Molecular epidemiology of microbial contamination in the operating room environment: Is there a risk for infection?

Background : Modern operating rooms are considered to be aseptic environments. The use of surgical mask, frequent air exchanges, and architectural barriers are used to reduce airborne microbial populations. Breaks in surgical technique, host contamination, or hematogenous seeding are suggested as causal factors in these infections. This study implicates contamination of the operating room air as an additional etiology of infection.

Methods : To investigate the potential sources of perioperative contamination, an innovative in situ air-sampling analysis was conducted during an 18-month period involving 70 separate vascular surgical procedures. Air-sample cultures were obtained from multiple points within the operating room, ranging from 0.5 to 4 m from the surgical wound. Selected microbial clonality was determined by pulse-field gel electrophoresis. In a separate series of studies microbial nasopharyngeal shedding was evaluated under controlled environmental conditions in the presence and absence of a surgical mask.

Results : Coagulase-negative staphylococci were recovered from 86% of air samples, 51% from within 0.5 m of the surgical wound, whereas Staphylococcus aureus was recovered from 64% of air samples, 39% within 0.5 m from the wound. Anterior nares swabs were obtained from 11 members of the vascular team, clonality was observed between 8 strains of S epidermidis, and 2 strains of S aureus were recovered from selected team members and air-samples collected throughout the operating room environment. Miscellaneous Gram-negative isolates were recovered less frequently (<33%); however, 7 isolates expressed multiple patterns of antimicrobial resistance. The traditional surgical mask demonstrated limited effectiveness at curtailing microbial shedding, especially during symptomatic periods of rhinorrhea.

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Improving Operating Room and Perioperative Safety: Background and Specific Recommendations

The 1999 Institute of Medicine report To Err Is Human put a spotlight on death from preventable medical errors. Surgically related errors are second only to medication errors as the most frequent cause of error-related death. Although many hospitals have ongoing programs to improve medication safety, most hospitals are not focused in a meaningful way on operating room (OR) safety despite the import of the OR to the hospital's finances and despite clearly efficacious available technologies.

The perioperative environment is a high-risk area with high velocity, high complexity, and high stakes. OR errors lead to disproportionately more harm than errors elsewhere in the hospital. Actual adverse events are relatively rare in any given OR suite, but near misses are rather common. It is possible to learn much from evaluating near misses (along with adverse events) with root-cause analyses and then instituting changes in processes and systems to assist humans from making their inevitable errors. This article outlines approaches that when combined can markedly improve safety in the OR.

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Postoperative Management of Patients with Hip Fracture

Deep Venous Thromboembolism

Patients who have sustained hip fracture are often started on deep venous thromboembolism (DVT) prophylaxis very soon after the fracture occurs and prior to surgery although evidence suggests there is little or no benefit to this approach. High-quality evidence does support the use of DVT prophylaxis following surgery. Medications used include low-dose unfractionated heparin, low-molecular-weight heparin, fondaparinux (Arixtra) and low-dose warfarin (Coumadin). Aspirin alone is insufficient for this purpose.8-10

Ideally, before a patient leaves the hospital, his or her family physician should work with the surgeon to establish a postdischarge plan. Many times, the surgeon will have already prescribed medication to prevent DVT. If that is not the case, the family physician will likely need to do so. Family physicians should know how to balance the risks and benefits of DVT prophylaxis. The most common reason for not initiating prophylactic anticoagulation is related to the amount of bleeding and fear of future bleeding at the surgical site. In patients who are at risk of bleeding, anticoagulants should not be administered for 12 to 24 hours after surgery.8 If the risk of anticoagulation is considered too high by the surgeon and the family physician, pneumatic hose, which are virtually free of side effects and are effective immediately after surgery, may be used to reduce risk of a thrombotic event. Evidence-based guidelines from the American College of Chest Physicians (ACCP) recommend extended DVT prophylaxis for 28 to 35 days after surgery, especially for patients who meet one or more of the following criteria: have a history of venous thromboembolism; are obese; aren’t ambulatory shortly following discharge; are of advanced age; and/or have cancer.8 Once a patient becomes ambulatory, the risk of pulmonary embolism decreases.

Anemia

Surgery and DVT prophylaxis increase the likelihood that anemia will complicate a patient’s recovery and rehabilitation. As such, it’s important to monitor for anemia throughout the recovery process. The family physician should be aware of the patient’s preoperative hemoglobin (Hgb) values so that he or she can appropriately assess the patient’s improvement following surgery. In general, patients who have an Hgb of at least 10 g per dL fare better in terms of ambulating independently than those with a lower count.11,12 For most patients who have a postoperative Hgb value of 8 g per dL or less, a blood transfusion will be necessary prior to hospital discharge. For other patients, however, taking a 325 mg dietary supplement of ferrous sulfate is generally sufficient. It’s important to keep in mind that constipation may already be an issue for the patient, owing to the discomfort that most people experience with using a bedpan while in the hospital. If iron supplementation exacerbates a patient’s constipation, the family physician may also need to prescribe a stool softener.

Pressure Ulcers

From the moment an individual’s hip breaks to the time he or she is ambulatory, the patient is at risk for pressure ulcers. The incidence of pressure ulcers among people who have sustained a hip fracture is reported to be between 10 percent and 40 percent.13 Such ulcers increase the length of hospital stay and the risk of nosocomial infection.

The National Guideline Clearinghouse offers a comparison of recently published evidence-based guidelines for the prevention of pressure ulcers. In summary, successful prevention relies on skin care measures, including inspection, cleansing and moisturizing; appropriate positioning (e.g., frequent turning or changes of position); use of pressure-relieving devices (e.g., air, water or gel mattresses); optimal nutrition (e.g., increased protein and caloric intake); and education of caregivers, including family members and/or nursing home staff.

Urinary Tract Infection

Urinary tract infection (UTI) is a common complication during the immediate postoperative period. Evidence supports removal of indwelling catheters within 24 to 36 hours after surgery to reduce the risk of UTI, even in the presence of transient urinary retention resulting from pain, opioid medications or anesthesia. If retention does not resolve spontaneously, an indwelling catheter can be reinserted for another 24 to 48 hours but should then be withdrawn again.14

Pain, Restlessness and Delirium

Length of hospital stay and the success of short- and long-term recovery are affected by how effectively postoperative pain is managed. Patient-controlled, intravenous delivery of morphine is a good choice for pain management immediately after surgery.15 Meperidine (Demerol) and pentazocine (Talwin), commonly used narcotics for postoperative pain management, should be avoided as they can cause excess confusion in the older patient.16 At the time of hospital discharge, most hip fracture patients will still require regularly scheduled oral pain medication (for example, acetaminophen supplemented with oxycodone).

Restlessness may be a problem for patients during their hospital stay, and addressing it can pose challenges for hospital staff. The family physician’s goal is to help patients get sufficient sleep while also ensuring that they are alert and energetic enough to begin the rehabilitation process. While sedatives may help the patient rest, they can also cause delirium and can have a negative effect on a patient’s willingness and ability to eat. Therefore, low-dose sedatives should be used cautiously (e.g., 5 mg of zolpidem [Ambien] or 25 mg of trazodone [Desyrel]).

Confusion or delirium should not be considered a “normal” side effect of surgery; however, some patients may have already had delirium prior to their hip repair. Evaluating fluid status is important during the postoperative period. Electrolyte and metabolic states can shift quickly in older patients, and a sodium level that is either too high or too low can negatively affect cognitive abilities. Among other things, confusion can cause problems with swallowing, thereby hindering a patient’s ability to take in sufficient calories to fuel recovery. If delirium-induced agitation does develop, management should include provision of a safe environment with a family member or professional sitter to stay with the patient.

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Pathophysiology of Myocardial Infarction

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Pathophysiology of Apendicitis

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Patient Safety in the Operating Room

Journal: Seminars in Plastic Surgery

Citation: 2006; 20: 214-218

Authors: Ellsworth, Warren A.; Iverson, Ronald E.

Maintaining patient safety in the operating room is a major concern of surgeons, hospitals, and surgical facilities. Circumventing preventable complications is essential, and the pressure to avoid these complications during elective cosmetic surgery is especially important. Traditionally, nursing and anesthesia staff have managed patient positioning and most safety issues in the operating room. As the number of office-based procedures in the plastic surgeon's practice increases, understanding and implementation of patient safety guidelines by the plastic surgeon is of increasing importance.

Key aspects of patient safety in the operating room include thoughtful patient positioning, ocular protection, proper handling of electrocautery, and airway management. If performed correctly with attention to certain anatomic landmarks, preoperative positioning of the patient can prevent nerve injury and postoperative joint or muscle pain. In this article we discuss proper patient positioning with attention to protection against nerve palsy. Further, we discuss common patient positions on the operative table and highlight special concerns associated with each position. Other safety issues including prevention of ocular injury and proper management of electrocautery are discussed.

Responsibility of postoperative complications ultimately lies with the surgeon. Careful attention to patient safety guidelines is of paramount importance to surgeons, especially during elective cosmetic procedures. Attention to detail in patient positioning, eye protection, and bovie use can help avoid unnecessary perioperative complications and significantly improve the patient's cosmetic surgery experience.

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Improving Operating Room and Perioperative Safety: Background and Specific Recommendations

Stephen C. Schimpff, MD
University of Maryland School of Medicine, Baltimore, and the University of Maryland School of Public Policy, College Park, Maryland

The 1999 Institute of Medicine report To Err Is Human put a spotlight on death from preventable medical errors. Surgically related errors are second only to medication errors as the most frequent cause of error-related death.

Although many hospitals have ongoing programs to improve medication safety, most hospitals are not focused in a meaningful way on operating room (OR) safety despite the import of the OR to the hospital's finances and despite clearly efficacious available technologies.

The perioperative environment is a high-risk area with high velocity, high complexity, and high stakes. OR errors lead to disproportionately more harm than errors elsewhere in the hospital. Actual adverse events are relatively rare in any given OR suite, but near misses are rather common. It is possible to learn much from evaluating near misses (along with adverse events) with root-cause analyses and then instituting changes in processes and systems to assist humans from making their inevitable errors. This article outlines approaches that when combined can markedly improve safety in the OR.

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GLOVE TEARS AND SHARP INJURIES IN THE OPERATING ROOM

Concern about occupational exposure to HIV has increased interest in the epidemiology of risk in the operating room. To learn more about how exposures happen, researchers at Yale-New Haven Hospital had nurses interview operating-room personnel immediately after a possible exposure occurred.

During the three-month study period, in which there were 2292 surgical procedures, 249 personnel had visible glove tears; 92 percent of them were wearing only one pair of gloves, and no mechanism for the tear could be identified in 67 percent of instances. There were 70 sharp injuries: 67 percent by needles, 10 percent by scalpels, and 23 percent by other instruments. The researchers identified three common mechanisms of injury: in 16 percent of cases, hands were injured, while stationary and holding an instrument, by a sharp instrument passed into or out of the field. In 17 percent, hands were injured while being used to retract tissue. Several injuries were caused by sharp instruments not in use, such as needles in needle holders; the researchers believed that many of these instruments should have been removed from the surgical field.

These data suggest that many sharp injuries can be prevented by modifying standard operating-room procedures, and that glove tears might be reduced through design changes and use of double gloves.

— THL

Published in Journal Watch General Medicine October 4, 1991

Citation(s):

Wright JG et al. Mechanisms of glove tears and sharp injuries among surgical personnel. JAMA 1991 Sep 25 266 1668-1671.

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Family Nursing Care Plan : Unhealthful lifestyle and personal practices specifically, inadequate rest and sleep

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Nursing Care Plan : Alteration of nutrition less than body requirements as manifested by the weight loss

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