Infection Control in the Surgical Center

1. Infection Control in the Surgical Center Linda Verchick, MS Epidemiology Supervisor Clark County Health District

2. Outpatient Surgery Outbreaks Mycobacterium sp. Mycobacterium sp. (non-TB) associated with outpatient/cosmetic surgery clinics. 2003 M. chelonae from multi-dose container of methylene blue used to mark muscle 2001 mycobacterial keratitis associated with a contaminated medical device Outbreaks of not TB mycobacterium have been associated with outpatient surgical centers. In 2003 Mycobacterium chelonae infection was associated with use of a multidose container of methylene blue which was used to mark the muscle during surgery. In 2001, several patients had acquired mycobacterial keratitis from a contaminated medical device used in Lasix surgery to correct vision problems.Outbreaks of not TB mycobacterium have been associated with outpatient surgical centers. In 2003 Mycobacterium chelonae infection was associated with use of a multidose container of methylene blue which was used to mark the muscle during surgery. In 2001, several patients had acquired mycobacterial keratitis from a contaminated medical device used in Lasix surgery to correct vision problems.

3. Key Recommendations of CDC and HICPAC Ventilation and water system performance Multidisciplinary risk assessment team Use of dust control procedures during construction, repair, renovation or demolition Environmental surface cleaning and disinfection strategies geared towards antimicrobial resistant organisms Note: There are actually 12 Key recommendations listed in “Guidelines for Environmental Infection Control in Health-Care Facilities”

4. Regulate the Operating Room Environment Ventilation = positive pressure. Variable air systems (positive pressure only) Air introduced at the ceiling and exhausted near the floor Humidity <68% Temperature control

5. Regulate the Operating Room Environment Minimize personnel traffic during operations

6. Cleaning and Disinfecting Environmental Surfaces Medical equipment surfaces knobs, handles on equipment such as x-ray machines, instrument carts Housekeeping surfaces floors, walls, chairs, and tabletops

7. Cleaning and Disinfecting Medical Equipment Manufacturer’s recommendation for sterilization Recommended chemical germicides Water-resistant properties Required decontamination after servicing Non-critical medical equipment (see intermediate level disinfection)

8. Cleaning and Disinfecting Housekeeping Surfaces Frequent hand contact “high touch surfaces Doorknobs, bedrails, light switches, wall areas around the toilet, edges of privacy curtain Clean/disinfect more frequently Minimal hand contact Hard surface floors and window sills Clean on a regular basis, when soiled, and when patient is discharged from facility Walls, blinds and window curtains Clean when visibly soiled

9. Cleaning A form of decontamination by removing organic matter, salts, and visible soils Physical action of scrubbing with detergents or surfactants and rinsing with water Necessary step prior to sterilization or disinfection

10. Cleaning Strategy Minimize contamination of cleaning solutions and tools Change cleaning solutions frequently Replace soiled cloths and mop heads with each cleaning solution change Launder cloths and mop heads after use and allow to dry before re-use or use disposable cloths and mop heads Use manufacturers recommended concentration

11. Cleaning Carpeting and Cloth Furniture Vacuum carpeting and cloth furniture on a regular basis Maintain vacuum to minimize dust dispersal by using HEPA filters Maintain wet cleaning equipment in good repair and allow to dry between uses Note: Avoid use of carpeting and cloth furnishings in areas where spills are likely to occur

12. Disinfection “The process that eliminates many or all pathogenic micro-organisms on inanimate objects with the exception of bacterial spores” Spaulding’s* three levels of disinfection: High-level Intermediate-level Low-level *for treatment of devices and surfaces that do not require sterility for safe use

13. High-level Disinfection Includes powerful sporocidal chemicals (glutaraldehyde, peracteic acid and hydrogen peroxide) Inactivates all vegetative bacteria, mycobacteria (TB), viruses, fungi, some bacterial spores, enveloped and non enveloped viruses Utilize for items that come into contact with intact mucous membranes and are heat sensitive semi-critical medical instruments (s/a flexible fiber optic endoscopes) thermometers vaginal speculums sigmoidoscopes

14. Intermediate-level Disinfection Includes Chlorine-containing compounds, alcohols (small surfaces), some phenolics, and some iodophors Inactivates a highly resistant organisms and exhibits some sporcidal activity Utilize for non-critical medical equipment s/a stethoscopes, blood pressure cuffs, dialysis machines, equipment knobs and controls.

15. Low-level Disinfection Includes quaternary ammonium compounds, some phenolics, and some iodophors Inactivates vegetative bacteria, fungi, and some lipid enveloped medium size viruses Utilize for items that come in contact with intact skin such as examining table top, baby weigh scale, blood pressure cuff

17. Special Pathogen Concern Recent studies indicate that MRSA and VRE are most likely transmitted either: Patient to patient contact Via health-care workers hands Hand transfer from contaminated environmental surfaces and patient care equipment Note: Use standard cleaning and disinfection protocols to control environmental contamination with antibiotic-resistant, gram-positive cocci People represent the primary reservoir of S. aureus. Although it has been isolated from a variety of environmental surfaces (e.g., stethoscopes, floors, charts, furniture, dry mops and hydrotherapy tanks), the role of environmental contamination in transmission of this organism in health care appears to be minimal. Colonized patients are the principal reservoir of VRE. The mechanisms by which cross-colonization take place are not well defined, although recent studies have indicated that both MRSA and VRE are most likely transmitted by the mechanisms outlined in this slide. In one survey, hand carriage of VRE in workers in a long-term care facility ranged from 13% to 41%.People represent the primary reservoir of S. aureus. Although it has been isolated from a variety of environmental surfaces (e.g., stethoscopes, floors, charts, furniture, dry mops and hydrotherapy tanks), the role of environmental contamination in transmission of this organism in health care appears to be minimal. Colonized patients are the principal reservoir of VRE. The mechanisms by which cross-colonization take place are not well defined, although recent studies have indicated that both MRSA and VRE are most likely transmitted by the mechanisms outlined in this slide. In one survey, hand carriage of VRE in workers in a long-term care facility ranged from 13% to 41%.

18. Hand Hygiene Avoid artificial nails and keep natural nails < ¼ in For visibly soiled hands use soap and water Use alcohol-based handrubs Before and after each patient Before and after glove use Improved hand hygiene adherence has: Terminated outbreaks in health care facilities ? transmission of AR organisms ? overall infection rates

19. References “Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC)” http://www.cdc.gov/ncidod/hip/enviro/Enviro_guide_03.pdf “Cleaning, Disinfecting and Sterilizing Office Instruments. CPSA Guideline” http://www.cpsa.ab.ca/publicationsresources/attachments_policies/Cleaning,%20Disinfecting%20&%20Sterilizing%20Office%20Instruments.pdf Centers for Disease Control and Prevention www.cdc.gov