Eliminating sternal wound infections: Why every cardiac surgery program needs an I hate infections team.

Objectives: The majority of studies examining deep sternal wound infection (DSWI) prevention focus on ameliorating 1 variable at a time. There is a paucity of data regarding the synergistic effects of combining clinical and environmental interventions. This article describes an interdisciplinary, multimodal approach to eliminate DSWIs at a large community hospital. Methods: We developed a robust, multidisciplinary infection prevention team to evaluate and act in all phases of perioperative care to achieve a cardiac surgery DSWI rate of 0, named: the I hate infections team. The team identified opportunities for improved care and best practices and implemented changes on an ongoing basis. Results: Patient-related interventions consisted of preoperative methicillin-resistant Staphylococcus aureus identification, individualized perioperative antibiotics, antimicrobial dosing strategies, and maintenance of normothermia. Operative-related interventions involved glycemic control, sternal adhesives, medications and hemostasis, rigid sternal fixation for high-risk patients, chlorhexidine gluconate dressings over invasive lines, and use of disposable health care equipment. Environment-related interventions included optimizing operating room ventilation and terminal cleaning, reducing airborne particle counts, and decreasing foot traffic. Together, these interventions reduced the DSWI incidence from 1.6% preintervention to 0% for 12 consecutive months after full bundle implementation. Conclusions: A multidisciplinary team focused on eliminating DSWI identified known risk factors and implemented evidence-based interventions in each phase of care to ameliorate risk. Although the influence of each individual intervention on DSWI remains unknown, use of the bundled infection prevention approach reduced the incidence to 0 for the first 12 months after implementation.

OR Traffic and Surgical Site Infections: A Quality Improvement Project.

Operating rooms are dynamic places with a lot of movement and people working as a concerted team. Operating room traffic can be necessary (eg, retrieving an unusual supply) or unnecessary (eg, a social visit). This quality improvement project aimed to reduce the amount of OR traffic to only necessary traffic and reduce the surgical site infection rates for the orthopedic ORs in a northern California community hospital. There were three principle interventions: door signs discouraging traffic, staff member relief in batches, and preference card review for accuracy. During the six-week post-intervention period, there were no reported surgical site infections for orthopedic procedures, and the standardized infection ratio decreased from 1.75 to 0 in 10 weeks. Operating room traffic decreased after implementation by 46.9%. The number of door openings per minute decreased from 1.96 per minute to 1.04 per minute at the project's conclusion. Staff members' awareness of OR traffic increased.

High Number of Door Openings Increases the Bacterial Load of the Operating Room.

Background: Operating room (OR) traffic and door openings have emerged as potential modifiable risk factors for the development of surgical site infections. Methods: This study compared the microbial load of a Control OR without traffic versus a Simulated OR with the traffic in a typical orthopedic surgery case. Air particle counts and colony forming units (CFUs) were measured. A novel iOS app was developed to provide real-time door counts. Results: There were 1,862 particles >5.0 mcm in the Simulated OR compared with 56 in the Control OR. The CFUs from plates in the Simulated OR ranged from 4-22 (on brain heart infusion [BHI] agar), 2-266 (on mannitol salt agar [MSA]), and 1-19 (on Pseudomonas isolation agar [PIA]), while all plates in the Control OR grew 0-1 CFUs. Conclusions: High number of door openings leads to more airborne bacteria in the OR and viable bacterial on OR surfaces. The increased bacterial load throughout the OR was independent of distance from the door.

Decreasing Room Traffic in Orthopedic Surgery: A Quality Improvement Initiative.

Operating room (OR) traffic and door openings increase potential for air contamination in the OR and create distractions for surgical teams. A multidisciplinary intervention was developed among OR staff, surgical staff, vendors, radiology, and anesthesia and approved by the hospital system's patient and quality safety department for implementation. Interventions included education, OR signage, and team-based accountability and behavioral interventions. After interventions were implemented, a second prospective, observational data collection was performed and compared to preintervention OR traffic. A total of 35 cases were observed over the 3-month period in the preintervention group; 42 cases were observed in the postintervention group. Average door openings per minute decreased by 22% (P = .0011) after intervention. All surgical groups excluding anesthesia had significant reductions in OR traffic following the intervention. Behavioral interventions that focus on education, awareness, and efficiency strategies can decrease overall OR traffic for orthopedic cases.

Reduction of Particles in the Operating Room Using Ultraviolet Air Disinfection and Recirculation Units.

BACKGROUND: Airborne bacteria are a major source for wound contamination during total joint arthroplasty. Crystalline ultraviolet C (C-UVC) filter units were designed to disinfect and recirculate air in the operating room (OR). This preliminary study assessed the particle reducing capacity of C-UVC units in a highly controlled OR setting. METHODS: A particle counter was deployed in a positive-pressure OR to measure total and viable particle counts (TPC/VPC). Thirty 23-minute experiments were performed. At 4 designated times a person would walk through the door to mimic OR traffic. Ten experiments were performed as controls, 10 experiments used a C-UVC unit 4 meters (m) from the door, and 10 cases with the C-UVC unit at 8 m. Outcomes included overall, change (Δ), and maximum TPC/VPC. Mann-Whitney U-tests determined statistical differences in TPC/VPC. RESULTS: Compared to controls, the cases with the C-UVC unit at 4 m had significantly lower particle levels. Overall TPC/VPC, changes in TPC/VCP, and maximum TPC/VPC were all significantly lower (P < .05) in the C-UVC unit (4 m) group compared to the controls. The C-UVC at 8 m significantly reduced TPC in all 3 outcomes (P < .05) compared to controls; however, it did not significantly reduce changes in VPC (P = .107) and maximum VPC (P = .052). There were no significant differences in any outcomes between the 4 m and 8 m group. CONCLUSION: C-UVC units have shown to be capable of significantly reducing TPC and VPC in a highly controlled OR setting. Reducing airborne particles using C-UVC units may reduce infection rates following total joint arthroplasty.