Cases & Commentaries

Environmental Safety in the OR

Commentary By Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE

The Case

The infection control department of a hospital
noticed a marked increase in the rates of post-operative sternal
wound infections in surgical patients admitted to the hospital for
coronary artery bypass graft (CABG) surgery. The increased
infection rates were accompanied by increased readmissions and
prolonged lengths of stay. Two patients had to have their sternum
removed because of infection; two others died. One cardiac surgeon
and his team were identified as having higher infection rates than
others, even though they used the same operating room (OR) suites
and facilities.

An infection control practitioner conducted
"environmental rounds" within the OR suite to observe the surgical
team during the entire CABG surgical procedure. She found that the
team was very "sloppy"—members of the team wore loose hair
and jewelry (earrings, necklaces); several also wore regular
sandals into the OR. The infection control practitioner noted also
that several team members did not re-scrub when moving from working
on the saphenous graft in the patient's leg back to the patient's
open chest.

The Commentary

This case involves an outbreak of sternal wound
infections that may be attributable to poor environmental infection
control practices. Deep sternal wound infections occur in less than
1%-2% of sternotomies during non-outbreak periods and are
associated with increased morbidity, mortality, and costs in
patients undergoing cardiac surgery.(1,2) If caused by medical errors, these infections are
considered preventable adverse events
requiring intervention to prevent harm to future patients.

Infection control programs perform surveillance
to benchmark
infection rates against past rates at a single institution or from
other medical centers, such as those available through the National
Nosocomial Infection Surveillance (NNIS) program at the Centers for
Disease Control and Prevention (CDC).(3) Increased rates of infection, as seen in this case,
should trigger an investigation to identify which modifiable
factors are associated with infection. Interventions are then
implemented to decrease the risk of infection in future patients.
In this case, a high rate of sternal wound infections appropriately
catalyzed an investigation by the infection control team.

Root cause
analysis, on the other hand, investigates sentinel
events—serious adverse events that may occur in only a single
patient—to determine what risk factors can be modified to
prevent future patients from suffering similar harm.(4) While infection control surveillance and root cause
analysis both attempt to identify ameliorable factors predisposing
to adverse events, they differ in what triggers an investigation.
The two methods should be considered complementary: surveillance
can detect problems that don't rise to the level of "sentinel
events" in individual patients, and root cause analysis can
identify system-level problems in the delivery of health care.

Attention has recently highlighted the need to
improve the safety of patients undergoing medical care.(5) The
central role of infection control within the broader arena of
patient safety was recently recognized with the recent inclusion of
infection control standards within the National Patient Safety
Goals of the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO).(6,7)
Beginning in 2004, these goals now include adherence to the CDC's
hand hygiene guidelines and surveillance for cases of permanent
loss of function or mortality due to healthcare-associated

The CDC's hand hygiene guidelines emphasize the
critical importance of hand hygiene in the prevention of
healthcare-associated infections.(9) An
inverse relationship has been demonstrated between proper hand
hygiene by health care workers and healthcare-associated infections
in patients. Alcohol-based hand rubs are even more effective in
reducing hand bacterial counts than hand washing with soap and
water, and may promote adherence by reducing the time it takes for
providers to clean their hands.

In this case, multiple breaks in procedure by
operating room personnel were noted. The CDC guidelines recommend
removing jewelry (or, in the case of necklaces, covering with
surgical gowns), covering head and facial hair, using surgical
masks, avoiding long or artificial nails, and covering the
The rationale for most of these recommendations is that the use of
precautions to prevent shedding of bacteria from health care
workers "seems prudent."(10)
Although research supporting these recommendations is limited and
few studies examine patient outcomes, the existing data are
suggestive. Bacteria shed from the skin or hair of surgical staff
have caused outbreaks of surgical site infections (11), and fewer bacteria are shed if a mask and surgical
hat are used.(12)
Rings and artificial nails result in higher levels of persistent
hand colonization with pathogenic bacteria after hand disinfection
compared with unadorned hands (13,14), and artificial nails have been implicated in
outbreaks among postoperative cardiovascular patients.(15)
Shoe coverings have not been shown to prevent surgical site
infections, but are recommended to protect staff from patient body
fluids in accordance with Occupational Safety and Health
Administration Regulations.(10,16)
No available recommendations or studies address rescrubbing when
moving between surgical sites in cardiac operations.

Changing the behavior of health care workers is
challenging. For example, although hand hygiene by health care
workers is known to decrease serious hospital-acquired patient
infections (17),
adherence to this important intervention typically hovers around
This may be due to the many barriers to proper hand hygiene on both
the individual and organizational level, including lack of
accessibility to hand hygiene agents and high workload.(18)

Behavioral theory can be used to explain some of
the difficulties in changing human behavior. The PRECEDE model
suggests that successful behavioral interventions for adults should
include predisposing, enabling, and reinforcing factors. The
acronym PRECEDE stands for "Predisposing, Reinforcing, Enabling,
Causes in, Educational Diagnosis and Evaluation."(20) Changing health care worker behavior—for
instance, improving the infection control practices of operating
room staff—can be framed using this model. First, staff must
believe that restraining loose hair and jewelry will decrease the
risk of surgical site infections (predisposing factors). Next,
barriers such as lack of comfortable head coverings and simple
forgetfulness need to be addressed (enabling factors). Finally,
staff needs to receive positive feedback when their adoption of
infection control interventions leads to lower infection rates
(reinforcing factors).

It may be difficult to effect changes when
definitive studies have not been performed. However, reasonable
arguments based on supportive data in the literature (and optimally
from local experience) may be enough to prompt health care workers
to change behavior. It may be particularly difficult to change
behavior where there is no supporting data, the potential for harm
is perceived as small, or the burden of complying is perceived as
large. Forbidding coffee consumption by physicians in the intensive
care unit may be an example of such situations.

A variety of interventions to improve health care
worker behavior have been tried. Consistent with the PRECEDE model,
multifaceted interventions are the most successful.(21) A reasonable approach for this case may include an
initial session with the operating room teams and the surgery
leadership to provide information about their current infection
rate and data supporting the importance of adequate infection
control practices. This could be followed by unscheduled audits to
check adherence to good infection control practices, and by
feedback on both the improvement in performance as well as any
change in the sternal wound infection rate. Emphasis should be
placed on practices likely to protect both patients and staff: in
this case, adequate hair covering, foot protection, and jewelry
removal. This model may not only be useful for improving infection
control, but, if adapted thoughtfully, might serve as a useful
model for the implementation of other patient safety

Take-Home Points

  • Infection control will
    increasingly be viewed as vital to patient safety.
  • Root
    cause analysis and benchmarking should be considered complementary
  • While definitive
    studies have not been performed for many aspects of surgical
    infection control, data suggest that the currently available
    recommendations will limit surgical site
  • Changing health care worker behavior is a
    challenging endeavor that requires a comprehensive approach for

Darren R. Linkin,
Hospital Epidemiologist, Philadelphia Veterans Administration
Medical Center
Faculty-Fellow, Center for Clinical Epidemiology and
Post-doctoral Fellow, Division of Infectious Diseases
University of Pennsylvania School of

Ebbing Lautenbach, MD,
Assistant Professor of Medicine and Epidemiology, Division of
Infectious Diseases
Associate Hospital Epidemiologist, Hospital of the University of
Senior Scholar, Center for Clinical Epidemiology and
University of Pennsylvania School of Medicine


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