Infection control practices change with technology
(Editor’s note: In this second part of a two-part series on sacred cows in the OR, we discuss five infection control practices and whether they can be changed safely. In last month’s issue, we discussed rituals that exist because "it’s always been done that way.")
It is not an easy thing to change operating room practices that have been in place since your "older" nurses were trained, says Hilda Guevara, RN, BSN, facility administrator of Central Park Surgery Center in Austin, TX. "It helps to understand why we have been performing certain rituals and what has changed in the past few years," Guevara says. "Understanding where we’ve been and why we can change eliminates much of the reluctance a same-day surgery manager might encounter," she adds.
The rituals that are most commonly undergoing evaluation or changes, according to Guevara are:
• Cover gowns. In the past, cover gowns were required any time you left the OR, says Guevara. There were two reasons, she says. "Members of the public would see surgical scrubs and wonder what you might have on them that could contaminate them or the food on the salad bar," she says. Although OR staff members always change into clean scrubs if they should get something on them during surgery, it was a matter of perception, she says. "We also wore cover gowns to keep our scrubs clean when we left the OR," she adds. Now, 75% of OR managers no longer require cover gowns,1 Guevara says. "Guidelines have been changed to reflect the myriad infection control studies that show no higher risk to the patient if cover gowns are not used," she explains.
• Shoe covers. Although many same-day surgery managers no longer require shoe covers, Guevara points out that this is a policy that can change depending on the situation. "One reason to wear shoe covers is to protect your shoes during surgery. The other reason is to avoid tracking dirt from the outside into the OR," she explains. Since many surgery staff members now keep a pair of "OR" shoes and a pair of outside shoes with them, the need for covers isn’t as great, she says. If someone doesn’t have separate shoes for inside and outside, common sense should determine if covers are needed, she says.
• Event-related expiration date. "We used to pull trays of instruments we had sterilized and wrapped after they had been on the shelf for three or six months and send them back to be sterilized again," Guevara says. "Now, we realize that once it’s sterile, it stays sterile as long as the packaging isn’t damaged." For this reason, it is common to leave trays on the shelf until needed unless the wrapping is damaged, she says.
• Hand scrub. A 10-minute initial surgical hand scrub with three to five minute scrubs between cases is one ritual that is still alive, says Guevara. "Although new scrubs, even some that don’t require brushes, do eliminate the need for lengthy scrubs,2 this is one ritual many OR staff members are reluctant to give up," she says. At Guevara’s facility, staff are given the option of reducing the initial scrub to five minutes with a three-minute scrub between cases. "Although some of the new surgical hand-scrub products are more costly, shorter scrub times are not as hard on the skin," she says. Shorter times help staff avoid various skin conditions such as eczema and rashes that result from constant scrubbing, she adds. (For more information about alternatives for surgical hand scrubs, see Same-Day Surgery, July 2001, "CDC draft recommends alcohol agents as alternatives for surgical scrubs.")
• Knife blade changes. Another ritual that may continue, depending on the surgeon’s preference, is the use of two knife blades, Guevara says. "Most surgeons have always used one knife for the initial incision and another for any other dissection," she says. Some surgeons choose to do so because they believe that making the initial incision dulls the knife’s edge, and they want a sharp blade for the rest of the procedure, she explains. Other surgeons believe the use of two blades is better from an infection control perspective, she adds. "There are data that show that there is no increased risk with the continued use of the first knife because the microbes on the knife are the patient’s own microbes," Guevara says.3 The best course of action for this ritual is to let the surgeon decide, she adds.
References
1. Sacred Cow Survey. OR Manager. September 2000; 16:1-22.
2. Larson EL. APIC guidelines for handwashing and handwashing antisepsis in healthcare settings. Am J Infect Control 1995; 23:251-269.
3. Hill R, Blair S, Neely J, et al. Changing knives a wasteful and unnecessary ritual. Ann R Coll Surg Engl 1985; 67: 149-151.
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