Back to Basics: Sterile Technique

Evaluation of Surgical Gown Cuff Contamination During Orthopaedic Surgery in a Veterinary Teaching Hospital

OBJECTIVE

 The objective of this study was to determine the frequency of positive cultures of the surgical gown cuffs among scrubbed personnel prior to and immediately after orthopaedic surgical procedures performed on client-owned dogs.

STUDY DESIGN

 In this cross-sectional study, the left and right surgical gown cuffs of three scrubbed persons in 10 orthopaedic surgical procedures were individually sampled using a sterile wipe prior to and immediately after surgery in order to determine the frequency of and risk factors associated with positive bacterial cultures.

RESULTS

 Fifty of 120 (41.6%) cultures were positive with an even distribution before and after surgery. The three most common genera were Staphylococcus, Corynebacterium and Streptococcus. Using multivariable logistic regression models, humidity in the operating room (odds ratio: 1.04, 95% confidence interval: 1.00-1.08; p = 0.038) and the number of individuals scrubbed into surgery (odds ratio: 0.59, 95% confidence interval: 0.39-0.91; p = 0.016) had a significant effect on the likelihood of positive culture after surgery. Of the nine patients available for follow-up, one dog developed osteomyelitis.

CONCLUSIONS

 Maintaining the humidity in the operating room to the lowest comfortable level may reduce contamination of the surgical gown cuffs. Confirmation of bacterial contamination of surgical gown cuffs warrants adherence to operative guidelines to minimize the risk of surgical gown cuffs' contact with sterile attire, equipment and the surgical field during surgical procedures.

Postoperative empyema following chronic subdural hematoma surgery: Clinically based medicine

INTRODUCTION

Subdural empyema (SDE) is a rare complication of chronic subdural hematoma (CSDH) surgery. We introduced antibiotic prophylaxis (AP) for this procedure in 2014 following a morbidity-mortality conference (MMC) in our department. We report the results of retrospective data analysis to assess the effect of systematic AP and to identify risk factors for SDE.

MATERIAL AND METHODS

Two hundred eight patients were recruited between January 2013 and December 2015; 5 were excluded for incomplete data: 107 without and 96 with AP (n=203). SDE was confirmed by clinical examination, imaging and bacteriological analysis. Comparisons between AP-(no cefuroxime) and AP+ (cefuroxime) groups were made with Chi² test and Student's t-test.

RESULTS

One empyema was found in each group, indicating that AP had no effect (P=1). The only criterion associated with SDE for these two patients was a greater number of reoperations for CSDH recurrence (P=0.013).

DISCUSSION

The incidence of postoperative empyema was 1%, similar to the range of 0.2%-2.1% reported in the literature. This rare incidence explains why we found no significant effect of AP. The medical decision taken at the MMC did not help to reduce the rate of postoperative SDE. MMCs can help to define factors associated with adverse surgical events and identify opportunities for improvement.

CONCLUSION

AP, introduced after an MMC, did not impact SDE rates. In practice, AP should be required only in case of reoperation for CSDH recurrence. However, we still continue to use AP following the MMC considering different parameters discussed in the manuscript.

A method for quantifying key components of the opening process for opening pouch-style packages containing medical devices

Healthcare-associated infections are a serious worldwide health concern. Although contaminated medical devices are an avenue for infection, little research has evaluated the techniques used to open sterile packages. The goal of this study was to develop a method to quantify aspects of the package opening process in accordance with opening guidelines and then to demonstrate this methodology through a small sample of clinicians opening two sizes of pouch-style packages. Using motion capture techniques, a method was designed to quantify 11 parameters associated with the opening process. The method was then tested with nine healthcare professionals. Results indicated that all participants crossed the sterile field when opening packages. When opening large packages, participants spent significantly more time over the simulated sterile field and there was a trend towards more manipulations as compared to opening smaller packages. This methodology can be used to quantify the opening process, compare opening practices, and for assessment during the learning process.

Surgical Gowning Technique: Are We Contaminated Before We Cut?

OBJECTIVES

To assess possible breaches of sterility during the initial gowning step.

DESIGN

Observational study. Twenty-seven gowning events were monitored for contamination during a simulated two-person gowning process in which a surgical technician assists a surgeon in the gowning process at the beginning of a surgical procedure. The lower portion of the technician's gown was coated with resin powder before the gowning process to simulate contamination.

SETTING

Single-institution Level 1 trauma center.

PARTICIPANTS

Three physicians and 3 tenured surgical technicians.

INTERVENTION

Observed contaminated areas represented by ultraviolet resin powder under ultraviolet light on the gown of the surgeon after the two-person gowning step.

MAIN OUTCOME MEASUREMENT

Number and surface area of contamination events.

RESULTS

There was a 66.67% rate of contamination of the surgeon's gown sleeves while being gowned by a surgical technician. The overall median contamination for the short surgeon was 1.3 cm. For the medium height surgeon, the overall median contamination was 1.4 cm. The tall surgeon had an overall median contamination of 2.9 cm. Of the short, medium, and tall surgeons, the number of contamination events was 6, 5, and 7, respectively. The study suggested that the surgeon's height was a significant source of variation (P = 0.046).

CONCLUSION

We present an observational pilot study that suggests that to reduce contamination in the operating room, the two-person method must be highly monitored. This study also proposes that the single-person gowning technique should be used to reduce contamination rate during the gowning process.