Leadership Learning Experience: Reinforcing Asepsis in the OR

Leadership Learning Experience: Reinforcing Asepsis in the OR

Identification and Explanation of the Problem/Issue

One of the primary goals of the surgical team is to prevent surgical site infections in the operating room(OR). As such, there are many activities put in place to support this goal which includes sterilization and disinfection of instruments, antibiotic prophylaxis and environmental cleaning. Still, the operating roomactivities that involve aseptic practices plays the greatest role in helping the surgical team decrease the risk of surgical site infections. The main goal of asepsis is in preventing the contamination of the operative site and this is accomplished by maintaining a sterile field designed to prevent microorganisms from entering Leadership Learning Experience: Reinforcing Asepsis in the OR.

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Evidence-based practice supported by a wide body of research suggests that aseptic technique is successful at preventing infections in the operating room (Beldi, Bisch-Knaden, Banz, Mühlemann & Candinas, 2009; Adams, Korniewicz & El-Masri, 2011; Labrague, Arteche, Yboa& Pacolor, 2012), yet compliance with this preemptive measure has demonstrated opportunities for improvement within my organization.This is an important issue in healthcare as breaks in sterile technique is a significant contributing factor in surgical site infections which are the second most common hospital-acquired infection (HAI) in hospitalized patients(Safe Care Campaign, 2014). This often result in an increase in patient mortality, length of stay and readmission rates. What’s more is that it has been estimated that roughly 40% to 60% of these infections are preventable(Safe Care Campaign, 2014).In addition, according to the Centers for Disease Control and Prevention (2009), the cost associated with surgical site infections are astronomical and ranges from $28 billion to $45 billion annually Leadership Learning Experience: Reinforcing Asepsis in the OR.

The problem identified within my organization is related to the practice of aseptic technique in the operation room. A trend was noted in the readmission rates in patients who underwent various orthopedic surgeries. For example, the Clinical Documentation Specialists within the Quality Improvement department conducted a 6-monthretrospective review of the readmissions relating to surgical procedures and found a significant increase in the number of readmissions linked to surgical site infections. More specifically, a 2.5% increase over the course of this 6-month period was noted. Leadership Learning Experience: Reinforcing Asepsis in the OR  As an RN working in the operating room, this is an issue that requires an intervention as it is a threat to patient safety.

Analysis of the Situation

In analyzing areas that might be contributing to the problem, a survey of the operating room personnel revealed that many of the staff reported a common factor that contributed to breaks in sterile technique:the fast-paced nature of the OR. In addition, direct observations during invasive procedures (catheter insertions, intubations etc) performed after the trend was noted revealed in many instances, gloves took the place of hand disinfection and were often used for a number of tasks. The use of gloves in an unsystematic manner increases the risk of HAIs Leadership Learning Experience: Reinforcing Asepsis in the OR. In addition, a total of 30 missed opportunities for aseptic technique in a 1-hour period was also noted based on observation. A deeper analysis of the data revealed that breaks in sterile techniques fell into one of four categories. These included category 1 which consisted of breaks in asepsis that were immediately noticed; category 2 consisted of breaks in asepsis that are realized shortly after the occurrence; category 3 comprised of breaks that were later realized and category 4 consisted of breaks that went unnoticed.

Proposing a Solution

Given that there are recommended standards, practices and guidelines created by organizations such as the Association of periOperative Registered Nurses (AORN) to be utilized by surgical teams to achieve aseptic practice in the perioperative setting, a careful review of these protocols and subsequent inclusion into a plan of correction was implemented. Since the principles of aseptic technique plays a vital role in the goal of asepsis in the OR, it is essentially the responsibility of all staff members to mindfully incorporate these principles into their practice. As such, operating room personnel (i.e. nurses, scrub techs, surgeons, anesthesiologists, etc) will be required to attend a two-day educational in-service “Beat the Bugs: Infection Control Fair” that places emphasis on the importance of creating and maintaining asepsis technique as well as plans of action to implement when a break in sterile technique is noted. Day one of the in-service will focus on games and simulated scenarios that that involve breaks in asepsis and interventions that can be implemented to ameliorate the situation. These scenarios will be designed to help staff draw upon their critical thinking skills. Leadership Learning Experience: Reinforcing Asepsis in the OR. Day 2 will consist of reviewing the principles of asepsis where the following five AORN principles will be discussed:

The sterile field consists of only scrubbed personnel: Although the surgical team consists of sterile and non-sterile individuals, only individuals who are scrubbed or sterile should be directly located in the sterile field. In contrast, non-sterile members remain outside the periphery of the sterile field. More so, all sterile members must don scrub attire inclusive of surgical mask, gown and gloves. In addition, prior to donning gloves and surgical gown, the sterile staff must perform surgical hand scrub and thereafter recognize that boundaries of the sterile area (Association of periOperative Registered Nurses [AORN], 2017) Leadership Learning Experience: Reinforcing Asepsis in the OR.

Sterile field is created using sterile drapes: The use of sterile drapes establishes a barrier to decrease the passage of microorganisms into the sterile field. As such, drapes should cover the patient and any equipment and furniture that are a part of the sterile field with the site of incision left exposed. Once drapes have been placed, it should not be moved and only the top surface is considered sterile(AORN, 2017).

The sterile field should only contain sterile items: It is evident that sterilization ensures that all instruments are without microorganisms, however, fluid and air can contaminate the sterile field. As such, sterile and non-sterile items should never occupy the same space and if a container or package has been compromised, it should be thought of a contaminated and replaced(AORN, 2017).

Sterility should be maintained when items are opened and added to the sterile field:In an attempt to preserve the integrity of the items and sterile field, the circulating nurse should use caution when placing items on the sterile field by securely handing them off to the scrubbed member or by placing them securely on the sterile field.When opening the sterile package, the non-sterile person must present the item to the sterile person in such a way to prevent contamination. In the same breadth, when opening a sterile solution only the top rim of the bottle and the contents of the bottle are considered sterile once the cover has been removed(AORN, 2017).

Sterile field must be maintained: Maintaining sterility is one of the OR staffs’ main responsibilities by making every effort to reduce the possibility of contamination. As such, when a breach in sterility occurs, it is of the utmost importance to take actions that will serve to reduce the risk of contamination. If there is ever a doubt about whether an item is sterile, it is best to consider it contaminated and replace it(AORN, 2017).

Recommendation of Sources and Timeline for Implementation

Resources will include incorporating and reinforcing policies created to assist OR staff to promote patient safety by being compliant with asepsis. These resources will draw upon the AORN, the Institute for Hospital Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ) as well as Joint Commission standards. In terms of a cost-benefits analysis, the 2-day in-service can be carried out without the assistance of a third-party vendor/ facilitator as the infection control nurse within the Quality Management department has the expertise to oversee this event. Leadership Learning Experience: Reinforcing Asepsis in the OR. As a result, the organization can expect this event to be fairly inexpensive while still providing a well-organized infection control fair. In terms of a timeline, planning for the event is expected to be a 1 week while the fair itself will last over the course of 2 days.

Identification of Key Stakeholders

The success of the “Beat the Bugs: Infection Control Fair” and educational in-service will depend largely, in part, on the attendance of the operating room staff. As such, the Chief Medical Officer (CMO), Chief Nursing Officer (CNO), NurseManager of the OR, and OR supervisor are crucial key players that are needed to obtain “buy-in” from the OR staff. The CMO and CNO are leadership positions, that oversee the physicians and nursing staff, respectively. As a result, they are influential and will play a key role in not only gaining support from key operating room personnel but driving home the importance of this event in relation to promoting patient safety. A meeting with both the CMO and CNO revealed enthusiasm and a dedication to getting this initiative underway. Both individuals noted a steadfast commitment to this project and a desire to move the practices of the operating room in the right direction to become more aligned with the patient safety goals noted in the mission and vision of the organization as well as the National Patient Safety Goals established by the Joint Commission.In fact, both parties, suggested that perhaps this initiative can be conducted on an annual basis. The involvement of the infection control nurse is another key stakeholder that cannot be overlooked due to the expertise in which a person in this position possesses Leadership Learning Experience: Reinforcing Asepsis in the OR. Still perhaps, two of the more important players are that of the OR Nurse Manager and Supervisor as they are considered the middle managers with a direct relationship and sphere of influence with the nurses and scrub techs.

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In terms of achieving success, communication is the foundation of any successful partnership or project particularly one that is comprised of a multidisciplinary team such as this one. As such, it is important keep the communication channels open. This can be done through encouraging the key stakeholders to continue to provide input as it relates to their respective roles, encouraging all members to report any concerns as well as continuously reinforce the purpose and goals of this initiative Leadership Learning Experience: Reinforcing Asepsis in the OR.

Discussion of Implementation and Evaluation of the Solution

As previously noted, a 2 day “Beat the Bugs: Infection Control Fair and Educational In-service” will be carried out that places emphasis on the importance of creating and maintaining asepsis technique as well as actionplans to implement when a break in sterile technique is noted. Day one of the in-service will focus on games and simulated scenarios that that involve breaks in asepsis technique and interventions that can be implemented to ameliorate the situation. These scenarios will be designed to help staff hone in on their critical thinking skills. Day 2 will consist of reviewing the principles of asepsis Leadership Learning Experience: Reinforcing Asepsis in the OR. Evaluation of this solution can be carried out using several techniques. First, with my assistance, the infection control nurse can conduct unannounced observance of the operating room personnel. This observation would determine how well the surgical team adheres to the principles of asepsis. Second, the readmissions related to surgical site infections can be monitored over a period of 3 to 6 months after the staff participated and were re-educated in the principles of asepsis. Ideally, the goal is to show a decrease in the number and rate of surgical site infections that were related to breaks in asepsis. These results can be reported on a monthly basis at the Quality Improvement meeting.

 

Explanation of Roles

The role of scientist was fulfilled by gathering and analyzing the data regarding the readmissions that were linked to surgical site infections.  The increasing trend in the rate of surgical site infections and its association with the breaks in asepsis techniques presented as scientific evidence that served as a barrier to providing safe and quality care for patients. In the same breadth, the role of detective was carried out upon surveying the staff to determine what they perceived as reasons for the breaks in sterile technique Leadership Learning Experience: Reinforcing Asepsis in the OR. As such, a common thread among their responses revealed that the fast-paced nature of the OR to be challenging. Where manager of the healing environment is concerned, the solution consisted of the 2-day infection control fair. This was an appropriate intervention that was not only creative and flexible but considered the contribution of multiple stakeholders with the primary goal of reinforcing patient safety in mind.

 

References

Adams, J. S., Korniewicz, D. M., & El-Masri, M. M. (2011). A descriptive study exploring the principles of asepsis techniques among perioperative personnel during surgery. Canadian Operating Room Nursing Journal, 29(4), 6-8.

Association of periOperative Registered Nurses. (2017). Aseptic technique. Retrieved January 20th, 2017 from https://www.aorn.org/guidelines/guideline-implementation-topics/aseptic-technique

Beldi, G., Bisch-Knaden, S., Banz, V., Mühlemann, K., & Candinas, D. (2009). Impact of intraoperative behavior on surgical site infections. The American Journal of Surgery, 198(2), 157-162.

Centers for Disease Control and Prevention. (2009). Direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved January 20th, 2017 fromhttp://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf. Leadership Learning Experience: Reinforcing Asepsis in the OR

Labrague, L. J., Arteche, D. L., Yboa, B. C., & Pacolor, N. F. (2012). Operating room nurses’ knowledge and practice of sterile technique. Journal of Nursing Care, 1(4).

Safe Care Campaign. (2014). Preventing health care and community associated infections. Retrieved January 20th, 2017 from http://www.safecare campaign.org/ssi.html. Leadership Learning Experience: Reinforcing Asepsis in the OR

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