The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial

A threshold of 100 or more colony-forming units on the anesthesia machine predicts bacterial pathogen detection: a retrospective laboratory-based analysis

PURPOSE

Preventing the spread of pathogens in the anesthesia work area reduces surgical site infections. Improved cleaning reduces the percentage of anesthesia machine samples with ≥ 100 colony-forming units (CFU) per surface area sampled. Targeting a threshold of < 100 CFU when cleaning anesthesia machines may be associated with a lower prevalence of bacterial pathogens. We hypothesized that anesthesia work area reservoir samples returning < 100 CFU would have a low (< 5%) prevalence of pathogens.

METHODS

In this retrospective cohort study of bacterial count data from nine hospitals, obtained between 2017 and 2022, anesthesia attending and assistants' hands, patient skin sites (nares, axilla, and groin), and anesthesia machine (adjustable pressure-limiting valve and agent dials) reservoirs were sampled at case start and at case end. The patient intravenous stopcock set was sampled at case end. The isolation of ≥ 1 CFU of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, Enterococcus, vancomycin-resistant Enterococcus, gram-negative (i.e., Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp.) or coagulase-negative Staphylococcus was compared for reservoir samples returning ≥ 100 CFU vs those returning < 100 CFU.

RESULTS

Bacterial pathogens were isolated from 24% (7,601/31,783) of reservoir samples, 93% (98/105) of operating rooms, and 83% (2,170/2,616) of cases. The ratio of total pathogen isolates to total CFU was < 0.0003%. Anesthesia machine reservoirs returned ≥ 100 CFU for 44% (2,262/5,150) of cases. Twenty-three percent of samples returning ≥ 100 CFU were positive for ≥ 1 bacterial pathogen (521/2,262; 99% lower confidence limit, 22%) vs 3% of samples returning < 100 CFU (96/2,888; 99% upper limit, 4%).

CONCLUSIONS

Anesthesia machine reservoir samples returning < 100 CFU were associated with negligible pathogen detection. This threshold can be used for assessment of terminal, routine, and between-case cleaning of the anesthesia machine and equipment. Such feedback may be useful because the 44% prevalence of ≥ 100 CFU was comparable to the 46% (25/54) reported earlier from an unrelated hospital.

Reducing Sternal Wound Infection Rates in Patients Undergoing Cardiothoracic Surgery with Sternotomy

LOCAL PROBLEM

Sternal wound infections (SWIs), whether superficial or deep, are associated with increased morbidity, mortality, and costs. From 2016 to 2017, our facility saw a 50% decrease in SWIs among patients undergoing cardiothoracic surgery with sternotomy. From 2017 to 2018, however, we identified a 33% increase in SWIs, prompting us to address our cardiac nurses' sternal wound care education and practice.

PURPOSE

The purpose of our quality improvement (QI) project was to identify opportunities for improvement in postoperative sternal incision care and to implement evidence-based processes to reduce the incidence of SWIs among cardiothoracic surgery patients.

METHODS

A literature review was performed to identify interventions focused on evidence-based SWI reduction. During the first quarter of 2019, our postoperative incision care guidelines were revised and released to staff, a new surgical wound cleansing product was supplied, and RN education was provided. Cardiac nurses were surveyed in April 2019 to identify any remaining knowledge and practice deficits and to assess their adherence to the new guidelines. The survey responses helped us to further improve our nurse education. We also provided periodic nurse reeducation and enhanced patient and family education. All such interventions were implemented by the end of June 2019.

RESULTS

Between January and June 2019, we had one SWI. From July 2019 through December 2020, an 18-month period, we experienced zero SWIs. Although beginning in 2021, we saw an increase in SWIs-four in 2021 and five in 2022-our incidence rates remain below 0.5% and we continue to work toward an SWI goal of zero.

CONCLUSION

This QI project identified opportunities for improvement, implemented evidence-based strategies for wound care and education, and successfully achieved a zero SWI rate for a period of 18 months.

Environmental cleaning and disinfection in the operating room: a systematic scoping review through a human factors and systems engineering lens

OBJECTIVE

To synthesize evidence and identify gaps in the literature on environmental cleaning and disinfection in the operating room based on a human factors and systems engineering approach guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model.

DESIGN

A systematic scoping review.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched 4 databases (ie, PubMed, EMBASE, OVID, CINAHL) for empirical studies on operating-room cleaning and disinfection. Studies were categorized based on their objectives and designs and were coded using the SEIPS model. The quality of randomized controlled trials and quasi-experimental studies with a nonequivalent groups design was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials.

RESULTS

In total, 40 studies were reviewed and categorized into 3 groups: observational studies examining the effectiveness of operating-room cleaning and disinfections (11 studies), observational study assessing compliance with operating-room cleaning and disinfection (1 study), and interventional studies to improve operating-room cleaning and disinfection (28 studies). The SEIPS-based analysis only identified 3 observational studies examining individual work-system components influencing the effectiveness of operating-room cleaning and disinfection. Furthermore, most interventional studies addressed single work-system components, including tools and technologies (20 studies), tasks (3 studies), and organization (3 studies). Only 2 studies implemented interventions targeting multiple work-system components.

CONCLUSIONS

The existing literature shows suboptimal compliance and inconsistent effectiveness of operating-room cleaning and disinfection. Improvement efforts have been largely focused on cleaning and disinfection tools and technologies and staff monitoring and training. Future research is needed (1) to systematically examine work-system factors influencing operating-room cleaning and disinfection and (2) to redesign the entire work system to optimize operating-room cleaning and disinfection.

The relative efficacy of multiple syringe tip disinfection techniques against virulent staphylococcus contamination

BACKGROUND

A recent study confirmed significant contamination of syringe tips following routine anaesthesia practice of at least 6 h in duration.

AIM

We assessed the relative efficacy of clinically relevant syringe tip disinfection techniques following contamination with the hyper transmissible and more pathogenic Staphylococcus aureus sequence type 5 (S. aureus ST5) strain characteristic associated with increased strength of biofilm formation and greater desiccation tolerance.

METHODS

Syringe tips (N=40) contaminated with S. aureus ST5 were randomized to 70% isopropyl pads with 10 or 60 s of drying time, scrubbing alcohol disinfection caps with 10 or 60 s of dwell time, or to non-scrubbing alcohol disinfection caps with 60 s of dwell time. The primary outcome was residual 24-h colony forming units (cfu) >10.

RESULTS

Scrubbing disinfection caps were more effective than alcohol pads (25% (12/48) <10 cfu for scrubbing caps (10- or 60-s dwell times) vs 0% (0/48) <10 cfu for alcohol pads (10 or 60 s of drying time), Holm-Sidak adjusted P=0.0016). Scrubbing disinfection caps were more effective than non-scrubbing alcohol disinfection caps (25% (12/48) <10 cfu for scrubbing alcohol caps (10- or 60-s dwell times) vs 2% (1/48) for non-scrubbing alcohol caps (60-s dwell time), adjusted P=0.0087).

CONCLUSIONS

Scrubbing alcohol caps are more effective than alcohol pads or non-scrubbing disinfecting caps for microbial reduction of syringe tips contaminated with the more pathogenic S. aureus ST5.

Estimation of the contribution to intraoperative pathogen transmission from bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen

BACKGROUND

Earlier studies showed net cost saving from anesthesia practitioners' use of a bundle of infection prevention products, with feedback on monitored Staphylococcus aureus intraoperative transmission. ESKAPE pathogens also include Enterococcus and gram-negative pathogens: Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter. We evaluated whether bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen all contribute meaningfully to ESKAPE pathogen transmission within anesthesia work areas.

METHODS

The retrospective cohort study used bacterial count data from nine hospitals, 43 months, and 448 ESKAPE pathogen transmission events within anesthesia areas of 86 operating rooms. Transmission was measured within and between pairs of successive surgical cases performed in the same operating room on the same day.

RESULTS

There were 203 transmission events with S. aureus, 72 with Enterococcus, and 173 with gram negatives. ESKAPE pathogens in the nose contributed to transmission for 50% (99% confidence limit ≥45%) of case pairs, on the groin or axilla for 54% (≥49%), on the hands for 53% (≥47%), on the anesthesia machine for 21% (≥17%), and in the intravenous lumen for 24% (≥20%). ESKAPE pathogens in the nose started a transmission pathway for 27% (≥22%) of case pairs, on the groin or axilla for 24% (≥19%), on the hands for 38% (≥33%), on the anesthesia machine for 11% (≥7.6%), and in the intravenous lumen for 8.0% (≥5.3%). All P ≤ 0.0022 compared with 5%.

CONCLUSIONS

To prevent intraoperative ESKAPE pathogen transmission, anesthesia practitioners would need to address all five categories of infection control approaches: nasal antisepsis (e.g., povidone-iodine applied the morning of surgery), skin antisepsis (e.g., chlorhexidine wipes), hand antisepsis with dispensers next to the patient, decontamination of the anesthesia machine before and during anesthetics, and disinfecting caps for needleless connectors, disinfecting port protectors, and disinfecting caps for open female Luer type connectors.

Epidemiology of Enterococcus , Staphylococcus aureus , Klebsiella , Acinetobacter , Pseudomonas , and Enterobacter Species Transmission in the Pediatric Anesthesia Work Area Environment With and Without Practitioner Use of a Personalized Body-Worn Alcohol Dispenser

BACKGROUND

Personalized body-worn alcohol dispensers may serve as an important tool for perioperative infection control, but the impact of these devices on the epidemiology of transmission of high-risk Enterococcus , Staphylococcus aureus , Klebsiella, Acinetobacter , Pseudomonas , and Enterobacter (ESKAPE) pathogens is unknown. We aimed to characterize the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment with and without a personalized body-worn alcohol dispenser.

METHODS

This controlled before and after study included 40 pediatric patients enrolled over a 1-year study period. Two groups of operating room cases were compared: (1) operating room cases caring for patients with usual care (December 17, 2019, to August 25, 2020), and (2) operating room cases caring for patients with usual care plus the addition of a personalized, body-worn alcohol hand rub dispenser (September 30, 2020, to December 16, 2020). Operating rooms were randomly selected for observation of ESKAPE transmission in both groups. Device use was tracked via wireless technology and recorded in hourly hand decontamination events.

RESULTS

Anesthesia providers used the alcohol dispenser 3.3 ± 2.1 times per hour. A total of 57 ESKAPE transmission events (29 treatment and 28 control) were identified. The personalized body-worn alcohol dispenser impacted ESKAPE transmission by increasing the contribution of provider hand contamination at case start (21/29 device versus 10/28 usual care; relative risk, [RR] 2.03; 99.17% confidence interval [CI], 1.025-5.27; P = .0066) and decreasing the contribution of environmental contamination at case end (3/29 device versus 12/28 usual care; RR, 0.24; 99.17% CI, 0.022-0.947; P = .0059). ESKAPE pathogen contamination involved 20% (8/40) of patient intravascular devices. There were 85% (34/40) of preoperative patient skin surfaces contaminated with ≥1 (1.78 ± 0.19 [standard deviation {SD}]) ESKAPE pathogens.

CONCLUSIONS

A personalized body-worn alcohol dispenser can impact the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment. Improved preoperative patient decolonization and vascular care are indicated to address ESKAPE pathogens among pediatric anesthesia work area reservoirs.

Surgical helmet systems in total joint arthroplasty: assessment of hood sterility and donning technique

BACKGROUND

The incidence of prosthetic joint infection (PJI) is increasing, coincident with the rising volume of joint arthroplasty being performed. With recent controversy regarding the efficacy of surgical helmet systems (SHS) in preventing infection, the focus has turned to the correct donning techniques and usage of surgical hoods. The aim of this study was to compare the bacterial contamination of the operating surgeon's gloves after two common donning techniques of SHS hoods. We also evaluated the baseline sterility of the SHS hoods at the beginning of the procedure.

METHODS

The bacterial contamination rate was quantified using colony-forming units (CFUs), with 50 trials performed per donning technique. Samples were cultured on 5% Columbia blood agar in ambient air at 37 °C for 48 h and all subsequent bacterial growth was identified using a MALDI-TOF mass spectrometer. In Group 1, the operating surgeon donned their colleague's hood. In Group 2, the operating surgeon had their hood applied by a non-scrubbed colleague. After each trial, the operating surgeon immediately inoculated their gloves onto an agar plate. The immediate sterility of 50 SHS hoods was assessed at two separate zones-the screen (Zone 1) and the neckline (Zone 2).

RESULTS

There was no significant difference in contamination rates between the two techniques (3% vs. 2%, P = 0.99) or between right and left glove contamination rates. Immediately after donning, 6/50 (12%) of SHS hoods cultured an organism. Contamination rates at both the face shield and neckline zones were equivalent. The majority of bacteria cultured were Bacillus species.

DISCUSSION

We found no significant difference in the operating surgeon's glove contamination using two common SHS hood-donning techniques when they were performed under laminar airflow with late fan activation. We suggest the SHS hood should not be assumed to be completely sterile and that gloves are changed if it is touched intraoperatively.

Most hospital patients at risk for bacterial infection undergo an anesthetic: implications for infection control practices related to the anesthesia workspace

PURPOSE

Even with nearly 100% compliance with prophylactic antibiotic protocols, many surgical patients (> 5%) develop surgical site infections, some caused by pathogens transmitted from the anesthesia workspace (e.g., anesthesia machine), including multidrug-resistant Staphylococcus aureus. Reducing contamination of the anesthesia workspace substantively reduces the risk of surgical site infections. We estimated the percentage of hospital patients at risk for health care-associated infections who may benefit from the application of basic preventive measures under the control of anesthesia practitioners (e.g., their hand hygiene).

METHODS

We conducted a retrospective cohort study which included every patient admitted to the University of Miami Health System from April 2021 through March 2022 for hospitalization, surgery, emergency department visits, or outpatient visits. Lists were created for the start date and times of every parenteral antibiotic administered and every anesthetic.

RESULTS

Among 28,213 patient encounters including parenteral antibiotic(s), more than half (64.3%) also included an anesthetic (99% confidence interval, 62.2 to 66.6). The hypothesis that most antibiotics were administered during encounters when a patient underwent an anesthetic was accepted (P < 0.001). This observation may seem counterintuitive because parenteral antibiotics were administered for fewer than half of the 53,235 anesthetics (34.2%). The result was a consequence of most anesthetics (63.5%) at the health system being conducted in nonoperating room locations, and only 7.2% of such patients received a parenteral antibiotic.

CONCLUSIONS

Because approximately two-thirds of patients who receive an intravenous antibiotic also undergo an anesthetic, greater use of effective infection control measures in the anesthesia operating room workspace has the potential to substantively reduce overall rates of hospital infections.

Quantifying and Interpreting Inequality in Surgical Site Infections per Quarter Among Anesthetizing Locations and Specialties

Background Earlier studies have shown that prevention of surgical site infection can achieve net cost savings when targeted to operating rooms with the most surgical site infections. Methodology This retrospective cohort study included all 231,057 anesthetics between May 2017 and June 2022 at a large teaching hospital. The anesthetics were administered in operating rooms, procedure rooms, radiology, and other sites. The 8,941 postoperative infections were identified from International Classification of Diseases diagnosis codes relevant to surgical site infections documented during all follow-up encounters over 90 days postoperatively. To quantify the inequality in the counts of infections among anesthetizing locations, the Gini index was used, with the Gini index being proportional to the sum of the absolute pairwise differences among anesthetizing locations in the counts of infections. Results The Gini index for infections among the 112 anesthetizing locations at the hospital was 0.64 (99% confidence interval = 0.56 to 0.71). The value of 0.64 is so large that, for comparison, it exceeds nearly all countries' Gini index for income inequality. The 50% of locations with the fewest infections accounted for 5% of infections. The 10% of locations with the most infections accounted for 40% of infections and 15% of anesthetics. Among the 57 operating room locations, there was no association between counts of cases and infections (Spearman correlation coefficient r = 0.01). Among the non-operating room locations (e.g., interventional radiology), there was a significant association (Spearman r = 0.79). Conclusions Targeting specific anesthetizing locations is important for the multiple interventions to reduce surgical site infections that represent fixed costs irrespective of the number of patients (e.g., specialized ventilatory systems and nightly ultraviolet-C disinfection).

A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters

OBJECTIVE

Ventriculoperitoneal (VP) shunt insertion and revision surgeries are some of the most common procedures that are performed by neurosurgeons. Shunt infections within the adult population are associated with significant morbidity and mortality and rates remain high. The objective of the current study was to use quality improvement (QI) methodology to create a standardized infection prevention bundle aimed at reducing the rate of shunt infections.

METHODS

A prospective, single-center, single-surgeon QI study was undertaken. Patients were included if they were 18 years of age or older and were undergoing a VP shunt insertion or revision. The primary outcome of the study was the development of a shunt-related surgical site infection, within 1 year of surgery, as defined according to the Canadian Nosocomial Infection Surveillance Program guidelines. There was no standardized protocol prior to July 2013. A bundle coined as the Calgary Adult Shunt Infection Prevention Protocol (CASIPP) was implemented on July 1, 2013, and updated on July 1, 2015, when 2% chlorhexidine gluconate in 70% isopropyl alcohol replaced povidone-iodine for preoperative skin antisepsis. Protocol compliance was regularly monitored using a standardized process. No antibiotic-impregnated catheters were used.

RESULTS

A total of 621 consecutive VP shunt insertions and revisions were included in the study. The rate of shunt infection was 5.8% during the period in which there was no standardized shunt protocol. After the implementation of the CASIPP the infection rate decreased to 4.0%, and after introduction of the chlorhexidine/alcohol skin antisepsis, the infection rate was 0% in 379 consecutive procedures (p < 0.0001). Multivariable logistic regression analysis demonstrated that the use of chlorhexidine/alcohol with CASIPP was associated with a significant reduction in the odds of developing a shunt infection (OR 0.032, 95% CI 0-0.19, p = 0.0005).

CONCLUSIONS

The implementation of a standardized shunt infection prevention bundle within the adult population, without the use of antibiotic-impregnated catheters, significantly reduced the rate of shunt infections which was sustained over many years. The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis may have played a significant role. Multicenter studies should be completed to verify the effectiveness of the authors' protocol.

Extension of patient safety initiatives to perioperative care

PURPOSE OF REVIEW

Patient safety has significantly improved during the intraoperative period thanks to the anesthesiologists, surgeons, and nurses. Nowadays, it is within the perioperative period where most of the preventable harm happened to the surgical patient. We aim to highlight the main issues and efforts to improve perioperative patient safety focusing and the relation to intraoperative safety strategies.

RECENT FINDINGS

There is ongoing research on perioperative safety strategies aiming to initiate multidisciplinary interventions on early stages of the perioperative period as well as an increasing focus on preventing harm from postoperative complications.

SUMMARY

Any patient safety strategy to be implemented needs to be framed beyond the operating room and include in the intervention the whole perioperative period.

Patient Safety in Anesthesia: Hand Hygiene and Perioperative Infection Control

Purpose of Review

This review highlights the importance of the anesthesia team in minimizing perioperative infection risks and prevention of surgical site infection. Due to the immense financial and patient care burden that results from perioperative infection, a foundational knowledge in preventive measures is essential.

Recent Findings

Perioperative infection control, the role of the anesthesia team in reducing infection risk, and more specifically the outsized importance of hand hygiene in this space have become increasingly apparent. Maintenance of workspace cleanliness along with hand hygiene forms the cornerstone of preventing microbial transmission. Unfortunately, improvements around perioperative infection control are lacking.

Summary

The importance of the anesthesia team in maintaining proper hand hygiene, a clean work environment, and appropriate patient conditions to minimize risk of perioperative infection cannot be overstated. Poor clinical outcomes, economic burden, and external pressure from payers highlight the need for anesthesia providers to have an up-to-date knowledge of best practices in this area. In this article, we will review the current recommendations for hand hygiene practices and perioperative infection prevention.

Evaluation of the Efficiency of Hand Hygiene Technique with Hydroalcoholic Solution by Image Color Summarize

Background and Objectives: The HH (hand hygiene) technique is relatively simple. Even so, in practice there are still non-conformities regarding this aspect. Lack of knowledge or lack of compliance can be reasons for non-adherence with HH techniques. In this context, the purpose of this study was to follow the realization of the hand-washing technique with hydroalcoholic solution, applied before and after receiving the HH recommendations. Materials and Methods: A descriptive, cross-sectional study was conducted from May 2022 to June 2022. Students from a second year dental medicine class teaching in French 2021/22 “Grigore T. Popa” University of Medicine and Pharmacy in Iasi were included in the study. The approval of the ethics commission was received: No. 184/05.05.2022. The study was conducted in two stages. In the first stage, HH was performed without any recommendation. In the second stage, the antiseptic hand rubbing technique was presented following the WHO recommendations. The fluorescent Fluo-Add solution, Wood lamp for dermatology (4 × 5.5 W ultraviolet tubes with a wavelength of 360 nm), and photo camera were used. Subjects performed their HH movement before and after receiving instructions according to WHO. Images were initially taken from the backhand and palm and were finally analyzed with Image Color Summarizer. The data were analyzed by the Mann–Whitney U Test, t-test paired samples using IBM-SPSS version 26 (IBM, Armonk, NY, USA), and p ≤ 0.05 was considered statistically significant. Results: After analyzing the images, there were 70 subjects, 45.7% (32) female and 54.33% (38) male. Final average covered area of backhand was 60.89% (±17.17), 28.84:86.11, compared to 52.07% (±17.04), 9:85.23. Final average covered area for palm was 69.91% (±13.5), 31.61:93.41 compared to 59.74% (±16.64), 26.13:92.72. No statistical significance was obtained by gender. Conclusions: The study showed an improvement in hand hygiene technique without highlighting gender differences.

The Utility of Perioperative Products for the Prevention of Surgical Site Infections in Total Knee Arthroplasty and Lower Extremity Arthroplasty: A Systematic Review

Surgical site infections (SSIs) are among the most prevalent and devastating complications following lower extremity total joint arthroplasty (TJA). Strategies to reduce the rates can be divided into preoperative, perioperatives, and postoperative measures. A multicenter trial is underway to evaluate the efficacy of implementing a bundled care program for SSI prevention in lower extremity TJA including: (1) nasal decolonization; (2) surgical skin antisepsis; (3) antimicrobial incise draping; (4) temperature management; and (5) negative-pressure wound therapy for selected high-risk patients. The purposes of this systematic review were to provide a background and then to summarize the available evidence pertaining to each of these SSI-reduction strategies with special emphasis on total knee arthroplasty. A systematic review of the literature was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Five individual literature searches were performed to identify studies evaluating nasal decolonization temperature management, surgical skin antisepsis, antimicrobial incise draping, and negative-pressure wound therapy. The highest level of evidence reports was used in each product review, and if there were insufficient arthroplasty papers on the particular topic, then papers were further culled from the surgical specialties to form the basis for the review. There was sufficient literature to assess all of the various prophylactic and preventative techniques. All five products used in the bundled program were supported for use as prophylactic agents or for the direct reduction of SSIs in both level I and II studies. This systematic review showed that various pre-, intra-, and postoperative strategies are efficacious in decreasing the risks of SSIs following lower extremity TJA procedures. Thus, including them in the armamentarium for SSI-reduction strategies for hip and knee arthroplasty surgeons should decrease the incidence of infections. We expect that the combined use of these products in an upcoming study will support these findings and may further enhance the reduction of total knee arthroplasty SSIs in a synergistic manner.

Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures: a post-implementation prospective case-cohort study

STUDY OBJECTIVE

A randomized controlled study demonstrated that an optimized intraoperative infection control program targeting basic preventive measures can reduce Staphylococcus aureus transmission and surgical site infections. In this study we address potential limitations of operating room heterogeneity of infections and compliance with behavioral interventions following adoption into clinical practice.

DESIGN

A post-implementation prospective case-cohort study.

SETTING

Twenty-three operating rooms at a large teaching hospital.

PATIENTS

A total of 801 surgical patients [425 (53%) women; 350 (44%) ASA > 2, age 54.6 ± 15.9 years] were analyzed for the primary and 804 for the secondary outcomes.

INTERVENTIONS

A multifaceted, evidence-based intraoperative infection control program involving hand hygiene, vascular care, and environmental cleaning improvements was implemented for 23 operating room environments. Bacterial transmission monitoring was used to provide monthly feedback for intervention optimization.

MEASUREMENTS

S. aureus transmission (primary) and surgical site infection (secondary).

MATERIALS AND METHODS

The incidence of S. aureus transmission and surgical site infection before (3.5 months) and after (4.5 months) infection control optimization was assessed. Optimization was defined by a sustained reduction in anesthesia work area bacterial reservoir isolate counts. Poisson regression with robust error variances was used to estimate the incidence risk ratio (IRR) of intraoperative S. aureus transmission and surgical site infection for the independent variable of optimization.

MAIN RESULTS

Optimization was associated with decreased S. aureus transmission [24% before (85/357) to 9% after (42/444), IRR 0.39, 95% CI 0.28 to 0.56, P < .001] and surgical site infections [8% before (29/360) and 3% after (15/444) (IRR 0.42, 95% CI 0.23 to 0.77, P = .005; adjusted for American Society of Anesthesiologists' physical status, aIRR 0.45, 95% CI 0.25 to 0.82, P = .009].

CONCLUSION

An optimized intraoperative infection control program targeting improvements in basic preventive measures is an effective and feasible approach for reducing S. aureus transmission and surgical site infection development.

Average and longest expected treatment times for ultraviolet light disinfection of rooms

BACKGROUND

Planning Ultraviolet-C (UV-C) disinfection of operating rooms (ORs) is equivalent to scheduling brief OR cases. The study purpose was evaluation of methods for predicting surgical case duration applied to treatment times for ORs and hospital rooms.

METHODS

Data used were disinfection times with a 3-tower UV-C disinfection system in N=700 rooms each with ≥100 completed treatments.

RESULTS

The coefficient of variation of mean treatment duration among rooms was 19.6% (99% confidence interval [CI] 18.2%-21.0%); pooled mean 18.3 minutes among the 133,927 treatments. The 50^th percentile of coefficients of variation among treatments of the same room was 27.3% (CI 26.3%-28.4%), comparable to variabilities in durations of surgical procedures. The ratios of the 90^th percentile to mean differed among rooms. Log-normal distributions had poor fits for 33% of rooms. Combining results, we calculated 90% upper prediction limits for treatment times by room using a distribution-free method (e.g., third longest of preceding 29 durations). This approach was suitable because, once UV-C disinfection started, the median difference between the duration estimated by the system and actual time was 1 second.

CONCLUSIONS

Times for disinfection should be listed as treatment of a specific room (e.g., "UV-C main OR16"), not generically (e.g., "UV-C"). For estimating disinfection time after single surgical cases, use distribution-free upper prediction limits, because of considerable proportional variabilities in duration.

Statistical Design of Overnight Trials for the Evaluation of the Number of Operating Rooms That Can Be Disinfected by an Ultraviolet Light Disinfection Robotic System

Background and objective

The number of ultraviolet light disinfection robot systems that are needed for a facility’s surgical suite(s) and/or procedure suite(s) depends in part on how many rooms need to be disinfected overnight by each robot and how long this will take. The answer needs to be determined separately for each surgical and procedure suite because those variables vary both among facilities and among operating rooms or procedure rooms within facilities. In this study, we consider statistical designs to assess how many rooms a facility can reliably (≥90% chance) disinfect overnight using an ultraviolet light disinfection robot system.

Methods

We used 133,927 observed disinfection times from 700 rooms as a population from which repeated samples were drawn with replacement in Monte-Carlo simulations. We used eight-hour and 10-hour shift lengths being multiples of 40 hours for full-time hourly employees.

Results

One possible strategy that we examined was to estimate total disinfection times by estimating the mean for each room and then summing up the means. However, that did not correctly answer the question of how many rooms can reliably be available for the next day’s first case. Summing up a percentile (e.g., 90%) instead also was inaccurate, because the proper percentile depended on the number of rooms.

A suitable strategy is a brief trial (e.g., nine nights or 19 nights) with the endpoint being the daily number of rooms disinfected. Empirically, the smallest count of rooms disinfected among nine nights or the second smallest count among 19 nights are 10^th percentiles (i.e., ≈90% probability that at least that number of rooms can be disinfected in the future). The drawback is that while this approach gives the probability of a night with fewer rooms disinfected, it does not give information as to how many fewer rooms may either skip ultraviolet decontamination or start late the next workday because disinfection was not completed. Our simulations showed that there is a substantial probability (≥95%) of at most two rooms fewer or one room greater than the 10^th percentile with a nine-night trial and one room fewer or greater with a 19-night trial.

Conclusions

Because probability distributions of disinfection times are heterogeneous both among rooms and among treatments for the same room, each facility should plan to perform its own trial of nine nights or 19 nights. This will provide results that are within two rooms or one room of the correct answer in the long term. This information can be used when planning purchasing decisions, leasing, and technician staffing decisions.

Recommendations for outpatient activity in COVID-19 pandemic

The spread of the COVID-19 disease substantially influenced the International Healthcare system, and the national governments worldwide had before long to decide how to manage the available resources, giving priority to the treatment of the COVID-infected patients. Then, in many countries, it was decided to limit the elective procedures to surgical oncology and emergency procedures. In fact, most of the routine, middle-low complexity surgical interventions were reduced, and the day surgery (DS) activities were almost totally interrupted. As a result of this approach, the waiting list of these patients has significantly increased. In the current phase, with a significant decrease in the incidence of COVID-19 cases, the surgical daily activity can be safely and effectively restarted. Adjustments are mandatory to resume the DS activity. The whole separation of pathways with respect to the long-stay and emergency surgery, an accurate preoperative protocol of patient management, with a proper selection and screening of all-day cases, careful scheduling of surgical organization in the operating room, and planning of the postoperative pathway are the goals for a feasible, safe, and effective resumption of DS activity.

Quantifying and interpreting inequality of surgical site infections among operating rooms

PURPOSE

The incidence of surgical site infection differs among operating rooms (ORs). However, cost effectiveness of interventions targeting ORs depends on infection counts. The purpose of this study was to quantify the inequality of infection counts among ORs.

METHODS

We performed a single-centre historical cohort study of elective surgical cases spanning a 160-week period from May 2017 to May 2020, identifying cases of infection within 90 days using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used the Gini index to measure inequality of infections among ORs. As a reference, the Gini index for inequality of household disposable income in the US in 2017 was 0.39, and 0.31 for Canada.

RESULTS

There were 3,148 (3.67%) infections among the 85,744 cases studied. The 20% of 57 ORs with the most and least infections accounted for 44% (99% confidence interval [CI], 36 to 52) and 5% (99% CI, 2 to 8), respectively. The Gini index was 0.40 (99% CI, 0.31 to 0.50), which is comparable to income inequality in the US. There were more infections in ORs with more minutes of cases (Spearman correlation ρ = 0.68; P < 0.001), but generally not in ORs with more total cases (ρ = 0.11; P = 0.43). Moderately long (3.3 to 4.8 hr) cases had a large effect, having greater incidences of infection, while not being so long as to have just one case per day per OR. There was substantially greater inequality in infection counts among the 557 observed combinations of OR specialty (Gini index 0.85; 99% CI, 0.81 to 0.88).

CONCLUSIONS

Inequality of infections among ORs is substantial and caused by both inequality in the incidence of infections and inequality in the total minutes of cases. Inequality in infections among OR and specialty combinations is due principally to inequality in total minutes of cases.

Healthcare professionals' experiences of being observed regarding hygiene routines: the Hawthorne effect in vascular surgery

Background

The Hawthorne Effect is the change in behaviour by subjects due to their awareness of being observed and is evident in both research and clinical settings as a result of various forms of observation. When the Hawthorne effect exists, it is short-lived, and likely leads to increased productivity, compliance, or adherence to standard protocols. This study is a qualitative component of an ongoing multicentre study, examining the role of Incisional Negative Pressure Wound Therapy after vascular surgery (INVIPS Trial). Here we examine the factors that influence hygiene and the role of the Hawthorne effect on the adherence of healthcare professionals to standard hygiene precautions.

Methods

This is a qualitative interview study, investigating how healthcare professionals perceive the observation regarding hygiene routines and their compliance with them. Seven semi-structured focus group interviews were conducted, each interview included a different staff category and one individual interview with a nurse from the Department for Communicable Disease Control. Additionally, a structured questionnaire interview was performed with environmental services staff. The results were analysed based on the inductive qualitative content analysis approach.

Results

The analysis revealed four themes and 12 subthemes. Communication and hindering hierarchy were found to be crucial. Healthcare professionals sought more personal and direct feedback. All participants believed that there were routines that should be adhered to but did not know where to find information on them. Staff in the operating theatre were most meticulous in adhering to standard hygiene precautions. The need to give observers a clear mandate and support their work was identified. The staff had different opinions concerning the patient’s awareness of the importance of hygiene following surgery. The INVIPS Trial had mediated the Hawthorne effect.

Conclusion

The results of this study indicate that the themes identified, encompassing communication, behaviour, rules and routines, and work environment, influence the adherence of healthcare professionals to standard precautions to a considerable extent of which many factors could be mediated by a Hawthorne effect. It is important that managers within the healthcare system put into place an improved and sustainable hygiene care to reduce the rate of surgical site infections after vascular surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06097-5.

Challenges in reducing the risk of infection when accessing vascular catheters

Injection safety is essential to reduce the risk of healthcare-associated infections (HAIs) when accessing vascular catheters. This general review evaluates the contamination of vascular catheter access ports and associated HAIs in acute care settings, focusing on open lumen stopcocks (OLSs) and disinfectable needleless closed connectors (DNCCs). PubMed was searched from January 2000 to February 2021. OLS intraluminal surfaces are frequently contaminated during patient care, increasing the risk of HAIs, and neither an isopropyl alcohol (IPA) pad nor a port-scrub device can reduce contamination effectively. In contrast, DNCCs can be disinfected, with most studies indicating less intraluminal contamination than OLSs and some studies showing decreased HAIs. While the optimal DNCC design to reduce HAIs needs to be determined, DNCCs alone or stopcocks with a DNCC bonded to the injection port should replace routine use of OLSs, with OLSs restricted to use in sterile fields. Compliance with disinfection is essential immediately before use of a DNCC as use of a non-disinfected DNCC can have equivalent or greater risk of HAIs compared with use of an OLS. The recommendations for access port disinfection in selected national and international guidelines vary. When comparing in-vitro studies, clinical studies and published guidelines, consensus is lacking; therefore, additional studies are needed, including large randomized controlled trials. IPA caps disinfect DNCCs passively, eliminate scrubbing and provide a contamination barrier; however, their use in neonates has been questioned. Further study is needed to determine whether IPA caps are more efficacious than scrubbing with disinfectant to decrease HAIs related to use of central venous, peripheral venous and arterial catheters.

Postoperative infectious complications in elderly patients after elective surgery in China: results of a 7-day cohort study from the International Surgical Outcomes Study

AIM

Despite initiatives to increase elderly patients' access to surgical treatments, the prevalence and impact of postoperative infectious complications (PICs) in elderly patients in China are poorly described. The aim of our study was to describe PICs and associated mortality in elderly patients undertaking elective surgery in China.

METHODS

We analyzed data about elderly patients from China during the International Surgical Outcomes Study (ISOS), a 7-day prospective cohort study of outcomes after elective surgery in in-patient adults. All elderly patients (age ≥60 years) from 28 hospitals in China included in the ISOS study were included in this study as well. A review of 2014 elderly patients who underwent elective surgery in April 2014 was conducted.

RESULTS

Of 2014 elderly patients, 209 (10.4%) developed at least one postoperative complication. Infectious complications were most frequent, affecting 154 patients (7.6%); there was one death, or 0.6% 30-day mortality, which was a significantly higher rate than among patients without PICs (0%). The most frequent infectious complication was superficial surgical-site infection (3.3%). The length of hospital stay was longer in elderly patients with PICs than in those without PICs. Moreover, a total of 142 elderly patients (7.1%) were routinely sent to critical care after surgery, of whom 97 (68.3%) developed PICs. Compared to elderly patients admitted to a standard ward, those admitted to critical care immediately after surgery had a higher postoperative complication rate and critical care admission rate to treat complications.

CONCLUSIONS

The present prospective, multicentre study found that 7.6% of elderly patients in China had PICs after elective surgery that could prolong hospital stay and increase 30-day mortality. The clinical effectiveness of admission to critical care after surgery on elderly patients is not identified. Initiatives to increase elderly patients' access to surgical interventions should also enhance safe perioperative care to reduce PICs in China.

Sample times for surveillance of S. aureus transmission to monitor effectiveness and provide feedback on intraoperative infection control

Background

Reductions in perioperative surgical site infections are obtained by a multifaceted approach including patient decolonization, vascular care, hand hygiene, and environmental cleaning. Associated surveillance of S. aureus transmission quantifies the effectiveness of these basic measures to prevent transmission of pathogenic bacteria and viruses to patients and clinicians, including Coronavirus Disease 2019 (COVID-19). To measure transmission, the observational units are pairs of successive surgical cases in the same operating room on the same day. In this prospective cohort study, we measured sampling times for inexperienced and experienced personnel.

Methods

OR PathTrac kits included 6 samples collected before the start of surgery and 7 after surgery. The time for consent also was recorded. We obtained 1677 measurements of time among 132 cases.

Results

Sampling times were not significantly affected by technician's experience, type of anesthetic, or patient's American Society of Anesthesiologists’ Physical Status. Sampling times before the start of surgery averaged less than 5 min (3.39 min [SE 0.23], P < 0.0001). Sampling times after surgery took approximately 5 min (4.39 [SE 0.25], P = 0.015). Total sampling times averaged less than 10 min without consent (7.79 [SE 0.50], P < 0.0001), and approximately 10 min with consent (10.22 [0.56], P = 0.70).

Conclusions

For routine use of monitoring S. aureus transmission, when done by personnel already present in the operating rooms of the cases, the personnel time budget can be 10 min per case.

Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic

We performed a narrative review to explore the economics of daily operating room management decisions for ambulatory surgery centers following resolution of the acute phase of the Coronavirus Disease 2019 (COVID-19) pandemic. It is anticipated that there will be a substantive fraction of patients who will be contagious, but asymptomatic at the time of surgery. Use multimodal perioperative infection control practices (e.g., including patient decontamination) and monitor performance (e.g., S. aureus transmission from patient to the environment). The consequence of COVID-19 is that such processes are more important than ever to follow because infection affects not only patients but the surgery center staff and surgeons. Dedicate most operating rooms to procedures that are not airway aerosol producing and can be performed without general anesthesia. Increase throughput by performing nerve blocks before patients enter the operating rooms. Bypass the phase I post-anesthesia care unit whenever possible by appropriate choices of anesthetic approach and drugs. Plan long-duration workdays (e.g., 12-h). For cases where the surgical procedure does not cause aerosol production, but general anesthesia will be used, have initial (phase I) post-anesthesia recovery in the operating room where the surgery was done. Use anesthetic practices that achieve fast initial recovery of the brief ambulatory cases. When the surgical procedure causes aerosol production (e.g., bronchoscopy), conduct phase I recovery in the operating room and use multimodal environmental decontamination after each case. Use statistical methods to plan for the resulting long turnover times. Whenever possible, have the anesthesia and nursing teams stagger cases in more than one room so that they are doing one surgical case while the other room is being cleaned. In conclusion, this review shows that while COVID-19 is prevalent, it will markedly affect daily ambulatory workflow for patients undergoing general anesthesia, with potentially substantial economic impact for some surgical specialties.

Perioperative Infection Transmission: the Role of the Anesthesia Provider in Infection Control and Healthcare-Associated Infections

PURPOSE OF REVIEW

This review aims to highlight key factors in the perioperative environment that contribute to transmission of infectious pathogens, leading to healthcare-associated infection. This knowledge will provide anesthesia providers the tools to optimize preventive measures, with the goal of improved patient and provider safety.

RECENT FINDINGS

Over the past decade, much has been learned about the epidemiology of perioperative pathogen transmission. Patients, providers, and the environment serve as reservoirs of origin that contribute to infection development. Ongoing surveillance of pathogen transmission among these reservoirs is essential to ensure effective perioperative infection prevention.

SUMMARY

Recent work has proven the efficacy of a strategic approach for perioperative optimization of hand hygiene, environmental cleaning, patient decolonization, and intravascular catheter design and handling improvement protocols. This work, proven to generate substantial reductions in surgical site infections, can also be applied to aide prevention of SARS-CoV-2 spread in the COVID-19 era.

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.

Sample sizes for surveillance of S. aureus transmission to monitor effectiveness and provide feedback on intraoperative infection control including for COVID-19

Reductions in perioperative surgical site infections are obtained by a multifaceted approach including patient decolonization, hand hygiene, and hub disinfection, and environmental cleaning. Associated surveillance of S. aureus transmission quantifies the effectiveness of the basic measures to prevent the transmission to patients and clinicians of pathogenic bacteria and viruses, including Coronavirus Disease 2019 (COVID-19). To measure transmission, the observational units are pairs of successive surgical cases in the same operating room on the same day. We evaluated appropriate sample sizes and strategies for measuring transmission.

There was absence of serial correlation among observed counts of transmitted isolates within each of several periods (all P ≥.18). Similarly, observing transmission within or between cases of a pair did not increase the probability that the next sampled pair of cases also had observed transmission (all P ≥.23).

Most pairs of cases had no detected transmitted isolates. Also, although transmission (yes/no) was associated with surgical site infection (P =.004), among cases with transmission, there was no detected dose response between counts of transmitted isolates and probability of infection (P =.25).

The first of a fixed series of tests is to use the binomial test to compare the proportion of pairs of cases with S. aureus transmission to an acceptable threshold. An appropriate sample size for this screening is N =25 pairs. If significant, more samples are obtained while additional measures are implemented to reduce transmission and infections. Subsequent sampling is done to evaluate effectiveness. The two independent binomial proportions are compared using Boschloo's exact test. The total sample size for the 1^st and 2^nd stage is N =100 pairs.

Because S. aureus transmission is invisible without testing, when choosing what population(s) to screen for surveillance, another endpoint needs to be used (e.g., infections). Only 10/298 combinations of specialty and operating room were relatively common (≥1.0% of cases) and had expected incidence ≥0.20 infections per 8 hours of sampled cases. The 10 combinations encompassed ≅17% of cases, showing the value of targeting surveillance of transmission to a few combinations of specialties and rooms.

In conclusion, we created a sampling protocol and appropriate sample sizes for using S. aureus transmission within and between pairs of successive cases in the same operating room, the purpose being to monitor the quality of prevention of intraoperative spread of pathogenic bacteria and viruses.