Nov 23, 2015

The Chain of Infection: A Patient Journey

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The Chain of Infection

Passing Thru the Gauntlet of Healthcare Associated Infections

Meet Mary J, an incoming patient. She’s been referred to your hospital because of its reputation as a state-of-the art facility and one that has minimized healthcare-associated infections – HAIs. Mary’s OB/GYN insisted that yours is the best hospital for her to have her surgery. What began as a persistent pain in her pelvic region has been diagnosed as ovarian cancer and a complete hysterectomy has been ordered. The life of this otherwise healthy, 46 year old mother and elementary school teacher has taken a dramatic turn. She must put her care in someone else’s hands, something she’s unaccustomed to doing. With her family and her students relying on her, the last thing Mary needs is to come through the procedure successfully but encounter an HAI. HAIs can be harbored in virtually any place Mary will be transiting.  According to a recent HAI prevalence survey1 administered by the CDC, 1 in 25 hospital patients in the US have experienced at least one HAI. Read how ready this facility is to mitigate and minimize the occurrence of HAIs in its commitment to patient safety.

Arrival – Let the Battle Begin

Hands, the most common source of pathogen transmission, are a critical battleground in the fight to reduce healthcare-associated infections so naturally they are at the center of the challenge. One challenge is that in order for any product to be effective, it would also need to be gentle enough to promote repeated and frequent use. In any hospital, an effective antiseptic hand solution should also be latex glove and Chlorhexidine Gluconate compatible. It should also be dye and fragrance-free and available in versatile and convenient point-of-care locations to promote compliance. Because your hospital has initiated a comprehensive hand hygiene policy using awareness training, products and tools that are effective against infection yet gentle on skin, Mary’s admission will be less of a risk. Your hospital has also incorporated appropriate environmental cleaning programs with detailed instructions to ensure consistent cleaning based on industry standards and best practices. Because of this, Mary’s chance to contract HAIs as she passes through the hallways and contacts various equipment is reduced. The OR has been cleaned and disinfected using a variety of cleaning products and tools including chemical management systems that mix disinfectants and other products in exacting quantities. Additionally, the Infection Preventionist and Environmental Services Manager routinely review a hygiene-management-system sampling plan to validate the cleaning process and address problem areas. In all areas where Mary will pass, particular attention is paid to disinfecting high-touch surfaces. Cleanliness is verified using a hygiene management and testing system that provides real-time results. The analysis confirms that environmental cleanliness is at or above the goal benchmark for frequently touched surfaces – where the risk of cross contamination tends to be the highest. In addition to physical testing, data-driven assessment tools also help provide facilities managers with the ability to track the cost of HAIs to their facilities and justify investments in infection prevention programs.

Pre-op – Even up Your Nose?

As Mary is prepped for her procedure, she is impressed and reassured to see that all personnel who come in contact with her sanitize their hands using an instant hand antiseptic. They are obviously well trained and sanitize their hands without a second thought. She changes into a forced-air warming gown which will keep her warm as she waits prior to surgery, as well as maintain a comfortable body temperature throughout her procedure. Her nurse administers the hospital pre-surgical cleansing policy, which includes nasal antiseptic applied to her intranasal cavity and even an oral rinse – no opportunity for an HAI is left to chance. Mary’s nurse explains that this routine will help minimize the bacteria in her nasal and oral passages, bacteria that could easily spread to her surgical wounds or her airway while she is on the breathing machine. Her skin is prepared for surgery using specially developed 2% chlorhexidine gluconate rinse-free cloths that address multidrug resistant organisms on the skin and are another layer of defense against surgical site infections. Mary is then transported into the operating room. Other members of the surgical team begin to arrive into the OR. The surgical assistant puts on a high fluid-resistant surgical mask, disinfects her hands with an antiseptic hand prep and then gowns up. All surgical tools are effectively monitored using chemical and biological indicators. These indicators serve as release criteria in the Central Sterile Supply Dept. (CSSD). CSSD places chemical indicators into each set before sterilization and then are checked prior to use in the OR to verify sterilization conditions have been met. This last step is adopted by the World Health Organization, Safe Surgeries Check List to indicate that sterilization conditions exist inside the set (http://apps.who.int/iris/bitstream/10665/44186/2/9789241598590_eng_Checklist.pdf)

The indicators show a “pass”, which means they have met the parameters for sterilization and the instruments are ready. Just before she goes under anesthesia, as part of the patient monitoring process, pre-wired monitoring electrodes are placed on Mary and connected to her monitors. These electrodes use a gentle, conductive adhesive that is repositionable and won’t tear delicate tissues when removed. Mary’s IV  is inserted and secured using a transparent dressing so her IV can be monitored without removing the dressing and exposing the IV site to additional bacteria. Your hospital realizes the importance and cost saving benefits to using dressings that provide superior wear time, gentle removal, and excellent moisture management in the battle against HAIs.

In the OR Zone

While Mary’s forced-air warming gown is keeping her warm before surgery, another warming product will be used during her procedure – a full access underbody blanket. (Recent studies found that underbody blankets delivered significantly warmer patients than resistive warming devices or standard warming therapy).2-5 Maintaining normothermia helps reduce the risk of infections as well as the hospital length of stay. Warmed blood and fluids are also beneficial in an effort to maintain normothermia and they will be administered using a leading blood and fluid warming device. Once Mary is anesthetized, her skin previously clipped of hair, done in periop, is prepared for surgery using an iodine povacrylex and isopropyl alcohol surgical solution, which keeps bacteria counts below baseline for at least 48 hours. During this time, the rest of the surgical team disinfects their hands with an antiseptic hand prep. Mary is then draped using a surgical drape that has an antimicrobial incise film to create a sterile surface. This front-line barrier provides a sterile surface all the way to the wound edge, and provides continuous broad-spectrum antimicrobial activity to further reduce the risk of SSIs and HAIs. Before making any incision, the team conducts a “time out” to make sure they are doing the right operation on the right patient, have all of the appropriate instrumentation present and confirm that the correct pre-surgical protocols have been followed. The team also makes introductions and states the roles they have in the surgery, all part of your hospital’s head- to-toe patient safety attitude. Satisfied that all of the proper procedures have been followed, her gynecologic oncologist initiates the operation. After successfully removing her uterus, fallopian tubes, omentum and ovaries, fluid and tissue samples are collected and sent for testing. Mary’s skin incision is then closed using a disposable skin stapler. Closing the incision this way maintains wound edge apposition, allowing for appropriate edema to occur and facilitate proper healing. The final touch is dressing the incision. Your hospital stocks an all-in-one dressing that is highly conformable; one that flexes with movement and swelling and provides a better exchange of moisture vapor and oxygen to reduce skin maceration. The post-surgical dressing of choice protects the wound while absorbing drainage, all of which promotes healing and greater comfort. At last, Mary is transferred to the recovery room and then the ICU.

Post op Success and New Horizons

As the staff ushers Mary though recovery, a new set of pre-wired monitoring electrodes are placed on her and connected to the patient monitor. Oral care is started with an oral rinse (Chlorhexidine Gluconate 0.12%). This process is done every four hours while Mary is in the Post Anesthesia Recover Unit, or PACU. Because the staff at your hospital had the right processes and products in place, from the surgical prep station to the sterilization room to the OR and onto the ICU, they helped reduce the risk of Mary walking away with a healthcare-associated infection. Why subject patients to needless risk of a HAI when risk can be mitigated?

References:

  1. CDC, Healthcare-associated Infections (HAIs), HAI Prevalence Survey, 2011, http://www.cdc.gov/HAI/surveillance/
  2. Tominaga A., Koitabashi T., et al. Efficacy of an underbody forced-air warming blanket for the prevention of intraoperative hypothermia. Anesth. 2007;107:A91.
  3. Insler SR., et al. An evaluation of a full-access underbody forced-air warming system during near-normothermic, on-pump cardiac surgery. Anesth Analg. 2008. 106(3):746-750.
  4. Teodorczyk JE., et al. Effectiveness of an underbody forced-air blanket in preventing postoperative hypothermia after coronary artery bypass graft surgery with normothermic cardiopulmonary bypass.  Critical Care. 2009. 13(1):P71.
  5. Engelen S, et al. A Comparison of under-body forced-air and resistive heating during hypothermic bypass. ASA Abstract. 2010. A075.
  6. World Health Organization, Health care-associated infections FACT SHEET, http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf

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