Infection Control Today

SEP 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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For the rest of the references, see the online version of this article at www.infectioncontroltoday.com 30 ICT September 2018 www.infectioncontroltoday.com Typically, when hospitals settle out of court the awards are far greater than those that go to trial and are likely, on average, far greater than the awards mentioned above. Beyond the orthopedic realm, but related to the aerosolizatiaon of bacteria, more than 10 lawsuits have been fi led against the manufacturer of the heater-cooler device found to be the source of M. chimaera. One suit is based on the patient's allegations that the device contributed to a potentially fatal chest incision infection. 39 Air Decontamination Technology: An Evidenced Based Solution Airborne pathogens are a known risk factor for SSIs. Particulate counts and bacterial colony forming units (CFUs) are key indicators of air quality utilized in critical environments. Yet, published data on airborne levels in operating rooms indicates that OR air is often no cleaner than the air in other units. 40 More than 90 percent of bacteria contaminating clean wounds come from the ambient air and a substantial part of these bacteria contaminate the wound directly during clean-wound surgery. 41 Precautions such as scrubbing and gowning, special skin prep procedures for both patients and clinicians, protocols to restrict access and movement in the OR, between case and terminal disinfection, surgical irrigants, antimicrobial sutures and special postoperative dressings are just a few of the interventions directed at reducing the incidence of SSI. Reduction of air contami- nation in the OR is accomplished primarily through a combination of fi ltration, dilution, pressurization and traffi c-related limitations. OR staff must ensure that temperature and humidity are controlled and that air handling systems receive preventative maintenance. These standards are largely architectural in nature and have been in-place for decades. Moreover, with some of these standards, most notably the required number of air changes per hour, there is no real agreement on whether they are suffi cient. It is also widely accepted that risk mitigation strategies aimed at maintaining air quality in the OR, such as limiting traffi c and door openings, can be only marginally enforced and therefore may also be of questionable effectiveness. To supplement traditional method- ologies, a variety of new technologies such as those utilizing ultraviolet (UV) disinfection have been developed to reduce airborne contamination. There is published data available which demonstrates that technology utilizing UV and recirculation can further reduce viable airborne particle concentrations in the OR setting. 42 The CDC, in Guidelines for Environmental Infection Control in Health-Care Facilities, states that "as a supplemental air-cleaning measure, ultraviolet germicidal irradiation is effective in reducing the transmission of airborne bacterial and viral infections in hospitals. 43 Fur ther paving the way for adoption, the American College of Governmental Industrial Hygienists (ACGIH) states that airborne infections can be prevented or reduced by maximizing removal rates of airborne infectious aerosols through dilution ventilation and use of air cleaners. 44 W hile there are no OR air qualit y standards in the U.S., as of this writing, the World Health Organization (WHO) has established limitations for microbial contamination in ORs of <50 CFU/m3 and <10 CFU/m3 for orthopedic, cardiac, and transplant ORs. 45 A number of EU states are also implementing air quality standards for the OR and other areas where patients are at high-risk risk for infection. 46 In light of the evidence and global movement toward air quality standards in the OR, infection preventionists may want to consider adoption of air quality technologies as a supplemental evidence-based solution for reduction of SSI. Where practices and processes are reliable and consistent with policy, technology solutions should be considered as an additional means of mitigating the risk. In cases where SSI rates are elevated, an audit should be conducted to identify if airborne contamination could have been a contributing factor. The audit should also include the costs of treating infections, the fi nancial consequences of any legal action, all costs related to penalties and incentives under the Affordable Care Act such as value-based purchasing, inpatient quality reporting, hospital acquired conditions and postoperative readmissions and penalties under the Defi cit Reduction Act for conditions that were not present on admission. This infor- mation can contribute to value analysis and bolster the foundation for implementation of evidence-based improvements and adoption of new technologies. Clinicians may want to consider the resources offered by medical technology companies as many employ clinical experts who are prepared to assist in performing assessments and audits. Companies are also often willing to assist with small studies that can be used in value analysis and provide an evidence-based, institutionally relevant foundation for adoption of innovative, new technological improvements. While there is a host of factors in OR environment and practice that can contribute to SSI, there is a growing body of evidence which suggests that air quality merits heightened attention on the part of the infection prevention community. For prevention of PJI in particular where procedural volume is high and growing and the clinical and economic costs of infection are also high, supplemental strategies that can further reduce infection risk should be on every IP's radar. Recent innovation in air decontamination technologies make signifi cant reduction in airborne bioburden in the OR, for the fi rst time, both technically and economically feasible offering a new asset in the quest to eliminate SSI and meet the evidence-based standard of care. References: 1. Heidelberg JF et al. Effect of aerosolization on culturability and viability of gram-negative bacteria. Appl Environ Microbiol. 1997:63(9):3585-3583. 2. Sommerstein R, Ruegg C, Kohler P, Bloemberg G, Kuster SP, Sax H. Transmission of mycobacterium chimaera from heater-cooler units during cardiac surgery despite an ultraclean air ventilation system. Emerg. Infect. Dis. 2016;22:1008-13. 3. Brachman PS. Hospital-acquired infection— airborne or not? Proceedings of the International Conference on Hospital-Acquired Infections, 1971. P. S. Brachman and T. C. Eickhoff, Eds., pp. 189-192, American Hospital Association. 4. Kundsin RB. Documentation of airborne infection during surgery. Annals of the New York Academy of Sciences, 1980. Vol. 353, pp. 255-261. 5. Whyte W, et al. The importance of airborne bacterial contamination of wounds. J Hosp Infect 1982;3:123-35. 17. 6. Lidwell O. (1983) Airborne contamination of wounds in joint replacement operations: the relationship to sepsis. J. Hosp Infect. 4, 111-131. 7. Dharan S, Pittet D. Environmental control in the operating theatres. J Hosp Infect 2002;51:79-84. 8. Sax H et al. Prolonged Outbreak of Mycobacterium chimaera Infection After Open-Chest Heart Surgery. Clin Infect Dis. 2015: 61 (1); 67-75. 9. Nontuberculous Mycobacterium Infections Associated with Heater-Cooler Devices: FDA Safety Communication. Oct. 2018. 10. Parvizi J, Barnes S, Shohat N, Edmiston C. Environment of care: Is it time to reassess microbial contamination of the operating room as a risk factor for surgical site infection in total joint arthroplasty? Am. J. Infect. Control (2017); Nov 1;45 (11): 1267- 72. 11. Parisi TJ, Konopka JF, Bedair HS. What is the long-term societal effect of periprosthetic infections after THA? A Markov analysis. Clin. Orthop. Relat. Res. 2017;doi:10.1007/s11999-017-5333-6. 12. Tande AJ, Patel R. Prosthetic joint infection. Clin. Microbiol Rev. 2014;27:302-45. 13. Lange J, Troelsen A, Soballe K. Chronic periprosthetic joint infection. A retrospective, observational study on the treatment strategy and prognosis in 130 non-selected patients. PLosONE 2016;11:e0163457.

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