5 Infection prevention and control in the PACU
Adverse Events: Untoward, undesirable, and usually unanticipated events, such as death of a patient, an employee, or a visitor in a health care organization. Incidents such as patient falls or improper administration of medications are also considered adverse events even if there is no permanent effect on the patient.
Airborne Transmission: (Microorganisms that are) carried or transported by the air.
Antibiotic Resistance: The selective pressure of antimicrobial therapy has resulted in the evolution of bacteria that are resistant to certain antibiotics. The resistance patterns of the microbes are constantly changing. These patterns are affected by patterns of antibiotic use, the prevalence of specific microorganisms, the mechanisms of resistance in these organisms, resistance transfer from one organism to another, and the patient population. The risk of infection or colonization with antibiotic-resistant microorganisms is higher among sicker and debilitated patients and in settings of high antimicrobial use and invasive technology (e.g., intensive care unit [ICU]). Infections from antibiotic-resistant organisms are difficult to treat and are often associated with high morbidity rates. These microbes can be spread from patient to patient through transient hand carriage and environmental contamination.
Antimicrobial Prophylaxis: Antibiotics that are given before the surgical incision for prevention of a surgical wound infection.
Artificial Nails: Nails with products affixed to them, such as gel, tips, jewelry, overlays, and wraps.
Attributable Mortality Rate: The death rate (expression of the number of deaths in a population during a specified time frame) that can be linked to a particular cause or source.
Barrier Precautions: The use of garb (e.g., masks, hair coverings, gowns, gloves) for protection to either the health care worker or the patient.
Bloodborne: Microorganisms that are carried or transmitted via the blood or fluids that contain blood.
Bloodborne Pathogens: Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
Central Line Associated Bloodstream Infection (CLA-BSI): Bacteremia or fungemia that develops in a patient with an intravascular central venous catheter.
Central Venous Catheter: A vascular access device that terminates at or close to the heart or one of the great vessels. An umbilical artery or vein catheter is considered a central line.
Chlorhexidine Gluconate (CHG): An antibacterial agent that is effective against a wide variety of gram-negative and gram-positive organisms and used as a topical antiinfective agent for the skin and mucous membranes.
Clostridium difficile: A bacterium that causes diarrhea and more serious intestinal conditions such as colitis. It is found in the normal gastrointestinal flora in about 3% of healthy adults and in 10% to 30% or more of hospitalized patients. Antibiotic use, even a short course given for prophylaxis or treatment of infections, often changes the normal gastrointestinal flora, which can lead to C. difficile overgrowth and toxin production. C. difficile accounts for 15% to 25% of all antibiotic-associated diarrhea. C. difficile colitis occurs in all ages but is most frequent in middle-aged and older adults or patients with debilitated conditions. C. difficile is shed in feces and is spread primarily via the hands of health care personnel who have touched a contaminated surface or item and via direct contact with a contaminated item. Hand hygiene performed with soap and water and thorough disinfection of the environment with diluted bleach reduce the risk of spreading C. difficile.
Colonization: Microorganisms that have become established in a habitat in a host but do not cause disease (infection) in this habitat.
Contact (Direct or Indirect): (Microorganisms that are) spread from contaminated hands or objects.
Contact Dermatitis: Inflammation of the skin that results from direct exposure to an irritant.
Contaminated Sharps: Any contaminated object that can penetrate the skin, such as needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.
Cross Transmission: Horizontal transmission of an organism in the health care setting; patient to patient.
Disinfection: To render free from infection, especially with destruction of harmful microorganisms.
Droplet Transmission: (Microorganisms that are) carried on airborne droplets of saliva or sputum. In general they travel from 0 to 3 feet.
Epidemiology: A branch of medical science that deals with the incidence, distribution, and control of disease in a population.
Exposure Control Plan: A formal document as defined by the Occupational Safety and Health Administration (OSHA) Regulations (Standards, 29 CFR) Bloodborne Pathogens 1910.1030; to exist in any institution with occupational exposure. The document is designed to outline the steps necessary to eliminate or minimize employee exposure.
Extended-Spectrum Beta-Lactamases (ESBL): Beta-lactamase is a type of enzyme responsible for bacterial resistance to beta-lactam antibiotics; among these are penicillins, cephalosporins, carbapenems, and others. In the middle 1980s, new types of beta-lactamase were produced by Klebsiella spp. and Escherichia coli that could hydrolyze the extended spectrum cephalosporins; these are collectively termed the extended spectrum beta-lactamases.
Fecal-Oral: Microorganisms that are spread through ingestion of contaminated feces.
Health Care–Associated Infections: Acquired or occurring in the health care setting.
Health Care Worker Flora: The microorganisms (as bacteria or fungi) that live in or on the bodies of personnel who work in a health care institution.
Hypothermia: Subnormal temperature of the body, defined as temperature less than 36° C.
Immunocompromised: Impairment or weakening of the immune system.
Medical Waste/Regulated Waste: Liquid or semiliquid blood or other potentially infectious materials; contaminated items that release blood or other potentially infectious materials in a liquid or semiliquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathologic and microbiologic wastes that contain blood or other potentially infectious materials.
Microbial Colony Counts: Enumeration via direct count of viable isolated bacterial or fungal cells or spores capable of growth on solid culture media. Each colony (i.e., microbial colony-forming unit) represents the progeny of a single cell in the original inoculum. The method is used routinely by environmental microbiologists for quantification of organisms in air, food, and water; by clinicians for measurement of patient microbial load; and in antimicrobial drug testing.
Moist Body Substances: All body fluids, including blood, body cavity fluids, breast milk, urine, feces, wound or other skin drainage, respiratory and oral secretions, mucous membranes.
Mucous Membranes: Mucous membranes line cavities or canals of the body that open to the outside, including the eyes, ears, mouth, nose, and genitals.
Multidrug Resistant Organisms (MDROs): Microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent (e.g., methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant Enterococcus [VRE]), these pathogens are frequently resistant to most available antimicrobial agents. These highly resistant organisms deserve special attention in health care facilities. In addition to MRSA and VRE, certain gram-negative bacteria, including those that produce ESBLs and Klebsiella pneumoniae carbapenemase–producing organisms are of particular concern.
N95 Respirator: An air-purifying filtering-facepiece respirator that is more than 95% efficient at removing 0.3-μm particles and is not resistant to oil.
Negative-Pressure Isolation Rooms: The difference in air pressure between two areas. A room that is under negative pressure has a lower pressure than adjacent areas, which keeps air from flowing out of the room and into adjacent rooms or areas.
Normothermia: Normal body temperature (i.e., 36° to 38° C).
Nosocomial Infections: Term used historically to denote infections that are acquired or occur in a hospital.
One-Handed “Scoop” Technique: A method of capping a needle if deemed necessary to do so. The needle cap is set on a stable surface and not touched. The needled device then is placed inside the cap with one hand. The cap is then secured into place with the other hand.
Parenteral Exposure: Piercing of mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.
Pathogenic Microorganisms: An organism of microscopic or ultramicroscopic size that is capable of causing disease.
Personal Protective Equipment (PPE): Specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts, blouses) not intended to function as protection against a hazard are not considered to be PPE.
Seroconversion Risk: The likelihood of conversion from negative virus status to positive virus status.
Susceptible: Little resistance to a specific infectious disease.
Transient Contamination: A microorganism that exists temporarily on the hands of a health care worker and is not part of the normal flora of the skin.
Vancomycin-Resistant Enterococcus (VRE): A strain of Enterococcus species that normally lives in the intestines and sometimes the urinary tract of all people. VRE has learned to resist or survive most antibiotics, including a strong antibiotic called vancomycin. VRE is acquired via direct contact (touching) with objects or surfaces that are contaminated with VRE. VRE is not spread through the air. People at risk for VRE infection are those who have chronic illnesses, have undergone recent surgery, have weakened immune systems, or have recently taken certain antibiotics.
Managing the environment and equipment
Environment
A safe and clean environment is essential for a reduction in the risk of transmission of microorganisms. Most equipment in a perianesthesia unit that comes into contact with patients is considered to have a low risk of infection transmission, most notably if the equipment is noninvasive and contacts only intact skin. Examples of these items are electrodes, stethoscopes, pulse oximeter devices, blood pressure cuffs, the outside surfaces of equipment (e.g., ventilators, intravenous pumps), and larger surfaces (e.g., tables, wheelchairs, bedside stands, floors, walls). Depending on the item and the nature of the contamination, simple surface cleaning is all that is necessary to ensure safety between uses. Many hospital-grade disinfectants are combined with a cleaning component so that both cleaning and disinfection can be achieved in one step. Disinfection wipes are an appropriate option as well because of their active ingredient. If visible blood or body fluid is present, then a hospital-grade disinfectant approved by the Environmental Protection Agency (e.g., a quaternary ammonium compound, 70% isopropyl, properly diluted bleach, or phenolic) is required per the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard.1
Sinks
The number and accessibility of sinks in the perianesthesia care unit is important for increased compliance with hand washing. The Guidelines for Design and Construction of Hospital and Health Care Facilities, published and updated periodically by the American Institute of Architects (AIA), should be referenced for current sink allotment recommendations. The guidelines are conceived as minimal construction requirements for hospitals, and the document includes engineering systems, infection control, and safety and architectural guidelines for design and construction. The Joint Commission states that the AIA guidelines should be used during new construction. The current AIA guidelines recommend at least one hand washing station with hands-free or wrist blade–operable controls for every four beds in a postanesthesia care unit (PACU).2
General infection control practices
Handwashing
The benefits of hand hygiene in a hospital setting were first recognized by Ignaz Semmelweis in 1847 after the death of his friend from an infection that he contracted after his finger was accidentally punctured with a knife during a postmortem examination. The friend’s autopsy showed a pathologic situation similar to that of the women who were dying from puerperal fever in one of the obstetric clinics. Semmelweis immediately proposed a connection between cadaveric contamination and puerperal fever and made a detailed study of the mortality statistics of the obstetric clinic attended by physicians who also performed autopsies with the statistics of the midwives’ clinics. The midwives did not participate in autopsies. He concluded that he and the students carried the infecting particles on their hands from the autopsy room to the patients they examined in the clinical setting. Semmelweis concluded that some unknown “cadaveric material” caused childbed fever. He instituted a policy requiring use of a solution of chlorinated lime for washing hands between autopsy work and the examination of patients and the mortality rate dropped from 12.24% to 2.38%, comparable to the midwives’ clinics’ rates.3
To this day, hand hygiene remains of paramount importance for preventing the spread of disease-causing germs in the perianesthesia setting. Hands should be washed with soap and water for at least 15 to 20 seconds with a hospital-approved liquid or foam soap (bar soap should be avoided). If hands are not visibly soiled, an alcohol-based hand rub can be used. Alcohol-based hand rubs significantly reduce the number of microorganisms on the skin, are fast acting, and cause less skin irritation.4 They should not be used if the hands are visibly contaminated with blood, body fluids, or soiling. Hand hygiene should be minimally performed before and after patient care, after handling of soiled equipment or linen, after removal of gloves, after use of the restroom, before and after eating, or whenever hands are soiled. Health care personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections (e.g., patients in intensive care units or in transplant units).
Adherence to hand hygiene practices has been studied in observational studies of health care workers (HCWs). Compliance rates to follow recommended hand hygiene procedures have been poor, with mean baseline rates of 5% to 81% (overall average, 40%). Perceived barriers to adherence with hand hygiene include skin irritation, inaccessible hand-hygiene supplies, interference with HCW-patient relationships, priority of care (i.e., the patient’s needs are given priority over hand hygiene), wearing of gloves, forgetfulness, lack of knowledge of hand hygiene policy, insufficient time for hand hygiene, high workload and understaffing, and the lack of scientific information or education indicating a definite effect of improved hand hygiene on health care–associated infection rates.5–11
Frequent and repeated use of hand hygiene products, particularly soaps and other detergents, is a primary cause of chronic irritant contact dermatitis among HCWs.12 To minimize this condition, HCWs should use hospital-approved hand lotion frequently and regularly on their hands. Small personal-use containers or multiuse pumps that are smaller than 16 ounces (and not refilled) should be used. Lotions that contain petroleum or other oil emollients can affect the integrity of latex gloves; therefore compatibility between the lotion and its possible effects on gloves should be considered at the time of product selection.1 Last, certain moisturizing products and surfactants have been shown to interfere with the residual activity of chlorhexidine gluconate (CHG), a skin antiseptic in liquid soap. Compatibility between a lotion and its possible effects on the efficacy of certain antiseptic soaps should be considered at the time of product selection.
Personal protective equipment
The most common personal protective equipment (PPE) used by HCWs is gloves. The Centers for Disease Control and Prevention (CDC) has recommended that HCWs wear gloves to: (1) reduce the risk of personnel acquiring infections from patients; (2) prevent HCW flora from being transmitted to patients; and (3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another.13 OSHA mandates that gloves be worn during all patient care activities that may involve exposure to blood or body fluids that may be contaminated with blood.1 They should also be worn for direct contact with mucous membranes, nonintact skin, open wounds, or items potentially contaminated with moist body substances. Gloves should also be worn in vascular access procedures. The effectiveness of gloves in prevention of contamination of the hands of HCWs has been confirmed in several clinical studies. Two of these studies, which involved personnel caring for patients with Clostridium difficile or vancomycin-resistant Enterococcus (VRE), revealed that wearing gloves prevented hand contamination among most personnel who had direct contact with patients.14–16 Wearing of gloves also prevented personnel from acquiring VRE on their hands when touching contaminated environmental surfaces.16 Prevention of heavy contamination of the hands is considered important because hand washing or hand antisepsis might not remove all potential pathogens when hands are heavily contaminated.17,18
