Download Infection Control in the Operating Room

Š
A SELF STUDY GUIDE
Registered Nurses
OVERVIEW
Working in the Operating Room (OR) requires highly skilled staff members to coordinate and deliver the care
necessary to surgically treat a wide variety of patients. The OR staff works in an intense, fast-paced, detailoriented, technically advanced environment to safely perform surgical procedures. In the perioperative
setting, good infection prevention and control is essential to ensure that patients who undergo any surgical
procedure receive safe and effective care. Safe working practices are also necessary to ensure the safety
of the OR team members as well. Risk of exposure to bloodborne pathogens and toxic chemicals is a major
concern among healthcare providers who work in the OR. In response to these risks, there should be a focus
on the impact of the surgical procedure on the perioperative team and how to prevent the surgical team
from acquiring infections as they administer care to the surgical patient. This continuing education activity
examines considerations necessary to prevent staff-related infections.
LEARNER OBJECTIVES
After completing this continuing nursing education activity, the participant should be able to:
1. Discuss surgical glove failure rates and the benefits of double gloving.
2. Discuss the potential benefits of innovative antimicrobial glove technology.
3. Describe the risks associated with surgical smoke and identify when the use of a surgical N95
respirator is recommended.
4. Discuss the advantages of single-use turnover kits to prevent contamination, infections and injuries.
5. Identify best practice to reduce sharp-related injuries in the operating room.
INTENDED AUDIENCE
The information contained in this self-study guidebook is intended for use by healthcare professionals who
are responsible for or involved in the following activities related to this topic:
• Educating healthcare personnel.
• Working in the Operating Room and other surgical environments.
• Establishing institutional or departmental policies and procedures.
• Decision-making responsibilities for safety and infection prevention products.
• Maintaining regulatory compliance.
• Managing employee health and infection prevention services.
INSTRUCTIONS
Ansell is a Recognized Provider of continuing education by the California Board of Registered Nursing,
provider #CEP 15538 and the Australian College of Perioperative Nurses (ACORN). This course has been
accredited for 2 (two) contact hours. Obtaining full credit for this offering depends on completion of the selfstudy materials on-line as directed below.
Approval refers to recognition of educational activities only and does not imply endorsement of any product
or company displayed in any form during the educational activity
To receive contact hours for this program, please go to the “Program Tests” area and complete the posttest. You will receive your certificate via email.
AN 85% PASSING SCORE IS REQUIRED FOR SUCCESSFUL COMPLETION
Any learner who does not successfully complete the post-test will be notified and given an opportunity to
resubmit for certification.
INFECTION
Ansell Healthcare Products LLC has an ongoing commitment to the development of quality products and
services for the healthcare industry. This self-study is one in a series of continuing educational services
provided by Ansell.
CONTROL IN THE
For more information about our educational programs or perioperative healthcare safety solution
topics, please contact Ansell Healthcare Educational Services by e-mail at [email protected]
OPERATING ROOM
Planning Committee Members:
Luce Ouellet, RN
Latisha Richardson, MSN, BSN, RN
Patty Taylor, BA, RN
Pamela Werner, MBA, BSN, RN, CNOR
As employees of Ansell Mrs. Ouellet, Mrs. Richardson, Mrs. Taylor and Ms. Werner have declared an
affiliation that could be perceived as posing a potential conflict of interest with development of this self-study
module. This module will include discussion of commercial products referenced in generic terms only.
2
TABLE OF CONTENTS
INTRODUCTION……………………………………………………………………..….…………4
SURGICAL GLOVES……........………………………………....……………………..……………5
SURGICAL SMOKE………………………………………....……………………………………...9
SINGLE USE VS. RE-USABLE BARRIER PRODUCTS………………………………………….12
SHARPS SAFETY………………………...……………………………………………………….14
SUMMARY………………………………………………………………………….……….……16
GLOSSARY………………………………………………………………………….………….…17
REFERENCES………………. ............………………………………………………………….…20
3
INTRODUCTION
The risk of infection from bloodborne pathogens in the
operating room (OR) is a constant challenge for the
perioperative team due to existing bloodborne pathogen risks,
drug-resistant pathogens and newly recognized pathogens as
well as the daily safety hazards of the working environment.
“Protecting patients and healthcare practitioners from
potentially infectious agent transmission continues to be a
primary focus of the perioperative registered nurses (RNs).”1
Personal Protective Equipment (PPE) has never been more
important than it is in today’s world. PPE is specialized clothing
and/or equipment for eyes, face, head, body, and extremities;
protective clothing; respiratory devices; and protective shields
and barriers that is designed to protect the worker from injury
or exposure to a patient’s blood, tissue, or body fluids. PPE
is used by perioperative team members, healthcare workers
and others any time it is needed to protect themselves from
a variety of hazards such as bloodborne pathogens, chemical
hazards, or mechanical irritants encountered in a manner
capable of causing injury or impairment in the function of any
part of the body through absorption, inhalation, or physical
contact. There are a multitude of exposure risks in the OR;
so the perioperative RN should be familiar with the potential
infection control issues in the OR, understand the exposure
risks and learn preventative measures. In this learning
activity, we will focus on significant areas of infection control:
surgical gloves; surgical smoke; single-use vs re-usable barrier
products and sharps safety. After completing this activity,
the participant should be able to discuss glove failure rates,
the benefit of double gloving and the benefits of antimicrobial
glove technology. The participant will also be able to describe
surgical smoke risks and know when to use the surgical N95
respirator along with discussing the advantages of using the
single-use turnover kit to prevent contamination, infection
and injuries.
INFECTION
CONTROL IN THE
OPERATING ROOM
4
SURGICAL GLOVES
Surgical gloves were first introduced in the 1890’s. According
to many sources, William Stewart Halsted of Johns Hopkins
Hospital is the surgeon who is credited with the introduction
of surgical gloves. “In 1890, he became surgeon-in-chief and
married Caroline Hampton, the head operating room nurse at
the hospital. Hampton had complained about the dermatitis she
experienced due to Halsted’s insistence that she use mercuric
bichloride as a surgical antiseptic, resulting in her future
husband drafting the Goodyear Rubber Company to produce
surgical gloves to protect his staff.”2
factory inspections before granting a Certificate of Standards
Conformity.
• In Europe, medical gloves are subject to the European
Standards EN 455 part 1-2-3, while the enforcement is
under the responsibility of each Member State through
national standards bodies and healthcare agencies.
The European EN 455 standard for surgical gloves was
approved by CEN (European Committee Standardization)
which the members are the National standards bodies
of Austria, Belgium, Bulgaria, Cyprus, Czech Republic,
Denmark, Estonia, Finland, France, Germany, Greece,
Hungary, Iceland, Ireland, Italy, Latvia, Lithuania,
Luxembourg, Malta, Netherlands, Norway, Poland,
Portugal, Romania, Slovakia, Slovenia, Spain, Sweden,
Switzerland and United Kingdom.
• The US FDA does not write standards but it does recognize
standards that are written by the American Society of
Testing and Materials (ASTM). Surgical gloves sold into
the US must meet the ASTM standards.
Goodyear Surgical Glove
The gloves soon became a commonly used item in the
operating room. In 1966, single-use powdered gloves became
available; these are the standard of care that still exists today.
Even though the use of latex gloves in surgery became a routine
practice after World War I, gloves were not consistently used
in most other patient care areas until the mid-1980’s with the
onset of the AIDS epidemic and the spread of hepatitis. The
importance of protective gloves, both as a barrier between
the surgeon and healthcare worker’s hands and the patient’s
wound and, more recently as protection from viruses derived
from the patient (HIV, hepatitis) and from environmental
hazards is self-evident to the perioperative professional today.
Surgical glove standards are governed by National Government
Standards. Quality specifications are written into each
Standard for a surgical glove product. They relate to physical
requirements like strength, thickness, measurements,
performance, and freedom from holes. Specifics include,
elasticity, elongation, protein and powder levels, allergenicity
or biocompatibility. These specifications require a statistical
sample scheme which, if passed, mathematically ensures a
maximum potential number of defined faults per 100 units.
This is called an AQL (Acceptable Quality Level). Batches
of product are rejected by the manufacturer if the number
of faults exceeds this number. Each Standard Organization
has varying requirements to be met and generally arrange
• ISO (International Organization for Standardization)
is an independent, non-governmental membership
organization and the world’s largest developer of voluntary
International Standards. Many countries require surgical
gloves entering their country to meet the ISO Standards.
All gloves that meet the above standards must provide barrier
protection against bloodborne pathogens such as HIV, HBV and
HCV. The strict manufacturing standards also must meld with
the customer’s needs for durability, tactile sensitivity, flexibility,
resiliency and comfort. Manufacturing high-quality gloves that
meet the customer’s needs without failures is very challenging.
“Glove failure during use can be caused by punctures, tears by
sharp devices, or spontaneous failures.”3 Factors that increase
the incidence of glove failures during use include:
• Length of procedure;
• Mechanical stress;
• Type of surgery;
• Number of instruments used in the surgical procedure; and
• The role of the glove wearer in the surgical procedure.
“The intact surgical glove is the most important barrier to
protect the patient from microorganisms from the hand of the
surgical team and vice versa.”4 The preoperative surgical hand
preparation can significantly reduce but not eradicate the
resident flora on the surgeon’s hands; this reduces but does not
eliminate any risk of transmission of these organisms into the
operative site.
5
PERFORATION RISK
Surgical Scrub
Conversely, blood-borne pathogens can be transmitted from
the patient to the surgeon and pose a safety risk to the
perioperative team members. The rates of glove failures
as reported in several different studies during a review of
pertinent articles vary from 10% to 61% during various types
of procedures. “Perforation rates as high as 61% for thoracic
surgeons and 40% for scrub personnel have been reported.”5
In fact, the type of surgery is a delineating factor in failure/
perforation of surgical gloves and has been studied frequently.
“A study conducted to estimate and compare the perforation
risk in different categories of surgery found perforations in
203 out of 655 operations (31%), with frequencies of 44.5%
in gastrointestinal surgery, 34.7% in orthopedic surgery,
31.1% in gynecology, 18.6% in vascular surgery and 9.2% in
general surgery.”6
INFECTION
CONTROL IN THE
OPERATING ROOM
Gastrointestinal Surgery
6
DOUBLE GLOVING
In the 2014 Edition, Perioperative Standards and Recommended
Practices for Inpatient and Ambulatory Settings,
Recommendation VI states “Perioperative personnel must wear
PPE when exposure to blood or other potentially infectious
materials is anticipated.”7 This recommendation goes into
great detail regarding the wearing of gloves and the evidence
based rationale supporting glove use in the prevention of risks
associated with infection control in the perioperative setting.
Some specific information related to glove failures includes:
• VI.a.2. Sterile gloves should be visually inspected
immediately upon donning and before contact with sterile
supplies or the sterile field. Gloves may have perforations
or tears that occur in the manufacturing process or as
gloves are donned.
• VI.a.3. Sterile gloves should be changed:
• After each patient contact;
• When a visible defect is noted;
• When suspected or actual contamination occurs; and
• When a suspected or actual perforation occurs.
Breaches in the glove barrier pose a risk for transmission
of bloodborne pathogens during surgical procedures.
Glove perforation also increases the risk of surgical site
infection (SSI).
Depending on the duration of wear, surgical gloves can develop
micro perforations that are not immediately recognizable to the
wearer. These perforations allow bacteria from the surgical
site to pass through to the wearer’s hands. One method
for preventing this is to mandate regular glove changes in
organizational policy. Changing gloves at regular intervals
may decrease the incidence of glove perforation and bacterial
contamination during surgical procedures.8
In addition to suggesting glove changes to decrease the
incidence of glove perforation, AORN recommends that
“Perioperative team members should wear two pairs of surgical
gloves, one over the other, during surgical and other invasive
procedures with the potential for exposure to blood, body fluids,
or other potentially infectious materials.”9 This use of double
gloving will add extra protection. Double gloving reduces the
risk of exposure to patient blood by as much as 87% when the
outer glove is punctured. Volume of blood on a solid suture
needle is reduced by as much as 95% when passing through
two glove layers, thereby reducing viral load in the event of a
contaminated percutaneous injury.10
Donning Surgeon
Double gloving has many benefits including:
• Wearing double gloves helps prevent SSI and protect
health care providers hands.11
• Effective way to reduce the risk of percutaneous injuries.
• May increase the wearer’s awareness of a perforation
which may protect against exposure during surgery.
• Minimizes the amount of blood that is transferred to the
healthcare provider’s hands during a needlestick injury.
• Reduces risk of glove perforation with a lengthy
procedure.
• Reduces the risk of perforation of the inner-most glove.
• “Perioperative personnel’s risk decreased by 70% when
double-gloving in comparison to wearing a single-glove.”12
• May protect the wearer’s skin from needlesticks because
breaches will most likely occur to the outer gloves, not the
inner gloves.
• “Laine and Aarmio suggested that the rate of
contamination with blood was 13 times higher with single
gloving as opposed to double gloving.”13
The color coded glove system (two-color glove system) is noted
to be an effective strategy for risk reduction when double
gloving because it aids in early and accurate detection of a hole
in the outer glove. The inner-glove is a brighter color (eg, bright
green) and the outer-glove is a neutral color (eg, white).
Double Gloving
7
STANDARDS OF PRACTICE
During surgery, if the glove is breached or fails in any way, the
color of the inner glove will be visible. This technique can increase
awareness, speed the detection of a failure, and is easy to
implement.
Several important professional organizations have taken
positions on double gloving as a standard of practice in the
perioperative environment. The following organizations have issued
recommendations and statements supporting and endorsing the use
of double-gloving:
• The Association of periOperative Registered Nurses (AORN);
• The American College of Surgeons (ACS);
• The American Association of Orthopaedic Surgeons (AAOS);
• Centers for Disease Control (CDC);
• The Australian College of Operating Room Nurses (ACORN);
• The International College of Surgeons (ICS);
• The European Center for Disease and Control (ECDC); and
• The World Health Organization (WHO).
INFECTION
CONTROL IN THE
OPERATING ROOM
8
There are innovations that continue to improve the ability of
surgical gloves to provide protection from bloodborne pathogens
and to decrease the risk of surgical site infections (SSI). One very
important new technology is the innovative antimicrobial glove
technology. Several recent studies have reported evidence that
microbial passage across surgical gloves can be reduced significantly
using an innovative antimicrobial glove technology. One such study
stated “Gloves serve as a mechanical protective barrier between
the surgeon’s hand and the surgical site, but we hypothesized that
antimicrobial gloves might also reduce the risk of contamination
of the surgical site in the event of an intraoperative glove breach
by suppressing the re-growth of skin flora during the course of a
surgical procedure.”14 After conducting the studies needed to satisfy
the hypothesis; the conclusion was: “The use of antimicrobial
surgical gloves may prevent bacterial contamination of the surgical
site and may therefore indirectly decrease the risk of SSI and thus
increase patient safety, particularly when the consequences of an
SSI are catastrophic, as in vascular surgery. The present study has
shown that a new antimicrobial surgical glove was able to suppress
the skin flora of surgeons’ hands during operation by a factor of
approximately 1.3 log 10 CFU/mL.”15
Antimicrobial decontamination gloves can be used by members of
the OR team to facilitate a safe a rapid turn-over between cases. The
antimicrobial decontamination glove protects the healthcare workers
hands from contamination and transfer of bacteria within the OR
environment. These innovative gloves have the potential to reduce
the environmental transfer of bacteria as well as provide increased
safety for the perioperative team and patients.
SURGICAL SMOKE
Smoke generated from the various energy modalities used in
today’s OR is a common occurrence. In fact, surgical personnel
are vulnerable to a variety of hazardous substances, including
potentially infectious agents present in surgical smoke given
their prolonged exposure to surgical smoke over the course
of their career.16 Energy in the OR is an area of innovation
with many modalities, which include: electrosurgery, lasers,
ultrasonic energy, argon enhanced coagulation, plasma
technology, vapor sealing technology, combination devices as
well as others. Most surgical procedures use some type of
energy and the combination of increased modalities and vast
usage mean that the hazards of surgical smoke in the OR are
receiving increased attention.
The smoke from these energy devices has been found to
contain many potentially hazardous particles such as:
• Toxic gases and vapors;
• Bio-aerosols;
• Dead and live cellular material;
• Blood fragments;
• Viruses (HIV, HPV);
• Infectious bacteria;
• Carcinogens;
• Neurotoxins;
• Lung-damaging dust; and
The composition and exposure hazards associated with surgical
smoke depend on a variety of factors such as:
• The type of surgical procedure and device (i.e., laser,
electrosurgical, ultrasonic);
• Type and infectious nature of the tissue;
• Extent of tissue ablation;
• The duration of surgery; and
• Worker proximity to the surgical field.
The surgical smoke, in high concentrations poses risks to
healthcare workers and others and can cause adverse health
conditions such as respiratory tract irritations and spread
of viruses and toxins through aerosolization. Some risks and
adverse health conditions include:
• Lung disease,
• Inhibition of tissue oxygenation,
• Mutations,
• Transmission of HIV, TB, Rubeola, and
• Respiratory changes such as emphysema, asthma, and
chronic bronchitis.
In the OR, smoke can cause decreased vision for the surgeon
and perioperative team members as well as offensive or
noxious odors. “In addition to respiratory problems, after
repeated exposures to surgical smoke, perioperative staff
members have reported signs and symptoms that include
burning and watery eyes, nausea, and headaches.”17
• Allergens.
Electrosurgery
9
IMPORTANCE OF PARTICLE SIZE
An important consideration when assessing the respiratory
hazards of surgical smoke is the size of the particles in the
smoke. The different types of energy used in the OR today
produce different size particles. The smallest particles can
travel the farthest and affect all perioperative team members
even those who are not scrubbed. Some particle sizes, in
microns, can be compared:
• Surgical Smoke:
»» Electrocautery – 0.07
»» Laser Ablation – 0.31
»» Ultrasonic Scalpel – 0.35-6.5
• Viruses:
»» HPV – 0.045
»» HIV – 0.18
»» Varicella – 0.1-0.2
HIV – CDC Photo
• Bacteria:
»» Anthrax – 1.0-3.0
»» TB – 2.0-4.0
INFECTION
CONTROL IN THE
OPERATING ROOM
TB – CDC Photo
10
EVALUATING SURGICAL MASKS
Surgical masks are evaluated by the FDA for bacterial filtration,
fluid resistance, differential pressure, and flammability and
while they are definitely appropriate for use as PPE and in the
perioperative setting, they do not have the filtration rating for
viruses and bacteria of extremely small particle sizes. AORN
recommends that “Perioperative personnel should wear N95 or
higher level respirators during aerosol-generating procedures
involving patients who have TB, SARS, or avian or pandemic
influenza viruses.”18 The N95 respirator is a type of filtering
face-piece respirator that prevents at least 95% of the particles
that are not resistant to oil from passing through. Taking it a
step further, “NIOSH recommends the use of properly fitted,
filtering face-piece respirators rather than surgical and laser
masks. Filtering face-piece respirators with an N95 filter class
designation prevent all sizes of particles from passing through
the filter media and entering the wearer’s breathing zone.
Even taking some face-piece seal leakage around the respirator
into account, a properly fitted N95 reduces the wearer’s
exposure against a range of very small particles (less than 1
μm) to large droplet sized particles (> 60 μm) by at least 10-fold.
Thus, healthcare personnel should wear respiratory protection
at least as protective as a fit-tested N95 filtering face-piece
respirator when working with known disease transmissible
cases (i.e., HPV) and/or during aerosol-generating procedures
or with aerosol transmissible diseases (i.e., TB, Varicella,
and Rubeola). Furthermore as a precautionary measure, it is
recommended that respiratory equipment as protective as a
fit-tested N95 be worn in the absence of properly functioning
smoke control measures (i.e., OR exchanges, LEV).”19
Both surgical masks and N95 respirators play a role in infection
prevention in the perioperative setting. They have some marked
similarities as well as differences. We have already discussed
the limitations of the surgical mask in protecting the user
from small particles. Both types are disposable and provide
a barrier to splash, droplets and sprays. The N95 is however;
more complex and as a high level respirator, has additional
characteristics. In addition to effectively filtering both small
and large particles from the air, the N95 is designed to fit
tight around the face, creating a seal around the perimeter
of the respirator to improve protection. The N95 comes in
multiple sizes.
N95 Mask
In addition to the information presented above, the N95
respirator is recommended for use in the following situations:
• Perioperative personnel should don a surgical mask, N95
or higher level respirator, depending on disease-specific
recommendations, before entering the room of a patient
who requires airborne precautions.20 TB is an example of
this recommendation.
• Regarding Electrosurgery, AORN Recommends: “Personnel
should wear respiratory protection (i.e., fit-tested
surgical N95 filtering face piece respirator, high-filtration
surgical mask) during procedures that generate surgical
smoke as secondary protection against residual plume
that has escaped capture by LEV, the primary means of
protection.”21
• Laser smoke plume has a similar recommendation.
AORN recommends: “Personnel should wear respiratory
protection (i.e., fit-tested surgical N95 filtering face
piece respirator or high-filtration surgical mask) during
procedures that generate surgical smoke as secondary
protection against residual plume that has escaped
capture by local exhaust ventilation.”22
11
SINGLE USE VS. RE-USABLE
BARRIER PRODUCTS
Hospital-associated infections (HAIs) affect close to two million
patients each year and the perioperative RN must be prepared
to look at all angles when striving to prevent infection control
issues in the OR. The OR is an aseptic environment; however;
it is also an environment that is hectic with a constant flow of
patients having a wide variety of procedures every day. These
procedures generate continuous exposure to blood, body fluids
and tissues either directly or indirectly as well as exposure to
airborne hazards, surgical smoke and other hazards. Personal
Protective Equipment (PPE) has been introduced to protect the
traditional cotton scrubs, surgical gowns, and lab coats that
can be found in the operating room when dealing with known
hazards such as blood and body fluids. In addition, disposable
single-use linens are used for everything from drapes, arm
board covers and table covers to surgical gowns in order
improve efficiency, safety and effectiveness.
“Surgical gowns, gloves, and drape products used during
operative and other invasive procedures must provide a barrier
and should be resistant to tears, punctures, and abrasions.”23
“Surgical site infections occur in 2% to of the US patients
who undergo surgery in inpatient facilities for a total of
approximately 500,000 SSIs each year, at a cost of up to $10
billion annually.”24 Damage to the integrity of surgical gowns,
gloves and drapes can lead to surgical site infections and
increased healthcare costs. There are many factors that should
be considered when selecting the types of linens to be used in
the perioperative setting:
INFECTION
CONTROL IN THE
OPERATING ROOM
12
Surgical PPE
Protection: High resistance to blood body fluids and other
potentially infectious substances is preferred, ability to
resist penetration.
• Performance: Overall quality in terms of liquid penetration,
microbial penetration, processing cycles (if reusable),
consistency.
• Safety: When considering reusable vs disposable linens,
it is usually considered safer for workers to handle
disposables only to dispose of them after use than to
handle reusable linens multiple times to reprocess them
risking disease transmission many times.
• Lint and Airborne Particulates: Since airborne particles
may play a role in developing SSIs, disposable linens
may be preferable due to the lint that may be present on
reusable linens;
• Product-specific Requirements: “Product-specific
requirements include contractual agreements,
compatibility with existing products, and implementation
of new products of differing material or construction.”25
• Procedure-specific Requirements: define what is necessary
for the procedure where the surgical gowns, gloves, and
drape products will be used.
• End-user Requirements and Preferences: Examples
include: the degree of protection from blood, body fluids,
and other potentially infectious materials; and preferences,
such as comfort.
products, 56% of the textiles showed serious faults impairing
functionality compared to 0% of the single-use products.”26
Other benefits of single-use disposable linens include:
• Consistent quality;
• Reduced need for sterilization;
• Lower risk of SSIs; and
• Reduces work load for central sterile personnel.
Another way to affect infection control in the perioperative
setting is to manage the process of OR room turnover in a way
that reduces the probability of the transmission of pathogens
and infectious disease. AORN Recommended Practices for
Environmental Cleaning outlines the steps necessary to
maintain a clean environment in the OR. Recommendation III
states “A clean environment should be reestablished after the
patient is transferred from the area.”27 It is very important for
the perioperative team to clean effectively and safely while
attempting to efficiently utilize time and resources during the
turnover. Turnover time must be sufficient to allow personnel
to thoroughly clean and disinfect surfaces that have come in
contact with the patient or are visibly soiled (eg, blood, tissue)
from the surgical procedure.28 There are many steps that must
be completed by the OR team in order to complete the turnover
process these steps include, but are not limited to:
• Clean and disinfect surfaces that have come in contact
with the patient or are visibly soiled from the surgical
procedure;
• Patient-related Requirements: Size or ability to conform to
the contours of the patient.
• Wipe down all mobile and fixed equipment (eg, OR lights,
monitors, patient transfer devices);
• Environmental Considerations: Potential to be recycled,
reprocessed or reduced waste.
• Mop floors;
• Compliance: Federal, state and local regulatory agencies
and compliance with standards-setting bodies including
the FDA, CDC, and OSHA, along with other regulatory
agencies plus standards-setting bodies like AORN.
• Clean OR bed and associated positioning devices; and
Comparing single-use and reusable linens does not end with
items that are used during surgical procedures. The infection
control risks in the perioperative area are so high that cleaning
the environment and the use of single-use versus disposable
items must also be considered. There can be significant
contamination on many surfaces in the OR environment as well
such as: mattresses; surfaces such as keyboard, mayo stands,
back tables, counter tops; and single-use medical devices.
Currently, single-use disposable linens are commonly used
in the perioperative setting. “The benefits of using singleuse disposable linens include the fact that product quality is
consistent. In a recent study comparing single-use and textile
• Replace damaged or single-use equipment;
• Remove trash, contaminated laundry.29
In an effort to assist with improvement of existing turnover
processes, “Manufacturers of OR turnover equipment are
assisting in this process by designing packaged kits with
disposable linens, trash bags, hamper liners, kick bucket liners,
wiping cloths, and mops designed to fit the unique needs of
each hospital. These kits provide standardization of the process
of room turnover and help ensure the right equipment is
accessible to clean and disinfect the room properly so turnover
is expedited without compromising infection prevention
efforts.”30 Although some facilities choose to package their
own turnover kits, single-use kits offer many advantages over
reusable kits just as single-use linens have proven to have
advantages over reusable linens.
13
SHARPS SAFETY
The final infection control risk that will be discussed in this
educational module is a very challenging concern for the
perioperative RN. “Annually, an estimated 384,325 hospital
healthcare workers sustain a percutaneous injury.”31 Sharps
injury is one of the primary concerns for the perioperative team.
The following perioperative professional associations have
developed sharps safety position and guidance statements:
• The Association of periOperative Registered Nurses
(AORN);
• The Association of Surgical Technologists (AST);
• The American Academy of Orthopaedic Surgeons (AAOS);
• The American College of Surgeons (ACS);
• The Council on Surgical & Perioperative Safety (CSPS);
• The European Agency for Safety and Health at Work (EUOSHA);
• The Alliance for Sharps Safety and Needlestick Prevention
in Healthcare Australia;
• The Australian College of Nurses; and
• The Australian Healthcare and Hospital Association.
(Note: this is not an all-inclusive list).
“The Centers for Disease Control and Prevention (CDC)
estimates that about 385,000 sharps-related injuries occur
annually among health care workers in hospitals.”32 This is
more than 1000 per day. Even more troublesome, it has been
estimated that at least a half or more of sharps injuries are not
reported. Most of the reported sharps injuries involve nursing
staff, but laboratory staff, physicians, housekeepers, and other
health care workers are also injured.
INFECTION
CONTROL IN THE
OPERATING ROOM
14
Injury related to needle sticks and other sharps objects
are associated with the transmission of a large number of
pathogens; however, there are three pathogens that pose the
greatest risk for perioperative team members: hepatitis B,
hepatitis C and HIV. We have already discussed on of the best
ways to reduce the risk of bloodborne pathogen contact with
skin during surgery, double gloving. This technique, especially
when using a colored underglove, also assists in the reduction
of risk from puncture. “The risks of bloodborne pathogen
exposure are higher in the OR because of prolonged contact
with surgical sites, manipulation of sharps, and exposure
to larger quantities of blood.”33 AORN has very specific
recommendations to aid in the prevention of infection control
risks related to sharps in the OR.
Recommendation II in the Recommended Practices for Sharps
Safety outlines the current best practices for sharps safety
in the perioperative setting. The recommendations states:
“Perioperative personnel must use work practice controls when
handling scalpels, hypodermic needles, suture needles, bone
fragments, K-wires, burrs, saw blades, drill bits, trocars, razors,
bone cutters, towel clips, scissors, electrosurgical tips, skin
hooks, retractors, and other sharp devices.”34 Ways to reduce
the risk of a sharps injury in the perioperative setting include:
»» Sharp handled by only one team member at a time; and
»» Place sharps in the neutral zone after use.
• Use no-touch technique when handling sharps.
• Suture needled should not be handled or manipulated with
gloved hands.
• Use a blunt instrument such as a forcep to manipulate and
guide the needle through tissue to avoid injury.
• Use an instrument to pick up sharp items such as knife
blades and suture needles.
• Only use sharp instruments when clinically necessary and
when there is not a safer method available.
• Use safe scalpel handling techniques and methods.
• Use alternative cutting devices such as innovative energy
modalities, when clinically indicated.
• Energy devices may be used as an alternative to scalpels.
• “Perioperative team members should use additional sharps
safety practices, including:
»» Maintaining situational awareness of all sharps on the
sterile field;
Unprotected Scalpel Blade
• Confine and contain sharps in specified areas of the sterile
field or within a sharps containment device.
• Scrub person should account for and confine all sharps on
the sterile field until the patient has been transported from
the room.
• Keep used sharps on the sterile field in a punctureresistant container.
»» Communicating the location of sharps on the sterile field
with other members of the perioperative team during
the procedure and at times of personnel change;
»» Removing suture needles from the suture before tying
(eg. cutting, control release);
»» Retracting tissue with instruments (eg. retractors) rather
than hands; and
»» Handling (eg. applying, passing, using, removing) saw
blades, sharp K-wires after they have passed through
the patient’s skin.35
• Obtain a new container if the needle disposal container on
the sterile field is full.
• Use safe practices when injecting medications or drawing
blood.
• Close needle containers securely before disposal.
• Do not bend, recap or remove contaminated needles
unless there is no alternative.
• Members of the surgical team should use a neutral zone
or hands free technique for passing sharp instruments,
blades, and needles. The use of a neutral zone should
include:
»» Neutral zone should be identified in the preoperative
briefing;
»» A basin, instrument mat, magnetic pad, or designated
area on the mayo stand as the neutral zone;
»» Place one sharp at a time in the neutral zone;
»» Orient the sharp for easy retrieval by the surgeon;
• Use needleless entry devices whenever possible.
• Practice ampule safety to minimize percutaneous risk of
injury.
Accidental sharps injuries in the perioperative setting are
serious problems and can cause perioperative team members
to acquire infectious diseases from bloodborne pathogens
or injuries in the course of their work. There is also a cost of
injury and exposure that is both emotional and financial on the
healthcare worker, their families and the facility.
15
SUMMARY
Preventing surgical site infection in the OR is one of the primary
goals of the perioperative team, and the team performs many
infection prevention best practices to support this goal. In the
perioperative setting, good infection prevention and control
is essential to ensure that patients who undergo any surgical
procedure receive safe and effective care. Safe working
practices are also necessary to ensure the safety of the OR
team members. Practices such as double gloving, utilizing
antimicrobial technology in surgical and decontamination gloves,
properly handling surgical smoke and wearing N95 surgical
masks when indicated, utilizing disposable barrier linens and
turnover kits and practicing sharps safety will reduce infection
risks for both patients and perioperative team members.
INFECTION
CONTROL IN THE
OPERATING ROOM
16
GLOSSARY
AEROSOL
ISOLATION PRECAUTIONS
A liquid or solution dispersed in the air in the form of a fine mist.
Special precautionary measures, practices, and procedures
used in the care of patients with contagious or communicable
diseases.
ANTIMICROBIAL
An agent that kills microorganisms or inhibits their growth.
BLOODBORNE PATHOGENS
Pathogenic microorganisms present in human blood that can
cause disease in humans. These include: hepatitis B virus (HBV),
hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
CONTACT PRECAUTIONS
Precautions designed to reduce the risk of transmission of
epidemiologically important microorganisms by direct or indirect
contact.
NEUTRAL ZONE
A safe work practice control technique used to ensure that
the surgeon and scrubbed person do not touch the same sharp
instrument at the same time. The technique is accomplished by
establishing a designated neutral zone on the sterile field and
placing sharp items within the zone for transfer of the item.
Also known as Hands-free technique.
OR TURNOVER TIME
The time between one patient’s exit and the next patient’s
entry to the same OR on the same day. The time it takes to
prepare the OR for the next surgical procedure.
DIRECT CONTACT
Person-to-person contact resulting in physical transfer of
infectious microorganisms between an infected or colonized
person and a susceptible host.
EXPOSURE INCIDENT
When as a result of the performance of an employee’s duties,
there is specific eye, mouth, other mucous membrane non-intact
skin, or parenteral contact with blood or potentially infectious
materials.
HANDS-FREE TECHNIQUE
Work practice that restricts members of the perioperative team
at the sterile field from touching the same sharp instrument at
the same time, also known as the neutral zone.
HOSPITAL ACQUIRED INFECTION (HAI)
An infection whose development is favored by a hospital
environment, such as one acquired by a patient during a hospital
visit or one developing among hospital staff. Such infections
include fungal and bacterial infections and are aggravated by
the reduced resistance of individual patients.
INDIRECT CONTACT
PERSONAL PROTECTIVE EQUIPMENT
(PPE) Specialized equipment or clothing for eyes, face, head, body,
and extremities; protective clothing; respiratory devices;
and protective shields and barriers designed to protect the
worker from injury or exposure to a patient’s blood, tissue,
or body fluids. Used by health care workers and others
whenever necessary to protect themselves from the hazards
of processes or environments, chemical hazards, or mechanical
irritants encountered in a manner capable of causing injury
or impairment in the function of any part of the body through
absorption, inhalation, or physical contact.
POTENTIALLY INFECTIOUS MATERIALS
Blood; all body fluids, secretions, and excretions (except sweat),
regardless of whether they contain visible blood; non-intact
skin; mucous membranes; and airborne, droplet, and contacttransmitted epidemiologically important pathogens.
PROCEDURE MASK
A mask that covers the nose and mouth and is intended for
use in general patient care situations. These masks generally
attach to the face with ear loops rather than ties or elastic.
Unlike surgical masks, procedure masks are not regulated by
the US Food and Drug Administration.
Contact of a susceptible host with a contaminated object (eg,
instruments, hands).
17
QUALITATIVE FIT TEST
A pass/fail test to assess the adequacy of N95 respirator
fit, as determined by an individual’s response to the certain
aerosolized test solutions.
RESPIRATOR
A personal protective device that is worn on the face and
covers at least the nose and mouth; it is worn to reduce the
wearer’s risk of inhaling hazardous airborne particles (including
infectious agents and dust particles), gases, or vapors. A
surgical N95 respirator prevents at least 95% of particles from
passing through the filter.
SINGLE-USE MATERIALS
Nonwoven materials are the essential component of single-use
surgical gowns and drapes. They are based on various forms of
natural and synthetic fibers, that is, components such as wood
pulp and cotton, or polyester, polyolefin and polypropylene.
STANDARD PRECAUTIONS
Primary strategy for successful infection control and reduction
of worker exposure. Precautions used for care of all patients
regardless of their diagnosis or presumed infectious status.
SURGICAL DRAPE
A sterile fabric or fabric-like material used to isolate the
surgical site from the rest of the body and other possible
sources of contamination. Their role is to improve patient
safety but also to minimize the spread of infectious agents such
antibiotic resistant bacterial strains, human immunodeficiency
virus (HIV), and others, and therefore to decrease the risk for
staff as well as other patients to be contaminated by these
infectious agents.
INFECTION
CONTROL IN THE
OPERATING ROOM
18
SURGICAL GOWN
A sterile fabric or fabric-like material that must be worn by
a member of the surgical team during a surgical procedure
in order to minimize the exposure of healthcare workers to
pathogenic organisms. Also gowns reduce the risk of “patientto-patient” transmission of pathogenic organisms and optimize
sterility during operative and invasive procedures.
SURGICAL MASK
A device worn over the mouth and nose by perioperative
team members during surgical procedures to protect both the
surgical patient and perioperative team members from transfer
of microorganisms and body fluids. Surgical masks are also
used to protect health care workers from contact with large
infectious droplets (>5 mcm in size).
SURGICAL SITE INFECTION (SSI)
An infection that occurs after surgery in the part of the body
where the surgery took place. Surgical site infections can
sometimes be superficial infections involving the skin only.
Other surgical site infections are more serious and can involve
tissues under the skin, organs, or implanted material.
SURGICAL SMOKE
Cellular debris, aerosols, vapors and gases that are created as a
byproduct of the pyrolysis of human tissue.
TRANSMISSION BASED PRECAUTIONS
Precautions designed to be used with patients known
or suspected of being infected or colonized with highly
transmissible or epidemiologically important pathogens that
need additional precautions to prevent transmission in the
practice setting.
TURNOVER KITS
Kits designed to help streamline the process of OR turn over
time. Either hospital assembled kits or commercially assembled
kits can include a variety of supplies to accomplish room
turnover. Most kits include the linens needed to remake the
bed, patient safety straps, mop heads, replacement waste bags
and fluid solidifier.
19
REFERENCES
1. AORN. Recommended Practices for Prevention of
Transmissible Infections in the Perioperative Practice Setting.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 385.
2. William S. Complete Dictionary of Scientific Biography.
Encyclopedia.com. http://www.encyclopedia.com/
doc/1G2-2830901836.html. Accessed December 29, 2014.
3. AORN. Recommended Practices for Prevention of
Transmissible Infections in the Perioperative Practice Setting.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 394.
4. Hubner N, Goerdt A, Stanislawski N. et al. Bacteria
migration through punctured surgical gloves under real surgical
conditions. BMC Infectious Diseases. 2010: 3.
5. McNeilly L. Double Gloving: Myth Versus Fact. http://www.
infectioncontroltoday.com/articles/2011/04/double-glovingmyth-versus-fact.aspx. Accessed January 4, 2015.
6. McNeilly L. Double Gloving: Myth Versus Fact. http://www.
infectioncontroltoday.com/articles/2011/04/double-glovingmyth-versus-fact.aspx. Accessed January 4, 2015.
7. AORN. Recommended Practices for Prevention of
Transmissible Infections in the Perioperative Practice Setting.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 393.
8. AORN. Recommended Practices for Prevention of
Transmissible Infections in the Perioperative Practice Setting.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 394.
INFECTION
9. AORN. Recommended Practices for Prevention of
Transmissible Infections in the Perioperative Practice Setting.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 394.
CONTROL IN THE
10. McNeilly L. Double Gloving: Myth Versus Fact. http://www.
infectioncontroltoday.com/articles/2011/04/double-glovingmyth-versus-fact.aspx. Accessed January 4, 2015.
OPERATING ROOM
11. AORN. Recommended Practices for Prevention of
Transmissible Infections in the Perioperative Practice Setting.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 394.
12. McNeilly L. Double Gloving: Myth Versus Fact. http://www.
infectioncontroltoday.com/articles/2011/04/double-glovingmyth-versus-fact.aspx. Accessed January 4, 2015.
20
13. Korniewicz D, El-Masri M. Exploring the Benefits of Double
Gloving During Surgery. AORN Journal. March 2012 March;
95(3): 333.
14. Assadian, et. al. Suppression of surgeons’ bacterial hand
flora during surgical procedures using a new antimicrobial
surgical glove. Surg Infect. 2013; October 12. http://www.ncbi.
nlm.nih.gov/pubmed/24116857. Accessed January 6, 2015.
15. Assadian, et. al. Suppression of surgeons’ bacterial hand
flora during surgical procedures using a new antimicrobial
surgical glove. Surg Infect. 2013; October 12. http://www.ncbi.
nlm.nih.gov/pubmed/24116857. Accessed January 6, 2015.
16. Benson S, Novak D, Ogg M. Proper Use of Surgical N95
Respirators and Surgical Masks in the OR. AORN Journal. 2013
April; 97(4): 458.
17. Ball K. The hazards of surgical smoke. AANA Journal. 2001;
69(2): 125-132.
18. AORN. Recommended Practices for Prevention of
Transmissible Infections in the Perioperative Practice Setting.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 397.
19. Beckers ASC Review. Understanding and Controlling the
Hazards of Surgical Smoke. http://www.beckersasc.com/
asc-accreditation-and-patient-safety/understanding-andcontrolling-the-hazards-of-surgical-smoke.html. Accessed
January 3, 2015.
20. AORN. Recommended Practices for Prevention of
Transmissible Infections in the Perioperative Practice Setting.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 392.
21. AORN. Recommended Practices for Electrosurgery. In:
Perioperative Standards and Recommended Practices For
Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 133.
22. AORN. Recommended Practices for Laser Safety in
Perioperative Practice Settings. In: Perioperative Standards and
Recommended Practices For Inpatient and Ambulatory Settings.
2014 ed. Denver, CO: Association of periOperative Registered
Nurses; 2014: 146.
25. AORN. Recommended Practices for Sterile Technique.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 91.
26. Pyrek K. Barrier-Protection Properties are key to Surgical
Gown Performance. Surgi Strategies. 2004 October: 1-3.
27. AORN. Recommended Practices for Environmental Cleaning.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 260.
28. Spencer M, Edmiston C. The Role of the OR Environment
in Preventing Surgical Site Infections. AORN Journal. 2014
December; 100(6): 605.
29. Spencer M, Edmiston C. The Role of the OR Environment
in Preventing Surgical Site Infections. AORN Journal. 2014
December; 100(6): 605-606.
30. AORN. Recommended Practices for Sharps Safety. In:
Perioperative Standards and Recommended Practices For
Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 351.
31. The National Institute for Occupational Safety and Health
(NIOSH). STOP STICKS CAMPAIGN. Centers for Disease Control
and Prevention (CDC). http://www.cdc.gov/niosh/stopsticks/
sharpsinjuries.html. Accessed January 6, 2015.
32. Cicconi L, Claypool M, Stevens W. Prevention of
Transmissible Infections in the Perioperative Setting. AORN
Journal. 2010 November; 92(5): 521.
33. AORN. Recommended Practices for Sharps Safety. In:
Perioperative Standards and Recommended Practices For
Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 351.
34. AORN. Recommended Practices for Sharps Safety. In:
Perioperative Standards and Recommended Practices For
Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 357.
35. AORN. Recommended Practices for Sharps Safety. In:
Perioperative Standards and Recommended Practices For
Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 360.
23. AORN. Recommended Practices for Sterile Technique.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 92.
24. AORN. Recommended Practices for Prevention of
Transmissible Infections in the Perioperative Practice Setting.
In: Perioperative Standards and Recommended Practices
For Inpatient and Ambulatory Settings. 2014 ed. Denver, CO:
Association of periOperative Registered Nurses; 2014: 397.
21
Š
Ansell Healthcare Products LLC.
111 Wood Avenue South, Suite 210
Iselin, NJ 08830 USA
Toll-free: (800) 952-9916
www.ansell.com
©2015-2017 Ansell Limited. All Rights Reserved.