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New recommended practices for preventing transmissible infections released
New recommended practices for preventing transmissible infections released Leslie Knudson Managing Editor he new “Recommended practices for prevention of transmissible infections in the perioperative practice setting,”1 have been electronically released and will be available in the 2013 edition of Perioperative Standards and Recommended Practices.2 The new recommended practices (RP) provide guidance for implementing standard and transmission-based precautions for infection prevention and include specific guidelines that address bloodborne pathogens, personal protective equipment (PPE), health care-associated infections, multidrug-resistant organisms (MDROs), and immunization. The recommendations reflect the new evidence review process, which uses the Johns Hopkins EvidenceBased Practice Model and the Oncology Nursing Society Putting Evidence into Practice (ONS PEP®) schema to appraise and rate content based on the strength of related evidence.
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Standard and transmission-based precautions The transmissible infections RP provides recommendations for standard precautions, including hand hygiene, PPE, patient resuscitation, sharps safety, and textiles and laundry and also includes new guidelines related to the environment and respiratory hygiene and cough etiquette. The RP specifically addresses environmental concerns related to contaminated hospital surfaces and states that improved cleaning and disinfection of environmental surfaces can reduce the spread of pathogens. The RP also stresses the importance of practicing respiratory hygiene and cough etiquette. According to the RP, respiratory hygiene and cough etiquette should include covering the mouth and nose with a tissue or sleeve when coughing or sneezing, quickly disposing of used tissues, performing hand hygiene after coming into contact with respiratory secretions, requiring individuals with signs of respiratory infection to wear surgical masks, and separating http://dx.doi.org/10.1016/S0001-2092(12)01343-9
© AORN, Inc, 2013
individuals with respiratory infections by more than three feet from uninfected individuals.1 The RP also provides a list of ways that health care organizations can promote proper respiratory hygiene and cough etiquette. The RP addresses contact precautions, including PPE, considerations for patient transport, environmental cleaning, and flushing mucous membranes and washing skin exposed to blood or other potentially infectious materials.1 Special cleaning considerations are noted for Clostridium difficile, a pathogen that can be transmitted through environmental contamination and requires infected patient areas to be cleaned with a 10 percent bleach solution and then allowed to air dry.1 In addition, the RP provides droplet and airborne precautions, and supports the Occupational Safety and Health Administration’s bloodborne pathogens standard for instances when there is a risk of exposure to blood or other potentially infectious materials.1 Health care-acquired infections A new section in the RP is dedicated to how perioperative personnel can take proactive measures to prevent the transmission of health care-acquired infections, including the adoption of a systematic approach to reduce the risk of surgical site infections (SSIs). The RP lists specific methods for preventing SSIs, including sterile technique, environmental cleaning, clean surgical attire, preoperative skin antisepsis, and proper hand hygiene. Evidence is provided regarding preoperatively testing and/or decolonizing patients who are nasal carriers of Staphylococcus aureus. The RP emphasizes the importance of limiting the spread of MDROs, and recommends that perioperative personnel collaborate with an infection preventionist for determining plans for surgical patients with an MDRO.1 The RP cites methicillin-resistant S. aureus and vancomycinresistant Enterococcus (VRE), and carbapanemresistant Enterobacteriaceae as MDROs presenting TRANSMISSIBLE Continued on C6 January 2013 Vol 97 No 1 • AORN Connections | C5
TRANSMISSIBLE Continued from C5
significant infection prevention challenges and emerging as serious public health concerns. “MDROs are becoming more prevalent and harder to eradicate,” said Lisa Spruce, DNP, RN, ACNP-BC, ANP-BC, ACNS-BC, CNOR, director of evidence-based perioperative practice at AORN and lead author of the transmissible infections RP. “If MDROs come into the hospital, they’re hard to get rid of and have high mortality rates, so they are a very serious focus.” The RP outlines factors that contribute to the transmission and persistence of MDRO strains, and notes that preventing and controlling MDROs often requires a combination of strategies. The RP supports the Centers for Disease Control and Prevention (CDC) guidelines for preventing central line infections, which advocate using sterile technique and maximal sterile barrier precautions when inserting central catheters.1 In addition, the RP supports the CDC guidelines for preventing catheter-associated urinary tract infections and provides specific guidelines for the insertion and care of urinary catheters. Immunization The RP recommends that all health care personnel be immunized against vaccine-preventable diseases and supports the CDC’s recommendations for health care providers to receive immunizations if they come into “contact with patients or infectious material from patients that may put them at risk for exposure and possible transmission of vaccinepreventable disease.”1 Specific vaccinations are recommended for diseases such as hepatitis B, influenza, measles, mumps, and rubella that pose risks in the workplace. The RP specifically states that all health care personnel without contraindications should receive annual influenza vaccinations, and provides strategies for health care organizations to help improve influenza vaccination rates among perioperative personnel. “It is a moral and ethical responsibility to get vaccinated to prevent giving diseases to patients in our care,” said Spruce. “The RP gives guidance to increase immunization rates among health care providers.” The RP includes requirements issued by The Joint Commission and the Centers for Medicare & Medicaid Services to report coverage levels and influenza vaccination rates, and highlights the need to improve vaccination rates among health care providers. Survey results are cited within the RP that point to specific demographics and
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variables that contribute to the likelihood of health care personnel obtaining an influenza vaccination. Health care personnel activities The RP provides recommendations related to activities of health care personnel with infections, exudative lesions, and nonintact skin and identifies restrictions for when activities pose a risk of transmission of infections to patients and other health care providers. The RP also includes a detailed table, “Guide for Perioperative Personnel Caring for Patients with Transmissible Infections,” that serves as a reference for identifying the type of precaution (contact, droplet, or airborne), the type of organism/disease, and then the recommended precautions for transport, unscrubbed personnel, and the preoperative area, and related environmental measures. In addition, the RP addresses documentation requirements for infection prevention and includes the AORN Surgical Wound Classification Decision Tree to help perioperative nurses accurately identify surgical wounds. Conclusion The prevention of infections and MDROs is a critical national focus, as an estimated 1.7 million health care-associated infections occur annually in the United States.3 The transmissible infections RP recommends perioperative team members should “participate in a variety of quality assurance and performance improvement activities to help monitor and improve the prevention of infections and MDROs.”1 Perioperative nurses should assume responsibility to monitor and improve cleaning and disinfection practices, participate in reporting infections and exposure incidents, monitor the proper use of PPE, and participate in surveillance programs for SSI to help reduce and prevent transmissible infections and contribute to a greater culture of safety. References 1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013. 2. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013. 3. Klevens RM, Edwards JR, Richard CL, Horan TC. Estimating health care-associated infections and death in US hospitals, 2002. Public Health Rep. 2007;122:160-167.
T
Standard and transmission-based precautions The transmissible infections RP provides recommendations for standard precautions, including hand hygiene, PPE, patient resuscitation, sharps safety, and textiles and laundry and also includes new guidelines related to the environment and respiratory hygiene and cough etiquette. The RP specifically addresses environmental concerns related to contaminated hospital surfaces and states that improved cleaning and disinfection of environmental surfaces can reduce the spread of pathogens. The RP also stresses the importance of practicing respiratory hygiene and cough etiquette. According to the RP, respiratory hygiene and cough etiquette should include covering the mouth and nose with a tissue or sleeve when coughing or sneezing, quickly disposing of used tissues, performing hand hygiene after coming into contact with respiratory secretions, requiring individuals with signs of respiratory infection to wear surgical masks, and separating http://dx.doi.org/10.1016/S0001-2092(12)01343-9
© AORN, Inc, 2013
individuals with respiratory infections by more than three feet from uninfected individuals.1 The RP also provides a list of ways that health care organizations can promote proper respiratory hygiene and cough etiquette. The RP addresses contact precautions, including PPE, considerations for patient transport, environmental cleaning, and flushing mucous membranes and washing skin exposed to blood or other potentially infectious materials.1 Special cleaning considerations are noted for Clostridium difficile, a pathogen that can be transmitted through environmental contamination and requires infected patient areas to be cleaned with a 10 percent bleach solution and then allowed to air dry.1 In addition, the RP provides droplet and airborne precautions, and supports the Occupational Safety and Health Administration’s bloodborne pathogens standard for instances when there is a risk of exposure to blood or other potentially infectious materials.1 Health care-acquired infections A new section in the RP is dedicated to how perioperative personnel can take proactive measures to prevent the transmission of health care-acquired infections, including the adoption of a systematic approach to reduce the risk of surgical site infections (SSIs). The RP lists specific methods for preventing SSIs, including sterile technique, environmental cleaning, clean surgical attire, preoperative skin antisepsis, and proper hand hygiene. Evidence is provided regarding preoperatively testing and/or decolonizing patients who are nasal carriers of Staphylococcus aureus. The RP emphasizes the importance of limiting the spread of MDROs, and recommends that perioperative personnel collaborate with an infection preventionist for determining plans for surgical patients with an MDRO.1 The RP cites methicillin-resistant S. aureus and vancomycinresistant Enterococcus (VRE), and carbapanemresistant Enterobacteriaceae as MDROs presenting TRANSMISSIBLE Continued on C6 January 2013 Vol 97 No 1 • AORN Connections | C5
TRANSMISSIBLE Continued from C5
significant infection prevention challenges and emerging as serious public health concerns. “MDROs are becoming more prevalent and harder to eradicate,” said Lisa Spruce, DNP, RN, ACNP-BC, ANP-BC, ACNS-BC, CNOR, director of evidence-based perioperative practice at AORN and lead author of the transmissible infections RP. “If MDROs come into the hospital, they’re hard to get rid of and have high mortality rates, so they are a very serious focus.” The RP outlines factors that contribute to the transmission and persistence of MDRO strains, and notes that preventing and controlling MDROs often requires a combination of strategies. The RP supports the Centers for Disease Control and Prevention (CDC) guidelines for preventing central line infections, which advocate using sterile technique and maximal sterile barrier precautions when inserting central catheters.1 In addition, the RP supports the CDC guidelines for preventing catheter-associated urinary tract infections and provides specific guidelines for the insertion and care of urinary catheters. Immunization The RP recommends that all health care personnel be immunized against vaccine-preventable diseases and supports the CDC’s recommendations for health care providers to receive immunizations if they come into “contact with patients or infectious material from patients that may put them at risk for exposure and possible transmission of vaccinepreventable disease.”1 Specific vaccinations are recommended for diseases such as hepatitis B, influenza, measles, mumps, and rubella that pose risks in the workplace. The RP specifically states that all health care personnel without contraindications should receive annual influenza vaccinations, and provides strategies for health care organizations to help improve influenza vaccination rates among perioperative personnel. “It is a moral and ethical responsibility to get vaccinated to prevent giving diseases to patients in our care,” said Spruce. “The RP gives guidance to increase immunization rates among health care providers.” The RP includes requirements issued by The Joint Commission and the Centers for Medicare & Medicaid Services to report coverage levels and influenza vaccination rates, and highlights the need to improve vaccination rates among health care providers. Survey results are cited within the RP that point to specific demographics and
C6 | AORN Connections
variables that contribute to the likelihood of health care personnel obtaining an influenza vaccination. Health care personnel activities The RP provides recommendations related to activities of health care personnel with infections, exudative lesions, and nonintact skin and identifies restrictions for when activities pose a risk of transmission of infections to patients and other health care providers. The RP also includes a detailed table, “Guide for Perioperative Personnel Caring for Patients with Transmissible Infections,” that serves as a reference for identifying the type of precaution (contact, droplet, or airborne), the type of organism/disease, and then the recommended precautions for transport, unscrubbed personnel, and the preoperative area, and related environmental measures. In addition, the RP addresses documentation requirements for infection prevention and includes the AORN Surgical Wound Classification Decision Tree to help perioperative nurses accurately identify surgical wounds. Conclusion The prevention of infections and MDROs is a critical national focus, as an estimated 1.7 million health care-associated infections occur annually in the United States.3 The transmissible infections RP recommends perioperative team members should “participate in a variety of quality assurance and performance improvement activities to help monitor and improve the prevention of infections and MDROs.”1 Perioperative nurses should assume responsibility to monitor and improve cleaning and disinfection practices, participate in reporting infections and exposure incidents, monitor the proper use of PPE, and participate in surveillance programs for SSI to help reduce and prevent transmissible infections and contribute to a greater culture of safety. References 1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013. 2. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013. 3. Klevens RM, Edwards JR, Richard CL, Horan TC. Estimating health care-associated infections and death in US hospitals, 2002. Public Health Rep. 2007;122:160-167.