minimise nosocomial postoperative infections. Health care-associated infection is a major cause of morbidity and mortality. The personal and financial consequences of avoidable infections are enormous in personaland global terms. Patients expect to be treated and cared for in clean conditions, and not be exposed to the risks of acquiring an infection by poor practice on the part of healthcare workers. Infection control and prevention in perioperative settings assumes an even greater significance because of the vulnerability of patients who are already ill or injured, and because surgery, anaesthesia and immediate postoperative recovery may expose them to invasive procedures, allowing more portals of entry for infection. This literature review will discuss cleaning within the perioperative setting; the importance of hand hygiene, surgical site infections and training for healthcare professionals to minimise infection risk.
A systematic search for literature was carried out using online databases such as, Pubmed, Medline, Cinahl, OVID and Cochrane Library . A search of online sources such as the Department of Health (DOH), Association of Peri-operative Registered Nurses and Science Direct sites has also been implemented. In addition the World Wide Web was searched using search engine Google/Google Scholar for relevant articles and web sites. The search terms for this literature review included a combination of infection control measures, infection control prevention in theatres, infection control risks, surgical site infections and peri-operative infection control. Publication dates used are between 2005-Present.
Cleaning regimes are paramount in controlling the spread of infection in the hospital environment. They play a significant role in reducing the instances of healthcare associated infections that can be transferred; from the healthcare practitioner to the patient; from the environment to the patient and from patient to patient. Theatre walls, ceiling and floor finishes should be impermeable to bacteria and able to endure frequent wet chemical cleaning. Curved joints between walls, ceilings and floor aid effective cleaning and drying (Davey and Ince 2004).Kim et al 2006 highlights the importance of high standards of ward cleaning to stop the spread of methicillin-resistant Staphylococcus aureus. British infection control doctors argue that instead of attempting to apply limited MRSA control measures, which are impossible to achieve, infection control has a duty to press for investment in cleaning (Barrett et al 2003). Hospital cleaning services play a key part in minimising the risk of hospital acquired infections, which have serious consequences for patients and lead to significant costs. A meta analysis of three randomised controlled trials showed that cleaning is essential to containing MRSA, gastrointestinal, and other types of infection outbreaks (Dancer 2005) (Anderson and Rasch 2005) (Griffith et al 2007). This view is reinforced by Noone and Griffiths2004 who conducted one large randomised study on hospitalised patients showing the only intervention used to combat a glycopeptide-resistant enterococci (GRE) infection outbreak at a UK hospital was a very thorough and systematic cleaning of the wards, after which reduction in both the level of environmental contamination and the numbers of infected patients were noted.
The use of flash sterilisation is commonplace in non-central sterilising facilities such as operating theatres, eliminating the need to transport instruments to a central location and permitting sterilisation of frequently used items for immediate use (AS, 2008; Bennett, 2005). Because the limitations of this process mean a wide margin of safety cannot be ensured, the Standard recommends that flash sterilisation should be reserved for emergencies only, and in certain instances should never be used, for example, for sterilising blind-ended cannulated instruments. The use of flash sterilisation also demands adequate decontamination/cleaning of instruments, and daily performance monitoring of cycles to ensure efficacy of the sterilisation process (AS, 2008). While steam sterilisation is always the sterilisation process of choice, it is not suitable for heat sensitive equipment such as flexible endoscopes, and glutaraldehyde is currently used in many hospitals to ‘sterilise’ such equipment between patients. Because this use of glutaraldehyde also lacks important quality controls to ensure a sterile instrument, the Standard recommends its use only for disinfection (AS, 2008). Options proposed to deal with this recommendation have included increases in endoscope inventory, use of disposable endoscopes, and use of alternative low temperature sterilisation techniques such as ethylene oxide (EtO). These options are likely to be impractical for busy endoscopy facilities because of their high costs and lengthy cycle times for EtO sterilisation (AS, 2008).
Sterilization is a process intended to kill all microorganisms and is the highest level of microbial kill that is possible. Sterilizers may be heat only, steam, or liquid chemical. Effectiveness of the sterilizer (e.g., a steam autoclave) is determined in three ways. First, mechanical indicators and gauges on the machine itself indicate proper operation of the machine. Second heat sensitive indicators or tape on the sterilizing bags change colour which indicate proper levels of heat or steam. And, third (most importantly) is biological testing in which a highly heat and chemical resistant microorganism (often the bacterial endospore) is selected as the standard challenge. If the process kills this microorganism, the sterilizer is considered to be effective. It should be noted that in order to be effective, instruments must be cleaned; otherwise the debris may form a protective barrier, shielding the microbes from the lethal process. Similarly care must be taken after sterilization to ensure sterile instruments do not become contaminated prior to use (Davey and Ince 2004). Disinfection refers to the use of liquid chemicals on surfaces and at room temperature to kill disease causing microorganisms. Disinfection is a less effective process than sterilization because it does not kill bacterial endospores.
Sterilization, if performed properly, is an effective way of preventing bacteria from spreading. It should be used for the cleaning of the medical instruments or gloves, and basically any type of medical item that comes into contact with the blood stream and sterile tissues. Other sterilization methods exist, though their efficiency is still controversial. These methods include gas sterilization, UV sterilization, and sterilization with other chemical agents such as peroxyacetic acid, paraformaldehyde and gas plasma sterilization (British Society of Gastroenterology 2008).
Hand hygiene is widely acknowledged to be the single most important activity for reducing the spread of infection, yet evidence suggests that many healthcare professionals do not decontaminate their hands as often as they need or use the correct technique. This means that areas of the hands can be missed. Hand decontamination refers to the process for the physical removal of blood, body fluids and transient microorganisms from the hands, i.e., hand washing, and/or the destruction of microorganisms. Transient Flora are acquired by touch e.g. from the environment, touching patients laundry, equipment etc. They are located superficially on the skin, readily transmitted to the next thing touched, and are responsible for the majority of healthcare associated infections. They are easily removed by hand Decontamination (Department of Health 2006).
Effective hand washing is one of the main contributions to infection control. An effective hand washing technique involves three stages: preparation, washing and rinsing and drying. Preparation requires wetting hands under tepid running water before applying the recommended amount of liquid soap or an antimicrobial preparation. The hand wash solution must come into contact with all surfaces of the hands. The hands must be rubbed together for a minimum of 10-15 seconds paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly before drying with paper towels (Pratt et al 2007).
Patients in hospital, nursing homes and long-term care facilities are at high risk of developing infections that they did not have before admission. Most healthcare-associated infections are spread by direct contact, especially via the hands of healthcare workers. Traditionally, hand hygiene, such as washing hands before and after touching patients, has been considered the single most important way of reducing infections. Increasingly, the use of alcohol-based hand rub is used alongside or in replacement of traditional washing with soap and water. However, compliance with hand hygiene is poor (Vernaz et al 2008).
A prospective study carried out by Pratt et al 2007 concluded there is still not enough evidence to be certain what strategies improve hand hygiene compliance. Introducing alcohol-based hand rub accompanied by education/training is not enough, while using multiple strategies, including involvement of staff in planning activities or applying social marketing strategies, may be helpful. Pratt summarised more research is needed. In addition Bellis 2006 summarised a hand hygiene program involving the use of pocket-sized containers of antiseptic gel and education could effectively increase adherence to hand rubbing and reduce the incidence of serious infections in LTCFs with elderly residents.
The practice of scrubbing hands before surgery has been highly regimented and ritualized. Scientific evidence to support many tradition-based perioperative practices such as surgical hand scrubs is lacking, and more studies are needed to build a body of empirical knowledge that demonstrates their efficacy. Well designed randomized controlled trials are needed to evaluate different scrubbing regimens such as different scrubbing durations, antiseptic products, and whether to use a brush (Luby et al 2006).
A study by Tanner, Blunsden and Fakis 2007 found that nail picks and nail brushes did not provide additional decontamination. Indeed the findings suggested a trend towards chlorhexidine alone being more effective than chlorhexidine used in conjunction with a brush or a nail pick, though a larger sample size would be needed to show statistical significance. The ineffectiveness of the nail bush is not surprising as scrubbing skin with a brush has already been shown to increase bacterial counts (Tanner, Swarbrook, Stuart 2008).
Drying is an essential part of the hand hygiene process. In November 2008, a non-peer-reviewed study was presented to the European Tissue Symposium by the University of Westminster, London, comparing the bacteria levels present after the use of paper towels, warm air hand dryers, and modern jet-air hand dryers. Of those three methods, only paper towels reduced the total number of bacteria on hands, with “through-air dried” towels the most effective.
A surgical site is the incision or cut in the skin made by a surgeon to carry out a surgical procedure. The position and size of the surgical site depends on the intended procedure and the type of surgery. For example, laparoscopic surgery (which uses fine instruments and a video-camera) requires very small incisions whereas more complex surgery may require a very large incision.
A SSI can occur when bacteria from the skin, other parts of the body or the environment enter the incision made by the surgeon and multiply in the tissues. This results in physical symptoms as the body tries to fight the infection. There may be pus, inflammation, swelling, pain and fever.
SSI is relatively rare. High standards of asepsis (procedures that reduce the risk of bacterial contamination e.g. sterile equipment) in operating theatres are key to minimising the risk of infection. However, they cannot always be prevented (Gould et al 2006).
The likelihood of an SSI depends on a number of factors related to both the patient and the surgical procedure. In particular, the risk of developing a SSI varies according to the type of surgery, the general health of the patient at time of operation and the length of the operation. There are three types of surgical site infection: Superficial, deep incisional and organ/space infections. As the names suggest the infections can affect simply the site of the wound itself causing redness, discharge and pain – a superficial wound infection; deeper layers of the tissues perhaps causing an abscess or infections involving organs or joints. Superficial infections are generally a cause of short term problems for the patient, with discomfort at the site of surgery being fairly rapidly treated with antibiotics, whereas in the case of joint infections for example following hip replacement surgery, the artificial hip joint may have to be removed. In all cases of true surgical site infection antibiotic therapy will be required and occasionally further surgery (Martone and Nichols 2007).
Surgical site infections are a major cause of patient injury, mortality, health care cost, and prolonged hospitalization. The Centres for Disease Control and Prevention estimates that approximately 290,000 SSIs occur every year and are associated with approximately 8,000 patient deaths annually. SSI is also one of the most prevalent negative outcomes reported by hospitals.
An SSI diagnostic tool is available to hospitals to assist in identifying a surgical site infection. A paper questionnaire is completed by surgical teams for each operation under surveillance. Details of any infections that occur within the hospital stay and for a certain length of time after discharge from hospital are completed at a later stage. Questionnaires are returned, where scanning software is used to turn the data into an electronic file that can be used for analysis (Gould et al 2006).
A recent systematic review looked at hand antisepsis and the incidence of SSI. The study found that alcohol rub preparation was as effective as aqueous scrubs in reducing SSI (McLaws, Berry and Whitby 2009).
Patients acquiring a deep SSI suffer significantly from pain, isolation, and insecurity. The SSI changes physical, emotional, social, and economic aspects of life in extremely negative ways, and these changes are often persistent.
Hospital acquired infection is known to be expensive and also extends patient stay in hospital. For this reason, NHS trusts have an obligation to do their reasonable best to reduce hospital acquired infection. This may include:
The use of an infection control link nurse helping with the improvement of clinical infections, such as: Knowledge and awareness of infection control issues in clinical areas; Providing information to assist in the early detection of outbreaks of infections in clinical settings (i.e. putting patients in isolation rooms); Supporting staffs to understand and use this information to minimise infection risk and increase patient’s safety (reporting to infection control officers of any outbreak); Providing mandatory training on infection control with regular update. To achieve these all healthcare workers needs to ensure that effective effort and practices on infection control are implemented in the care of the patient (Malley and Pratt 2007).
In conclusion the articles read has confirmed the importance of cleaning, hand hygiene and staff training in preventing surgical site infection and controlling the spread of pathogens in the hospital setting.
Cleaning regimes can significantly reduce the instances of cross infection and protects both the patient and healthcare worker from becoming infected with harmful bacteria (Davey and Ince 2004).
Failure to meet required cleaning standards can seriously increase risks for hospital acquired infections and reduce patients’ confidence in the ability of the hospital to provide safe and effective medical care. There is considerable subjective evidence that over the past 10 years hospitals have been cutting back cleaning staff, not replacing staff when they are off on sick leave, and therefore compromising the health and well being of patients and residents (Kim et al 2006). This requires further investigation. In addition, the plans to contract-out housekeeping could further compromise infection control standards and patient health. In conclusion, the research suggests that the focus should be on increased staffing levels and cleaning standards – not on contracting-out (Barrett et al 2003).
Aseptic technique is a key component of all invasive medical procedures. Similarly, infection control measures are most effective when Standard Precautions (health care) are applied because undiagnosed infection is common (Kim et al 2006).
Two methods of hand disinfection are in vogue in current surgical practice. The first and most common is the traditional surgical hand scrub with various antiseptic solutions. The second, but less commonly practiced method, is rubbing the hands with an alcohol solution, which has been a common practice in northern Europe and Germany for many years (Pratt et al 2007). Recently, new alcohol preparations and gels have been advocated for disinfecting the hands of health care workers and the community to control the transmission and spread of pathogenic bacteria with a better compliance when compared to hand washing. However, surgeons and researchers have
questioned their efficacy for preoperative hand disinfection in relation to the incidence of SSI (Luby et al 2006).
Postoperative SSI is an important cause of morbidity and mortality in surgical patients. Also, SSI contributes to increase hospital stay and costs. One of the documented sources for SSI is the surgeon’s hands. Therefore, preoperative hand disinfection with various antiseptic solutions has become the standard practice for many decades (Martone and Nichols 2007).
Health care professionals should focus on strategies to enable early diagnosis and treatment of SSIs. The unacceptable suffering related to the infection, medical treatment, and an insufficient patient-professional relationship should be addressed when planning individual care, because every effort is needed to support this group of patients and minimize their distress (Gould et al 2006). All possible measures should be taken to avoid bacterial contamination of the surgical wound during and after surgery to prevent the development of SSI (McLaws, Berry and Whitby 2009).
The emergence of life-threatening infections such as severe acute respiratory syndrome (SARS) and re-emerging infectious diseases like plague and tuberculosis have highlighted the need for efficient infection control programmes in all health care settings and capacity building for health care workers so they can implement them. An infection control programme puts together various practices which, when used appropriately, restrict the spread of infection (Malley and Pratt 2007).
A breach in infection control practices facilitates transmission of infection from patients to health care workers, other patients and attendants. It is therefore important for all health care workers, patients, their family members, friends and close contacts to adhere to the infection control guidelines strictly. It is also imperative for health care administrators to ensure implementation of the infection control programme in health care facilities (Martone and Nichols 2007).
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