Maureen Spencer

Surgical wound irrigation: a call for evidence-based standardization of practice.

Surgical wound irrigation has long been debated as a potentially critical intraoperative measure taken to prevent the development of surgical site infection (SSI). Unlike many other SSI prevention efforts, there are no official practice guidelines or recommendations from any major medical group for the practice of surgical irrigation. As a result, practitioner implementation of the 3 major irrigation variables (delivery method, volume, and solution additives) can differ significantly. A focus group of key thought leaders in infection prevention and epidemiology convened recently to address the implications of different surgical irrigation practices. They identified an urgent need for well-designed clinical trials investigating surgical irrigation practices, improved collaboration between surgical personnel and infection preventionists, and examination of existing evidence to standardize irrigation practices. The group agreed that current published data are sufficient to support the elimination of antibiotic solutions for surgical irrigation; the avoidance of surfactants for surgical irrigation; and the use of sterile normal saline, sterile water, and 1 medical device containing a sterile 0.05% chlorhexidine gluconate solution followed by sterile saline. Given the current lack of sufficient evidence identifying ideal delivery method and volume choices, expert opinion must be relied on to guide best practice.

Evidence for a Standardized Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4%, in Surgical Patients

IMPORTANCE To reduce the amount of skin surface bacteria for patients undergoing elective surgery, selective health care facilities have instituted a preadmission antiseptic skin cleansing protocol using chlorhexidine gluconate. A Cochrane Collaborative review suggests that existing data do not justify preoperative skin cleansing as a strategy to reduce surgical site infection. OBJECTIVES To develop and evaluate the efficacy of a standardized preadmission showering protocol that optimizes skin surface concentrations of chlorhexidine gluconate and to compare the findings with the design and methods of published studies on preoperative skin preparation. DESIGN, SETTING, AND PARTICIPANTS A randomized prospective analysis in 120 healthy volunteers was conducted at an academic tertiary care medical center from June 1, 2014, to September, 30, 2014. Data analysis was performed from October 13, 2014, to October 27, 2014. A standardized process of dose, duration, and timing was used to maximize antiseptic skin surface concentrations of chlorhexidine gluconate applied during preoperative showering. The volunteers were randomized to 2 chlorhexidine gluconate, 4%, showering groups (2 vs 3 showers), containing 60 participants each, and 3 subgroups (no pause, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each. Volunteers used 118 mL of chlorhexidine gluconate, 4%, for each shower. Skin surface concentrations of chlorhexidine gluconate were analyzed using colorimetric assay at 5 separate anatomic sites. Individual groups were analyzed using paired t test and analysis of variance. INTERVENTION Preadmission showers using chlorhexidine gluconate, 4%. MAIN OUTCOMES AND MEASURES The primary outcome was to develop a standardized approach for administering the preadmission shower with chlorhexidine gluconate, 4%, resulting in maximal, persistent skin antisepsis by delineating a precise dose (volume) of chlorhexidine gluconate, 4%; duration (number of showers); and timing (pause) before rinsing. RESULTS The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P < .001) in the 1- and 2-minute pause groups compared with the no-pause group in participants taking 2 (978.8 [234.6], 1042.2 [219.9], and 265.6 [113.3] µg/mL, respectively) or 3 (1067.2 [205.6], 1017.9 [227.8], and 387.1 [217.5] µg/mL, respectively) showers. There was no significant difference in concentrations between 2 and 3 showers or between the 1- and 2-minute pauses. CONCLUSIONS AND RELEVANCE A standardized preadmission shower regimen that includes 118 mL of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface (16.5 µg/cm2) concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram-negative surgical wound pathogens. This showering regimen corrects deficiencies present in current nonstandardized preadmission shower protocols for patients undergoing elective surgery.

Implementation and evaluation of an algorithm for isolation of patients with suspected pulmonary tuberculosis.

OBJECTIVE To implement and evaluate an algorithm designed to assist in the consistent placement of patients with suspected pulmonary tuberculosis into negative-pressure isolation rooms (NPIRs). DESIGN A standard algorithm was designed for the appropriate room placement of patients with suspected pulmonary tuberculosis using clinical, radiographic, and laboratory criteria and reported risk factors. A case-patient was defined as an inpatient who had at least one Mycobacterium tuberculosis culture-positive respiratory specimen from January 1, 1993, through December 31, 1994. Demographic, clinical, laboratory, case contact, and isolation and room placement data were collected prospectively on all case patients. SETTING A 900-bed university teaching and referral center. RESULTS During 1993 and 1994, 69 patients were evaluated for possible pulmonary tuberculosis, and 31 case-patients were identified. Of the 31 case-patients, 26 (84%) were placed on respiratory isolation in NPIRs, including 19 (61%) who were isolated within 24 hours of admission (1993, 14 of 20 [70%]; 1994, 5 of 11 [45%]). Seven case-patients (23%) were isolated in NPIRs following delays that ranged from 2 to 31 days (median, 9 days), and five case-patients (16%) never were isolated during admissions of from 3 to 28 days (median, 4 days). These 12 case-patients contributed a total of 136 patient-exposure days during their hospitalizations. Misclassification of patient risk status by user error delayed isolation of five (42%) of the 12 improperly isolated case-patients. CONCLUSIONS The use of an algorithm incorporating radiographic, laboratory, and clinical criteria and reported risk factors may assist in the rapid isolation of patients with suspected pulmonary tuberculosis.

Empowering the Surgical Patient: A Randomized, Prospective Analysis of an Innovative Strategy for Improving Patient Compliance with Preadmission Showering Protocol

BACKGROUND Surgical site infections (SSIs) are responsible for significant morbidity, mortality, and excess use of health care resources. The preadmission antiseptic shower is accepted as an effective strategy for reducing the risk for SSIs. The study analyzes the benefit of an innovative electronic patient alert system (EAS) for enhancing compliance with a preadmission showering protocol with 4% chlorhexidine gluconate (CHG). STUDY DESIGN After providing informed consent, 80 volunteers were randomized to 4 CHG showering groups. Groups A1 and A2 showered twice. Group A1 was prompted to shower via EAS. Groups B1 and B2 showered 3 times. Group B1 was prompted via EAS. Subjects in groups A2 and B2 were not prompted (non-EAS groups). Skin-surface concentrations of CHG (μg/mL) were analyzed using colorimetric assay at 5 separate anatomic sites. Study personnel were blinded to the randomization code; after final volunteer processing, the code was broken and individual groups were analyzed. RESULTS Mean composite CHG skin-surface concentrations were significantly higher (p < 0.007) in EAS groups A1 (30.9 ± 8.8 μg/mL) and B1 (29.0 ± 8.3 μg/mL) compared with non-EAS groups A2 (10.5 ± 3.9 μg/mL) and B2 (9.5 ± 3.1 μg/mL). Overall, 66% and 67% reductions in CHG skin-surface concentrations were observed in non-EAS groups A2 and B2 compared with EAS study groups. Analysis of returned (unused) CHG (mL) suggests that a wide variation in volume of biocide was used per shower in all groups. CONCLUSIONS The findings suggest that EAS was effective in enhancing patient compliance with a preadmission showering protocol, resulting in a significant (p < 0.007) increase in skin-surface concentrations of CHG compared with non-EAS controls. However, variation in amount of unused 4% CHG suggests that rigorous standardization is required to maximize the benefits of this patient-centric interventional strategy.

To bathe or not to bathe with chlorhexidine gluconate: is it time to take a stand for preadmission bathing and cleansing?

any health care facilities have incorporated an antiseptic skin cleansing protocol, often referred to as preoperative bathing and cleansing, to reduce the endogenous microbial burden on the skin of patients undergoing elective surgery, with the aim of reducing the risk of surgical site infections (SSIs). According to a recent study by Injean et al, 91% of all facilities that perform coronary artery bypass surgery in California have a standardized preoperative bathing and cleansing protocol for patients. Historically, this practice has been endorsed by national and international organizations, such as the Hospital Infection Control Practice Advisory Committee and the Centers for Disease Control and Prevention, the Association for Professionals in Infection Control and Epidemiology (APIC), AORN, the Institute for Healthcare Improvement (IHI), and the National Institute for Health and Care Excellence (NICE), which recommend bathing and/or cleansing with an antiseptic agent before surgery as a component of a broader strategy to reduce SSIs. The 2008 Society for Healthcare Epidemiology of America (SHEA)/ Infectious Diseases Society of America (IDSA)/Surgical Infection Society (SIS) strategies to prevent SSIs in acute care hospitals declined to recommend a specific application policy regarding selection of an antiseptic agent for preoperative bathing but acknowledged that the (maximal) antiseptic benefits of chlorhexidine gluconate (CHG) are dependent on achieving adequate skin surface concentrations.

Preadmission Application of 2% Chlorhexidine Gluconate (CHG): Enhancing Patient Compliance While Maximizing Skin Surface Concentrations.

OBJECTIVE Surgical site infections (SSIs) are responsible for significant morbidity and mortality. Preadmission skin antisepsis, while controversial, has gained acceptance as a strategy for reducing the risk of SSI. In this study, we analyze the benefit of an electronic alert system for enhancing compliance to preadmission application of 2% chlorhexidine gluconate (CHG). DESIGN, SETTING, AND PARTICIPANTS Following informed consent, 100 healthy volunteers in an academic, tertiary care medical center were randomized to 5 chlorhexidine gluconate (CHG) skin application groups: 1, 2, 3, 4, or 5 consecutive applications. Participants were further randomized into 2 subgroups: with or without electronic alert. Skin surface concentrations of CHG (μg/mL) were analyzed using a colorimetric assay at 5 separate anatomic sites. INTERVENTION Preadmission application of chlorhexidine gluconate, 2% RESULTS Mean composite skin surface CHG concentrations in volunteer participants receiving EA following 1, 2, 3, 4, and 5 applications were 1,040.5, 1,334.4, 1,278.2, 1,643.9, and 1,803.1 µg/mL, respectively, while composite skin surface concentrations in the no-EA group were 913.8, 1,240.0, 1,249.8, 1,194.4, and 1,364.2 µg/mL, respectively (ANOVA, P<.001). Composite ratios (CHG concentration/minimum inhibitory concentration required to inhibit the growth of 90% of organisms [MIC90]) for 1, 2, 3, 4, or 5 applications using the 2% CHG cloth were 208.1, 266.8, 255.6, 328.8, and 360.6, respectively, representing CHG skin concentrations effective against staphylococcal surgical pathogens. The use of an electronic alert system resulted in significant increase in skin concentrations of CHG in the 4- and 5-application groups (P<.04 and P<.007, respectively). CONCLUSION The findings of this study suggest an evidence-based standardized process that includes use of an Internet-based electronic alert system to improve patient compliance while maximizing skin surface concentrations effective against MRSA and other staphylococcal surgical pathogens.

Assessment of an innovative antimicrobial surface disinfectant in the operating room environment using adenosine triphosphate bioluminescence assay

Terminal cleaning in the operating room is a critical step in preventing the transmission of health care-associated pathogens. The persistent disinfectant activity of a novel isopropyl alcohol/organofunctional silane solution (ISO) was evaluated in 4 operating rooms after terminal cleaning. Adenosine triphosphate bioluminescence documented a significant difference (P < .048) in surface bioburden on IOS-treated surfaces versus controls. RODAC plate cultures revealed a significant (P < .001) reduction in microbial contamination on IOS-treated surfaces compared with controls. Further studies are warranted to validate the persistent disinfectant activity of ISO within selective health care settings.

Endoscope reprocessing in 2014: why is the margin of safety so small?

lexible endoscopes become heavily contaminated with bioburden (eg, blood, body fluids, other potentially infectious materials) during use. In a busy clinical practice, the same device may be used multiple times within an eightto 12-hour period. The complexity of these devices with their multiple ports and channels poses a challenge for personnel tasked with cleaning and reprocessing the instruments for the next patient use. Rigid endoscopic devices that enter intrinsically sterile spaces undergo cleaning and then a traditional steam sterilization regimen; these instruments are classified as critical devices. Flexible endoscopes and equipment, which come into intimate contact with intact mucous membranes, are classified as semicritical devices, so reprocessing involves cleaning and then high-level disinfection. This process kills all vegetative microorganisms, mycobacteria, selective none lipid-containing and lipid-containing viruses, and fungal spores; however, high-level disinfection does not kill all bacterial spores. Numerous recent reports highlight the infection risks of endoscopic equipment that is improperly reprocessed. The rise in drug-resistant pathogens, such as carbapenem-resistant Enterobacteriaceae (CRE), makes it even more important that sterile processing personnel ensure thorough and complete reprocessing takes place. Current standards of practice for endoscope reprocessing are vulnerable

Considering a new domain for antimicrobial stewardship: Topical antibiotics in the open surgical wound

&NA; The global push to combat the problem of antimicrobial resistance has led to the development of antimicrobial stewardship programs (ASPs), which were recently mandated by The Joint Commission and the Centers for Medicare and Medicaid Services. However, the use of topical antibiotics in the open surgical wound is often not monitored by these programs nor is it subject to any evidence‐based standardization of care. Survey results indicate that the practice of using topical antibiotics intraoperatively, in both irrigation fluids and powders, is widespread. Given the risks inherent in their use and the lack of evidence supporting it, the practice should be monitored as a core part of ASPs, and alternative agents, such as antiseptics, should be considered.

Perioperative hair removal in the 21st century: Utilizing an innovative vacuum-assisted technology to safely expedite hair removal before surgery

BACKGROUND Perioperative hair removal using clippers requires lengthy cleanup to remove loose hairs contaminating the operative field. We compared the amount of hair debris and associated microbiologic contamination produced during clipping of surgical sites using standard surgical clippers (SSC) or clippers fitted with a vacuum-assisted hair collection device (SCVAD). METHODS Trained nurses conducted bilateral hair clipping of the chest and groin of 18 male subjects using SSC or SCVAD. Before and during clipping, measurements of particulate matter and bacterial contamination were evaluated on settling plates placed next to each subjects chest and groin. Skin condition after clipping and total clipping/cleanup times were compared between SSC and SCVAD. RESULTS The microbial burden recovered from residual hair during cleanup in the SSC group was 3.9 log10 CFU and 4.6 log10 CFU from respective, chest, and groin areas. Use of the SCVAD resulted in a significant (P < .001) reduction in both residual hair and microbial contamination within the operative field compared with SSC. CONCLUSIONS Use of SCVAD resulted in significant (P < .001) reduction in total time required to clip and clean up residual hair contaminating the operative field compared with standard practice (ie, SSC), eliminating the need to physically remove dispersed hairs, which can harbor a significant microbial burden, from within the operative field.