SSI Reduction Idea

[TheFireKeeper]

I am curious about what the community thinks of this idea. The idea came to me while we were talking about how orthopedic surgery has a 1-5% surgical site infection Have we ever used an antiseptic on the second layer of gloves after donning? how do we know that every pair of gloves is truly sterile(as in no failures or mistakes or compromises on the manufacturing and distribution side)? what do you all think of the idea?

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[Smurfette]

I am curious about what the community thinks of this idea. The idea came to me while we were talking about how orthopedic surgery has a 1-5% surgical site infection Have we ever used an antiseptic on the second layer of gloves after donning? how do we know that every pair of gloves is truly sterile(as in no failures or mistakes or compromises on the manufacturing and distribution side)? what do you all think of the idea?

Why do you think the SSIs are from gloves? Why not put antiseptic on all the instruments, implants, gloves, gowns, light handles, etc. too?

 

[wholeheartedly]

I am curious about what the community thinks of this idea. The idea came to me while we were talking about how orthopedic surgery has a 1-5% surgical site infection Have we ever used an antiseptic on the second layer of gloves after donning? how do we know that every pair of gloves is truly sterile(as in no failures or mistakes or compromises on the manufacturing and distribution side)? what do you all think of the idea?

I worked infection control for a few years. SSI can have so many different causes that just blindly targeting something with an intervention without any indication it’s a possible or probable cause just doesn’t make a lot of sense and could actually cause harm in some cases. I’m not aware of anything that suggests gloves are an issue. There are process controls for sterilizing gloves just as for surgical instruments.

Also sometimes the cause is outside the OR or even outside the hospital.

 

[DoctwoB]

You’ll never get bacterial counts to zero. The OR environment is not sterile. The lights, ceiling, etc are shedding bacteria. Sterile processing is not perfect; things like biofilms allow bacteria to survive. Even disposables aren’t always sterile as you allude to.

So we make do with reasonable precautions like scrubbing, gowning, sterilizing, irrigating before closure, etc. But realize that well perfused tissue with a healthy immune system and good DM control will matter a hell of a lot more then how long you scrub or any of the other sterility theater you or I perform.

 

[TheFireKeeper]

Why do you think the SSIs are from gloves? Why not put antiseptic on all the instruments, implants, gloves, gowns, light handles, etc. too?

It is more that I am curious what sort of impact/affect/effect that that variable has on the SSI product of the equation known as the operating OR. There is also the fact that depending upon the procedure and what is going on that it does come into contact with the body meaning that if there was a problem it would cause SSI.

The thinking came to me like this; we scrub our hands because they are not sterile; we wear a pair of gloves because there may still be microbes left; we wear a second layer in case there is a tear; but why not a safety net for the glove itself (due to manufacturing, distribution, and storage flaws) if it is that important for our hands to be sterile. That is what I was thinking.

 

[palmerspoint]

It is more that I am curious what sort of impact/affect/effect that that variable has on the SSI product of the equation known as the operating OR. There is also the fact that depending upon the procedure and what is going on that it does come into contact with the body meaning that if there was a problem it would cause SSI.

The thinking came to me like this; we scrub our hands because they are not sterile; we wear a pair of gloves because there may still be microbes left; we wear a second layer in case there is a tear; but why not a safety net for the glove itself (due to manufacturing, distribution, and storage flaws) if it is that important for our hands to be sterile. That is what I was thinking.

I think you’re misunderstanding why surgeons wear gloves. Not to mention the majority of attendings (and a good deal of residents) don’t double glove

 

[Terrainport]

I may be in the minority but I think our ritual scrubbing is likely not a big factor to begin with. The water coming out of the sink is not sterile. My shoes are never sterile walking to an OR. I think we put a lot of emphasis on antiseptic technique but a lot of it is patient risk factors, some of which are not modifieable.

 

[HighPriest]

just blindly targeting something with an intervention without any indication it’s a possible or probable cause just doesn’t make a lot of sense

….isn’t this how we make most of our Joint Commission/CMS/policy decisions?!?? It seems like it might make sense so let’s mandate it and then hire 10,000 people nationwide to make sure it happens, but never actually check on the outcomes?

 

[HighPriest]

You’ll never get bacterial counts to zero. The OR environment is not sterile. The lights, ceiling, etc are shedding bacteria. Sterile processing is not perfect; things like biofilms allow bacteria to survive. Even disposables aren’t always sterile as you allude to.

So we make do with reasonable precautions like scrubbing, gowning, sterilizing, irrigating before closure, etc. But realize that well perfused tissue with a healthy immune system and good DM control will matter a hell of a lot more then how long you scrub or any of the other sterility theater you or I perform.

Another issue is: it’s one thing to do a series of studies showing that an action decreases SSIs, and that the cost:benefit is worth it. It’s another thing to make a policy because I seems to make sense, and then mandate it.

Infections depend not only upon everything mentioned here, but factors such as the patient’s lifestyle and the type of surgery.

As an ENT guy, I can’t tell you how much I love it any time there’s some new policy that gets implemented because there’s been an increase in SSI in Ortho, and I have to follow it because it’s a blanket policy, but here I am where SSIs in non-oncologic ENT surgery are as close to non-existent as they will ever be (or, alternatively, approaching 100% like in the case of sinus survery where it was infected to begin with.) Nurses who refuse to start a septoplasty case until they’ve prepped the patients face….amazingly, his nose is full of bacteria and that’s where the surgery is actually taking place…

Or when the hospital system has its annual rotation of demanding that we autoclave our NP scopes instead of dipping them despite there being research showing it doesn’t matter, but GI does it that way so we should too. At greater expense, with increasing equipment failure rates and longer turnover times…

…ok, I’m done…

 

[ThoracicGuy]

….isn’t this how we make most of our Joint Commission/CMS/policy decisions?!?? It seems like it might make sense so let’s mandate it and then hire 10,000 people nationwide to make sure it happens, but never actually check on the outcomes?

It's certainly how all the AORN nonsense gets filtered into new OR regulations...

 

[HighPriest]

It's certainly how all the AORN nonsense gets filtered into new OR regulations...

Every single bit of it is nothing but a cry for attention.

 

[dpmd]

Another issue is: it’s one thing to do a series of studies showing that an action decreases SSIs, and that the cost:benefit is worth it. It’s another thing to make a policy because I seems to make sense, and then mandate it.

Infections depend not only upon everything mentioned here, but factors such as the patient’s lifestyle and the type of surgery.

As an ENT guy, I can’t tell you how much I love it any time there’s some new policy that gets implemented because there’s been an increase in SSI in Ortho, and I have to follow it because it’s a blanket policy, but here I am where SSIs in non-oncologic ENT surgery are as close to non-existent as they will ever be (or, alternatively, approaching 100% like in the case of sinus survery where it was infected to begin with.) Nurses who refuse to start a septoplasty case until they’ve prepped the patients face….amazingly, his nose is full of bacteria and that’s where the surgery is actually taking place…

Or when the hospital system has its annual rotation of demanding that we autoclave our NP scopes instead of dipping them despite there being research showing it doesn’t matter, but GI does it that way so we should too. At greater expense, with increasing equipment failure rates and longer turnover times…

…ok, I’m done…

Let me tell you about how they prep for cases where the very first action I take is to stick a finger up the patient's butthole.

 

[HighPriest]

Let me tell you about how they prep for cases where the very first action I take is to stick a finger up the patient's butthole.

I imagine lots of lighting and a low boom mic.

 

[wholeheartedly]

It's certainly how all the AORN nonsense gets filtered into new OR regulations...

As a former infection preventionist trained in clinical lab science with a graduate degree in epidemiology and not a nurse, nothing frustrates me more than nursing research…. they just aren’t trained in properly critically reviewing the literature or conducting research properly. AORN is just…ugh.

One good thing is there are a lot more non nurse folks with epidemiology training entering infection prevention. On the discussion boards there was a decent number of us trying to push back on improper interpretation and use of research studies. I don’t think it’s malicious on their part, it really mostly just seemed like people who wanted to help patients but were pretty clueless about research and a lot of people just get dumped into the role with no training or support and have to figure it out for themselves. A lot just were told x so they continue x. A lot were pretty receptive to education when we pointed out flaws in their thinking.

But yeah, hoping with more epi folks entering the ranks some more of that stuff gets shut down.