Environment

A safe and clean environment is essential for a reduction in the risk of transmission of microorganisms. Most equipment in a perianesthesia unit that comes into contact with patients is considered to have a low risk of infection transmission, most notably if the equipment is noninvasive and contacts only intact skin. Examples of these items are electrodes, stethoscopes, pulse oximeter devices, blood pressure cuffs, the outside surfaces of equipment (e.g., ventilators, intravenous pumps), and larger surfaces (e.g., tables, wheelchairs, bedside stands, floors, walls). Depending on the item and the nature of the contamination, simple surface cleaning is all that is necessary to ensure safety between uses. Many hospital-grade disinfectants are combined with a cleaning component so that both cleaning and disinfection can be achieved in one step. Disinfection wipes are an appropriate option as well because of their active ingredient. If visible blood or body fluid is present, then a hospital-grade disinfectant approved by the Environmental Protection Agency (e.g., a quaternary ammonium compound, 70% isopropyl, properly diluted bleach, or phenolic) is required per the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard.¹

Laundry

The risk of actual disease transmission from soiled linen is negligible, although laundry can harbor large numbers of pathogenic microorganisms. Simple hygienic practices for the processing and storage of linens are recommended for a reduction in the likelihood of transmitting infectious diseases.

Soiled linens should be handled as little as possible and with minimal agitation for prevention of gross microbial contamination of the air and of persons who handle the linens. All soiled linens should be bagged or placed in containers in the care unit; they should never be sorted or rinsed in the location of use. Linens heavily contaminated with blood or other body fluids should be bagged and transported in a manner that prevents leakage.

Commercial laundry facilities often use water temperatures of at least 160° F (71° C) and 50 to 150 ppm of chlorine bleach for removal of significant quantities of microorganisms from grossly contaminated linens. Commercial dry cleaning of fabrics soiled with blood also renders these items free of the risk of pathogen transmission. Last, clean linen should be handled, transported, and stored by methods that ensure its cleanliness.

Furnishings and equipment

All furnishings in a perianesthesia environment should be evaluated before purchase and assessed for the ability to resist staining and tearing. Furnishing and medical equipment ease of cleaning and ability to withstand harsh disinfections, including 10% diluted bleach, should also be considered. Ease of disassembly for the purposes of cleaning and disinfection should be reviewed. Absorbent upholstery should be avoided if the likelihood of contamination is present. Torn mattress pads and seating should be repaired or replaced promptly for prevention of contamination. All manufacturers’ instructions for cleaning and disinfection should be obtained, and the appropriate personnel responsible for this task should be trained initially and regularly thereafter.

Sinks

The number and accessibility of sinks in the perianesthesia care unit is important for increased compliance with hand washing. The Guidelines for Design and Construction of Hospital and Health Care Facilities, published and updated periodically by the American Institute of Architects (AIA), should be referenced for current sink allotment recommendations. The guidelines are conceived as minimal construction requirements for hospitals, and the document includes engineering systems, infection control, and safety and architectural guidelines for design and construction. The Joint Commission states that the AIA guidelines should be used during new construction. The current AIA guidelines recommend at least one hand washing station with hands-free or wrist blade–operable controls for every four beds in a postanesthesia care unit (PACU).²

Bays and isolation rooms

Appropriate space allotment and other design features for patient bays and rooms during new construction and renovation can be obtained from the AIA guidelines reference. Additional local and state stipulations may apply. Provisions should be available for the isolation of infectious patients, but an airborne (respiratory) infection isolation room is not required in a preoperative or postanesthesia care unit. However, each individual setting needs to conduct an infection control risk assessment for the need for an isolation room based on the epidemiology of airborne diseases (e.g., frequency of tuberculosis in the community, medically or surgically treated in the institution).

Traffic flow

The movement of staff members, patients, visitors, and equipment in the preoperative and PACU setting is an important consideration in the design or renovation of space. Areas in which invasive procedures (e.g., central line insertions) take place should be away from main traffic areas, entrances, and exits to reduce the likelihood of contamination.

Handwashing

The benefits of hand hygiene in a hospital setting were first recognized by Ignaz Semmelweis in 1847 after the death of his friend from an infection that he contracted after his finger was accidentally punctured with a knife during a postmortem examination. The friend’s autopsy showed a pathologic situation similar to that of the women who were dying from puerperal fever in one of the obstetric clinics. Semmelweis immediately proposed a connection between cadaveric contamination and puerperal fever and made a detailed study of the mortality statistics of the obstetric clinic attended by physicians who also performed autopsies with the statistics of the midwives’ clinics. The midwives did not participate in autopsies. He concluded that he and the students carried the infecting particles on their hands from the autopsy room to the patients they examined in the clinical setting. Semmelweis concluded that some unknown “cadaveric material” caused childbed fever. He instituted a policy requiring use of a solution of chlorinated lime for washing hands between autopsy work and the examination of patients and the mortality rate dropped from 12.24% to 2.38%, comparable to the midwives’ clinics’ rates.³

To this day, hand hygiene remains of paramount importance for preventing the spread of disease-causing germs in the perianesthesia setting. Hands should be washed with soap and water for at least 15 to 20 seconds with a hospital-approved liquid or foam soap (bar soap should be avoided). If hands are not visibly soiled, an alcohol-based hand rub can be used. Alcohol-based hand rubs significantly reduce the number of microorganisms on the skin, are fast acting, and cause less skin irritation.⁴ They should not be used if the hands are visibly contaminated with blood, body fluids, or soiling. Hand hygiene should be minimally performed before and after patient care, after handling of soiled equipment or linen, after removal of gloves, after use of the restroom, before and after eating, or whenever hands are soiled. Health care personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections (e.g., patients in intensive care units or in transplant units).

Adherence to hand hygiene practices has been studied in observational studies of health care workers (HCWs). Compliance rates to follow recommended hand hygiene procedures have been poor, with mean baseline rates of 5% to 81% (overall average, 40%). Perceived barriers to adherence with hand hygiene include skin irritation, inaccessible hand-hygiene supplies, interference with HCW-patient relationships, priority of care (i.e., the patient’s needs are given priority over hand hygiene), wearing of gloves, forgetfulness, lack of knowledge of hand hygiene policy, insufficient time for hand hygiene, high workload and understaffing, and the lack of scientific information or education indicating a definite effect of improved hand hygiene on health care–associated infection rates.^5–11

Frequent and repeated use of hand hygiene products, particularly soaps and other detergents, is a primary cause of chronic irritant contact dermatitis among HCWs.¹² To minimize this condition, HCWs should use hospital-approved hand lotion frequently and regularly on their hands. Small personal-use containers or multiuse pumps that are smaller than 16 ounces (and not refilled) should be used. Lotions that contain petroleum or other oil emollients can affect the integrity of latex gloves; therefore compatibility between the lotion and its possible effects on gloves should be considered at the time of product selection.¹ Last, certain moisturizing products and surfactants have been shown to interfere with the residual activity of chlorhexidine gluconate (CHG), a skin antiseptic in liquid soap. Compatibility between a lotion and its possible effects on the efficacy of certain antiseptic soaps should be considered at the time of product selection.

Personal protective equipment

The most common personal protective equipment (PPE) used by HCWs is gloves. The Centers for Disease Control and Prevention (CDC) has recommended that HCWs wear gloves to: (1) reduce the risk of personnel acquiring infections from patients; (2) prevent HCW flora from being transmitted to patients; and (3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another.¹³ OSHA mandates that gloves be worn during all patient care activities that may involve exposure to blood or body fluids that may be contaminated with blood.¹ They should also be worn for direct contact with mucous membranes, nonintact skin, open wounds, or items potentially contaminated with moist body substances. Gloves should also be worn in vascular access procedures. The effectiveness of gloves in prevention of contamination of the hands of HCWs has been confirmed in several clinical studies. Two of these studies, which involved personnel caring for patients with Clostridium difficile or vancomycin-resistant Enterococcus (VRE), revealed that wearing gloves prevented hand contamination among most personnel who had direct contact with patients.^14–16 Wearing of gloves also prevented personnel from acquiring VRE on their hands when touching contaminated environmental surfaces.¹⁶ Prevention of heavy contamination of the hands is considered important because hand washing or hand antisepsis might not remove all potential pathogens when hands are heavily contaminated.^17,18

Additional forms of PPE include fluid-resistant gowns, aprons, or other protective clothing. This PPE should be worn to protect clothing and all areas of exposed skin when contact with moist body substances is reasonably anticipated. Gowns shall be used once and discarded after use. Face protection, such as masks and protective eyewear (goggles or glasses with side shields), should be worn to prevent contact of blood or other moist body substances with the mucous membranes of the nose and mouth, which can occur when moist body substances are splashed, sprayed, or splattered. Face shields can be worn in place of protective eyewear and masks.