The increasing prevalence rate of multidrug-resistant organisms combined with the increasing complexity of care and the volume of patients seen in a busy perianesthesia unit, and the potential need to utilize perianesthesia units as overflow areas in infectious disease pandemics underscore the importance of having an infection prevention and control program in place.
Patients with a wide range of infectious diseases, some communicable, commonly receive care in the preoperative and postoperative settings. The goal of infection prevention and control is prevention of the transmission of pathogenic microorganisms among patients, staff members, and visitors. A multitude of variables needs to be managed for this prevention, ranging from environment, to equipment, to health care worker behaviors and practices.
The following policies and procedures that are based on published guidelines and recommendations can help to minimize the infectious risks present in a perianesthesia care unit. Education, compliance, monitoring, and quality improvement are essential to the success of the infection control efforts.
antibiotic resistance; bloodborne pathogens; catheter-associated urinary tract infection (CAUTI); central line–associated bloodstream infection (CLABSI); Clostridioides difficile; COVID-19; disinfection; exposure control plan; hand hygiene; health care–acquired infection (HAI); multidrug-resistant organisms; pandemic; personal protective equipment (PPE)
Patients with a wide range of infectious diseases, some communicable, commonly receive care in the preoperative and postanesthesia settings. The goal of infection control is prevention of the transmission of pathogenic microorganisms among patients, staff members, and visitors. A multitude of variables need to be managed, ranging from environment, to equipment, to health care worker behaviors and practices. Education, compliance, monitoring, and quality improvement are essential to the success of the infection control efforts.
Adverse EventsUntoward, undesirable, and usually unanticipated events, such as death of a patient, an employee, or a visitor in a health care organization. Incidents such as patient falls or improper administration of medications are also considered adverse events even if there is no permanent effect on the patient.
Airborne Transmission(Microorganisms that are) carried or transported by the air.
Alcohol-based hand rub (ABHR)A waterless hand sanitizing agent commonly comprising at least 62% ethyl alcohol.
Antibiotic ResistanceThe selective pressure of antimicrobial therapy has resulted in the evolution of bacteria that are resistant to certain antibiotics. The resistance patterns are affected by patterns of antibiotic use, the prevalence of specific microorganisms, the mechanisms of resistance in these organisms, resistance transfer from one organism to another, and the patient population. The risk of having antibiotic-resistant microorganisms is higher among sicker and debilitated patients and in settings of high antimicrobial use and invasive technology (e.g., intensive care unit [ICU]). Infections from antibiotic-resistant organisms are difficult to treat and are often associated with high morbidity rates. These microbes can be spread from patient to patient through transient hand carriage and environmental contamination.
Antimicrobial ProphylaxisAntibiotics that are given before the surgical incision for prevention of a surgical wound infection.
Artificial NailsNails with products affixed to them, such as gel, tips, jewelry, overlays, and wraps.
Barrier PrecautionsThe use of garb (e.g., masks, hair coverings, gowns, gloves) for protection of either the health care worker or the patient.
Bloodborne PathogensPathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
Catheter-Associated Urinary Tract Infection (CAUTI)An infection in the urinary tract caused by either bacteria or fungi that develops in a patient with an indwelling urinary drainage device.
Indwelling Urinary Drainage DeviceIncludes a drainage tube connected to a collection bag that is inserted into the bladder through the urethra. Commonly referred to as a Foley catheter, named after Dr. Frederick E.B. Foley who invented the medical device in 1927.
Central Line–Associated Bloodstream Infection (CLABSI)Bacteremia or fungemia that develops in a patient with an intravascular central venous catheter.
Central Venous CatheterA vascular access device that terminates at or close to the heart or one of the great vessels. An umbilical artery or vein catheter is considered a central line.
Chlorhexidine Gluconate (CHG)An antibacterial agent that is effective against a wide variety of gram-negative and gram-positive organisms and used as a topical antiinfective agent for the skin and mucous membranes.
Clostridioides difficile:A spore-forming bacterium that causes diarrhea and more serious intestinal conditions such as colitis. It is found in the normal gastrointestinal flora in about 3% of healthy adults and in 10% to 30% or more of hospitalized patients. Antibiotic use, even a short course given for prophylaxis or treatment of infections, often changes the normal gastrointestinal flora, which can lead to C. difficile overgrowth and toxin production. C. difficile is spread primarily via the hands of health care personnel who have touched a contaminated surface or item and via direct contact with a contaminated item. C. difficile spores can live for extended periods of time in the environment and are resistant to most hospital disinfectants.
ColonizationMicroorganisms that have become established in a habitat in a host but do not cause disease (infection) in this habitat.
Contact (Direct or Indirect)(Microorganisms that are) spread from contaminated hands or objects.
Contact DermatitisInflammation of the skin that results from direct exposure to an irritant.
Contaminated SharpsAny contaminated object that can penetrate the skin, such as needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.
COVID-19The disease state caused by the novel coronavirus that emerged from Wuhan, China, in December 2019. CO = corona; VI = virus; D = disease.
Cross TransmissionHorizontal transmission of an organism in the health care setting; patient to patient.
DisinfectionTo render free from contamination, especially with destruction of harmful microorganisms (e.g., bacteria, virus, and fungus).
Droplet Transmission(Microorganisms that are) carried on airborne droplets of saliva or sputum. In general they can travel from 0 to 6 feet.
EbolaA filovirus that is one of the viral hemorrhagic fever viruses. Named after the Ebola River in 1976 where it was first discovered. Historically this virus caused isolated outbreaks in Africa but with increased travel and mobility resulted in a worldwide crisis in 2014–15. Transmission is through direct contact with blood or body fluids from someone who is showing symptoms of infection.
EpidemiologyA branch of medical science that deals with the incidence, distribution, and control of disease in a population. Common variables to evaluate are person, place, and time linkages.
Exposure Control PlanA formal document as defined by the Occupational Safety and Health Administration (OSHA) Regulations (Standards, 29 CFR) Bloodborne Pathogens 1910.1030; to exist in any institution with occupational exposure. The document is designed to outline the steps necessary to eliminate or minimize employee exposure to bloodborne pathogens such as HIV, HBV, and HCV.
Extended-Spectrum Beta-Lactamases (ESBLs)Beta-lactamase is a type of enzyme responsible for bacterial resistance to beta-lactam antibiotics; among these are penicillin, cephalosporins, carbapenems, and others. In the mid-1980s, new types of beta-lactamase were produced by Klebsiella spp. and Escherichia coli that could hydrolyze the extended-spectrum cephalosporins; these are collectively termed the extended-spectrum beta-lactamases.
Fecal-OralMicroorganisms that are spread through ingestion of contaminated feces.
Health Care–Associated Infection (HAI)An infection that is acquired or occurring in the health care setting.
HypothermiaSubnormal temperature of the body, defined as temperature less than 36°C.
ImmunocompromisedImpairment or weakening of the immune system.
Medical Waste/Regulated WasteLiquid or semiliquid blood or other potentially infectious materials; contaminated items that release blood or other potentially infectious materials in a liquid or semiliquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathologic and microbiologic wastes that contain blood or other potentially infectious materials.
Methicillin-Sensitive Staphylococcus aureus (MSSA)A strain of the bacteria S. aureus that is sensitive to the common antibiotic used to treat this infection, methicillin (or oxacillin).
Microbial Colony CountsEnumeration via direct count of viable isolated bacterial or fungal cells or spores capable of growth on solid culture media. Each colony (i.e., microbial colony-forming unit) represents the progeny of a single cell in the original inoculum. The method is used routinely by environmental microbiologists for quantification of organisms in air, food, and water; by clinicians for measurement of patient microbial load; and in antimicrobial drug testing.
Moist Body SubstancesAll body fluids, including blood, body cavity fluids, breast milk, urine, feces, wound or other skin drainage, respiratory and oral secretions, mucous membranes.
Mucous MembranesMucous membranes line cavities or canals of the body that open to the outside, including the eyes, ears, mouth, nose, and genitals.
Multidrug-Resistant Organisms (MDROs)Microorganisms that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent (e.g., methicillin-resistant S. aureus [MRSA], vancomycin-resistant Enterococcus [VRE]), these pathogens are frequently resistant to most available antimicrobial agents. In addition to MRSA and VRE, certain gram-negative bacteria, including those that produce ESBLs and carbapenem-resistant Enterobacteriaceae (CRE) are of particular concern.
N95 RespiratorAn air-purifying filtering facepiece respirator that is more than 95% efficient at removing 0.3-μm particles and is not resistant to oil. The person wearing an N95 respirator must be properly fit, tested, and trained.
Negative-Pressure Isolation RoomsThe difference in air pressure between two areas. A room that is under negative pressure has a lower pressure than adjacent areas, which keeps air from flowing out of the room and into adjacent rooms or areas. May also be referred to as airborne infection isolation room (AIIR).
NormothermiaNormal body temperature (i.e., 36°C to 38°C).
One-Handed “Scoop” TechniqueA method of capping a needle if deemed necessary to do so. The needle cap is set on a stable surface and not touched. The needled device then is placed inside the cap with one hand. The cap is then secured into place with the other hand.
PandemicThe emergence of a novel (new) pathogen that causes a worldwide outbreak.
Parenteral ExposurePiercing of mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.
Pathogenic MicroorganismsAn organism of microscopic or ultramicroscopic size that is capable of causing an infectious disease.
Personal Protective Equipment (PPE)Specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts, blouses) not intended to function as protection against a hazard are not considered to be PPE.
Severe Acute Respiratory Syndrome Coronavirus, strain 2: (SARS-CoV-2).The novel coronavirus that emerged in 2019 and causes the infection COVID-19.
Seroconversion RiskThe likelihood of conversion from negative virus status to positive virus status.
Special PathogenDescribes a potentially new infectious agent that is not routinely seen in the health care setting that can be part of a bioterrorism event or a large-scale outbreak. May require special environmental and infection control prevention practices and policies to contain and prevent the spread.
Surge PlanA document that will outline a facilities response plan and the designated locations for patient admissions as part of the larger emergency, pandemic, or disaster plan.
SusceptibleLittle if any antimicrobial resistance to a specific infectious disease.
Transient ContaminationA microorganism that exists temporarily on the hands of a health care worker and is not part of the normal flora of the skin.
Vancomycin-Resistant Enterococcus (VRE)A strain of Enterococcus species that lives in the intestines and sometimes the urinary tract of all people. This strain is resistant to the antibiotic vancomycin. VRE is acquired via direct contact (touching) with objects or surfaces that are contaminated with VRE. VRE is not spread through the air. People at risk for VRE infection are those who have chronic illnesses, have undergone recent surgery, have weakened immune systems, or have recently taken certain antibiotics.
VectorMicroorganisms that are spread through insects.
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. It should be noted that the risk is not zero, though, and that transmission of infection can occur if the equipment is soiled or contaminated. Examples of these items are glucometers, 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). Soft surfaces and fabrics can become contaminated as well, such as cubicle curtains and furniture. Depending on the item and the nature of the contamination, simple surface cleaning and disinfection is all that is necessary to ensure safety between uses of solid surfaces. 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 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 as per the OSHA Bloodborne Pathogens Standard.1 There have been outbreaks of bloodborne pathogens (e.g., HBV) linked to contaminated glucometers going patient-to-patient with inadequate disinfection. All manufacturer’s instructions, or “IFUs” (instructions for use) should be reviewed before purchasing a new piece of equipment or whenever changing hospital disinfectant products, to ensure consistency in practice with what the manufacturer recommends. Failing to do so may result in the voiding of the manufacturer’s warranty as well as causing damage or harm to the equipment itself.
The risk of actual disease transmission from soiled linen is negligible, although laundry, including cubicle curtains, 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. Cubicle curtains should be inspected on a routine basis and changed immediately if visibly contaminated before placement of a new patient in the bay. A schedule should be established for routine laundering of cubicle curtains. There are many new fabrics on the market with claims of bacterial growth resistance or inhibition properties. All product claims, efficacy, and outcomes data should be carefully reviewed on these items before decisions to purchase are made.
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.
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.
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 Best practice is for sinks to be easily accessible and, if behind a door, there should be hands-free access to enter the area.
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).
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.
The benefits of hand hygiene in a hospital setting were first recognized by Ignaz Semmelweis in 1847 after he noted a difference in the outcomes of the women who were dying from puerperal fever in one of the obstetric clinics depending on who delivered their babies—the midwifes or the physicians. The physicians were noted to move between the autopsy room and the delivery unit, whereas the midwives stayed in the delivery unit. Semmelweis immediately proposed a connection between cadaveric contamination and puerperal fever and he concluded that the physicians were carrying the contamination on their hands. 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. If hands are not visibly soiled, an ABHR can be used. ABHRs 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 ICUs or in transplant units).
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 multi-use 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 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.
The most common 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 C. difficile or 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.
Facilities should select PPE based on the exposure or contamination risks, as well as the fit, design, availability, and quality of the product. Compliance with PPE can be increased if the HCW finds the fit to be comfortable and not intrusive to their work. Cost should never be the only driving factor in selection of a product. Training on how to don (put on) and doff (take off) the equipment is essential to minimize the risk of contamination and spread of infection. Employees should be provided written information as well as be offered the opportunity to practice properly donning and doffing the equipment until they are considered competent. Posters and checklists are helpful tools to increase competency.
Standard Precautions synthesize the major features of Universal Precautions (Blood and Body Fluid Precaution, designed to reduce the risk of transmission of bloodborne pathogens) and body substance isolation (designed to reduce the risk of transmission of pathogens from moist body substances) and apply to all patients who receive care in hospitals, regardless of diagnosis or presumed infection status. Standard Precautions apply to: (1) blood; (2) all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; (3) nonintact skin; and (4) mucous membranes. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.19
In addition to the aforementioned use of hand hygiene and PPE, Standard Precautions also encompass the management of patient care equipment. They stipulate that used patient care equipment that is soiled with blood, body fluids, secretions, and excretions should be managed in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Reusable equipment should be cleaned and reprocessed appropriately before use for the care of another patient, and single-use items (or items labeled as disposable) should not be reprocessed and reused and should be discarded properly.
Standard Precautions also encompass the practices of environmental control (e.g., that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces) and ensure that these procedures are followed. Last, Standard Precautions reiterate the importance of the Occupational Health and Bloodborne Pathogens Rule and proper patient placement for prevention of transmission of disease, both of which are discussed later in this chapter.
Respiratory Hygiene/Cough Etiquette is an infection control component of the CDC Standard Precautions in care of patients. The protocol is optimized by giving patients tissues and instructions to cover their mouth and nose when coughing or sneezing and disposing of tissues in the trash. Hand washing must be reinforced with accessible hand washing facilities or ABHR. Patients with a persistent cough are to be given a surgical mask while in a waiting room or other common areas and instructed to ask for a new mask if their old mask becomes soiled or moistened. Respiratory Etiquette signage is a Joint Commission requirement for outpatient/ambulatory centers within hospital institutions, but is encouraged to be used in all settings, especially during flu season.
The chain of infection is a concept that shows the essential requirements for the perpetuation of a disease-causing microorganism (Fig. 5.1). All infectious diseases are caused by a microorganism (e.g., bacteria, virus, mold, fungi, parasite). For survival, each microorganism sustains itself in a source. The source may be a living host, such as a human or animal, or a nonliving source, such as biohazardous waste or a laboratory specimen. To cause disease, the microorganism must have a portal of exit from the source (e.g., respiratory tract, spill) and a method of spread. The six main methods of spread for infectious diseases include airborne, droplet, contact (direct or indirect), bloodborne, vector, and fecal-oral. With its unique method of spread, an organism must find a way to enter its next host. The entry point may be the same as the exit from the source of the infection (such as respiratory route to respiratory route or blood to blood), or it may be different (such as fecal exit to oral entry). The last component to the chain of infection is the susceptible person. A person may be more susceptible because of underlying illness, such as immunocompromise from chemotherapy or AIDS, or because of the risks of an open incision or invasive procedure. Likewise, a person may be less susceptible to the infection as a result of history of vaccination or natural immunity from past exposure or disease.