STANDARDIZATION OF ISOLATION PRACTICES IN THE PERIOPERATIVE CARE SETTING Lorrie Ingram, BSN, RN, Infection Control Practitioner; Susie (Treasa) Leming-Lee, MSN, RN, CPHQ, Director of Perioperative Quality Management; Vicki Brinsko, BSN, RN, CIC, Infection Control Practitioner, Dept. Coordinator; Jena Skinner, BSN, RN, CIC, Infection Control Practitioner; Ann H. Benco, MSTD, BSN, RN, CNOR, Perioperative Nurse Educator; Erin Kuhn, RN, MSN, CNOR, Perioperative Nurse Educator; Audrey H. Kuntz, EdD, RN, Director of Perioperative Education/Operative Services; Stephanie Randa, MHA, RN, Director of Operative Services; Thomas R. Talbot, III, MD, MPH, Hospital Epidemiologist, Infectious Disease, Titus L. Daniels, MD, MPH, Assistant Professor of Medicine-Infectious Disease, Associate

Hospital Epidemiologist; Addison K. May, MD, FACS, FCCM, Associate Professor of Surgery and Anesthesiology

ABSTRACT RESULTSIMPLEMENTATION: DESIGN: FLOW OF WORK PROCESS

INTRODUCTION

CONCLUSION & LESSONS LEARNED

The management of operating room (OR) traffic, environmental cleaning, patient transport, supplies and appropriate signage were other key elements of concentration identified for practice change. Improved compliance with isolation practices was observed soon after implementation. While not directly attributable to the perioperative isolation enhancements (simultaneous interventions were introduced in the critical care areas) no further HR-ACBA cluster outbreaks were identified (Fig. 3).

Although most staff understood the institution’s isolation mandates for contact, droplet and airborne precautions, problems were identified with communication between departments on patient isolation status and proper practices for transporting patients between perioperative areas and critical care. The concept that the OR environment, with respect to routine practices of sterile and aseptic technique, would inherently prevent cross transmission of organisms from patients in isolation was deficient as it did not include appropriate practice patterns prior to and after surgery.

This intervention project served to increase awareness and education of the perioperative staff regarding infection prevention and control practices with their isolated patient population. Behavioral changes reflecting improved compliance were influenced by staff collaboration, use of new electronic case boarding prompts and creative methods of communication and education. with similar clinical challenges.

Lessons Learned Include:1. Ensure need for support of project by visible leadership.2. Provision of a standardized process algorithm to guide staff adherence

and education was a vital component of this quality improvement process. These concepts are reproducible for other service areas.

3. Early Solicitation of staff input in the development of this process, as were the specific tools, was vital to overall success.

4. Education of all perioperative staff and faculty was critical to the ownership of the process, and for its continued success.

A multidisciplinary team was formed with representatives from surgical critical care, perioperative education, operating room personnel and infection control to review the existing practices used for handling patients in isolation and to map out an enhanced process for improvement. System barriers to compliance were identified in all phases of the perioperative patient care process. System enhancements were identified and implemented to facilitate compliance. These included specific education and training modules developed for all levels of staff, including physicians. Perioperative isolation practice standards were formally incorporated into the departmental policy and procedure manual.

METHODOLOGY/TRAINING

# of ACBA Clusters Outbreaks

0

2

4

6

8

July Aug Sept Oct Nov Dec Jan Feb March April May June

Months-2007-2008(8 months with no ACBA out breaks)

Implementation of

New Isolation Pr ecaution Processes

6 ACBA Outbreaks, J uly 2007

Key Fundamental Infection Control Concepts Applied:1. Strict Hand Hygiene adherence2. Strict/Consistent use of PPE for specific precautions3. Appropriate Environmental cleaning/disinfection processes4. Special indications (i.e. for air handling/exchanges for TB)5. Continuous good communication during surgery “booking” process,

between the referral/transferring dept.; the Periop Services regarding patients isolation status

6. Highlights and education pertaining to very specific and highly transmittable organisms in the healthcare environment reviewed

NEW ISOLATION PRECAUTION PROCESS IN ACTION

Surgeon or surgical resident

boards the surgical case

Isolation Precautions Process Thursday October 18TH 2007

Scheduler selects from computer program one of the following pt. precaution status:· None· Contact· Droplet· Airborne

Anesthesia provider

arrives in pt’s room

Is the pt. on isolation precautions?

No

Yes

Continue current surgical care process

SCHEDULING PHASE PRE-SURGERY & Patient Unit PHASE: PREPARATION AND TRANSPORT OF PT. TO OR

Anesthesia provider

assesses pt’s condition and

equipment needed for transport

Anesthesia provider and pt’s bedside

nurse conduct a handoff which

includes:Verification of

isolation precautions

status

CTI arrives in pt’s

room and verifies pt. on

isolation precaution

status

CTI, Anesthesia provider, and or Nurse· place a clean

sheet on patient· place all pt.

monitoring equipment, O2 tank, chart/s (in clear plastic bag) on pt.’s bed

· place isolation signs on pt.’s bed

· assigns “Clean Person” to assist in transporting pt. to open doors, push elevator buttons, etc.

CTI , Anesthesia

provider, and or Nurse

transport pt. directly to operating

room if coming from

ICU or on airborne

precautions

CTI assist Anesthesia

provider and or

Nurse with the

preparation to transport

pt. to OR

Circulator in OR calls receiving

unit charge nurse to inform that pt

is ready to be transported back and verifies pt.’s

isolation precautions

status

Anesthesia provider calls

pt. report to unit bedside nurse or unit charge

nurse and verifies pt.’s

isolation precautions

status

Circulator in OR conducts “rolling call”

to pt. destination

as pt. leaves OR

Pt. unit receives rolling call and notifies charge

nurse and bedside nurse that pt. is in transit and verifies

pt.’s isolation precautions

CTI, Anesthesia provider, Surgical

Resident and assigned “Clean

Person” transport pt. to receiving unit

CTI, Anesthesia provider, &

Surgical resident don new PPE for transport of

pt. to receiving

unit

CTI and OR staff move

pt. from bed/

stretcher to OR table

Surgery starts

Surgery ends

Pt. arrives in

receiving unit

CTI, Anesthesia Provider and

Surgical Resident remove PPE and

perform hand hygiene before

leaving pt.’s room

CTI moves pt. bed into hallway and follow the requirements for

bed cleaning below:

PATIENT UNIT PHASE: PREPARATION AND TRANSPORT OF PT. TO OR INTRAOPERATIVE PHASE OF CARE

INTRAOPERATIVE CARE PHASE CONTINUES POST-OPERATIVE CARE PHASE OR TO PATIENT UNIT

b

b

a

a

Blue = New Step Red = Verification of Isolation Precaution status

2

3

Does Scheduler know the pt.’s type of

isolation precautions?

Scheduler calls Pt. Care Unit to ascertain type of pt. isolation

precaution

No

Yes

Does MR Know the type of isolation precautions the pt.

is under?

MR calls bedside nurse to determine type of isolation precaution

Anesthesia provider

and bedside nurse conduct

handoff verifying pt.’s isolation

precaution status

Cleaning Process:· Don appropriate PPE· Remove sheets from bed and place in linen

bag· Spray germicidal disinfectant agent on bed

rails, springs, head board & wipe down bed · Place isolation type sign on bed during

drying phase· Wait 10 mins· Dress bed with clean sheets · Drape bed with clear plastic sheet· Place isolation signs on pt’s bed

OR PREP BEFORE

PT. ENTERS

OPERATING ROOM

OR PREP AFTER PT LEAVESOPERATING ROOM

CTI performs

hand hygiene & dons

PPE before

entering pt’s

room

Is pt. on isolation precautions?

Charge Nurse reviews E-Board

and assigns outside runner to operating room

Yes

No

Anesthesia provider performs

hand hygiene & dons PPE

before entering pt.’s

room

Is pt. on air borne isolation?

Charge Nurse reviews E-Board and

orders Hepafilter

Yes

No

Place clean sheet over pt. before

leaving OR

Do not remove pt. chart from plastic bag

unless needed

Scheduler schedules

surgical case for end of

day if possile

Is pt. under air borne

isolation precautions?

Anesthesia provider recovers non ICU pt. for 30-50 mins in OR

ICU patient may be recovered in negative pressure room on their

assigned unit

Yes

No

CTI wipes down all transport monitors

and other equipment with a

germicidal disinfectant

agent before leaving the patient’s room

Is pt. on airborne

isolation ?

Bedside nurse places

surgical mask on

pt.

Is pt. on droplet

Isolaton?

Bedside Nurse places

surgical mask on

pt.

NoNo

Yes Yes

OR Staff removes any unnecessary

equipment from OR

OR Staff closes all cabinet doors in OR

Circulating Nurse ensures all

surgical case supplies and

equipment are in the OR

Circulating Nurse or designee post:

· “No Traffic” Sign on OR Door

· “Isolation type precaution” sign on OR Door

2

Isolation Precautions Process-Before Pt. Enters OR

Circulating Nurse pulls up

Whiteboard and confirms Pt.’s

isolation status

Circulating Nurse calls the board who

assigns “clean person” to aid in transporting pt.

back to ICU

All OR Staff dons PPEs prior to pt. entering OR

CTI:· Don N95 Respirator· Bring Hepafilter

into OR· Place Hepafilter in

center of room away from return air vent

· Plug Hepafilter into electrical outlet and turns Hepafilter on

Hepafilter runs for one hour

Is pt. under air borne isolation

precautions?

Yes

No

Is pt. under droplet or contact

isolation precautions?

Yes

No

OR Staff cleans OR according to standard cleaning

methods

CTI wipes outside of isolation cart with a

germicidal disinfectant and sends Isolation Cart to Central Supply for

cleaning and restocking

3

OR Cleaning Staff cleans OR

according standard cleaning

procedures *No N95 Respirator

needed after hepafilter has run

for one hour*

Anesthesia provider recovers non ICU

pt. in OR for 30-50 minutes

ICU ICU pt. may be recovered in

negative pressure room on assigned

unit

Anesthesia Technician

cleans Anesthesia

machine according to

standard cleaning methods

Airborne, Droplet, & Contact Isolation Process- End of Surgical Case

OR Staff don

appropriate PPECleans OR

according to standard cleaning

methods

CTI wipes outside of isolation cart with a

germicidal disinfectant and sends Isolation Cart to Central Supply for

cleaning and restocking

AcknowledgementsDaniel Beauchamp, MD, Chair of Surgical Sciences

Mike Higgins, MD, MPH, Executive Medical Director of Perioperative ServicesNancye Feistritzer, MSN, RN Associate Hospital Administrator, Director of Perioperative Services

Surgical Site Infection Prevention Collaborative Committee

2008 APIC Abstract2008 APIC AbstractSubject CategorySubject Category - Quality Management Systems/Process Improvement/Adverse Outcomes - Quality Management Systems/Process Improvement/Adverse Outcomes

Standardization of Isolation Practices in the Perioperative Service LineStandardization of Isolation Practices in the Perioperative Service LineLorrie Ingram, BSN, RN,Lorrie Ingram, BSN, RN, Infection Control Practitioner; Infection Control Practitioner; Vicki Brinsko, BSN, RN, CICVicki Brinsko, BSN, RN, CIC, , Infection Control Practitioner, Dept. Coordinator; Infection Control Practitioner, Dept. Coordinator; Jena Skinner, BSN, RN, CICJena Skinner, BSN, RN, CIC, Infection , Infection Control Practitioner; Control Practitioner; Ann Benco, RNAnn Benco, RN, Nurse Educator, Operative Services; , Nurse Educator, Operative Services; Erin Kuhn, RN, Erin Kuhn, RN, MSNMSN, , CNORCNOR, Perioperative Nurse Educator; , Perioperative Nurse Educator; Audrey H. Kuntz, EdD, RNAudrey H. Kuntz, EdD, RN, Director of , Director of Perioperative Quality Mgmt/Operative Services; Perioperative Quality Mgmt/Operative Services; Susie Leming-Lee, MSN, RN, CPHQSusie Leming-Lee, MSN, RN, CPHQ, , Associate Director of Perioperative Quality Management/Operative Services, Associate Director of Perioperative Quality Management/Operative Services, Thomas R. Talbot, Thomas R. Talbot, III, MDIII, MD, , MPHMPH, Hospital Epidemiologist, Infectious Disease, Assistant Professor of Medicine and , Hospital Epidemiologist, Infectious Disease, Assistant Professor of Medicine and Preventive Medicine, Preventive Medicine, Titus L. Daniels, MD, MPHTitus L. Daniels, MD, MPH, Assistant Professor of Medicine-Infectious , Assistant Professor of Medicine-Infectious Disease, Associate Hospital EpidemiologistDisease, Associate Hospital EpidemiologistISSUE:ISSUE:A cluster of Highly-resistant A cluster of Highly-resistant Acinetobacter baumanniiAcinetobacter baumannii (HR-ACBA) cases in the surgical critical (HR-ACBA) cases in the surgical critical care unit of a large tertiary care medical center provided the impetus for detailed scrutiny of care unit of a large tertiary care medical center provided the impetus for detailed scrutiny of isolation practices, particularly for patients requiring multiple trips to surgery. Noncompliance isolation practices, particularly for patients requiring multiple trips to surgery. Noncompliance with aspects of isolation was observed for patients during transport between surgery and critical with aspects of isolation was observed for patients during transport between surgery and critical care. Further investigation revealed a systems approach to improvement would be needed, not care. Further investigation revealed a systems approach to improvement would be needed, not only to prevent transmission during transport, but to enhance compliance for all areas of patient only to prevent transmission during transport, but to enhance compliance for all areas of patient contact throughout the perioperative service line.contact throughout the perioperative service line.PROJECT:PROJECT: A multidisciplinary team was formed with representatives from surgical critical care, perioperative A multidisciplinary team was formed with representatives from surgical critical care, perioperative education, operating room personnel and infection control, to review the existing practices used for education, operating room personnel and infection control, to review the existing practices used for handling patients in isolation and to map out an enhanced process (Figure 1) for improvement. handling patients in isolation and to map out an enhanced process (Figure 1) for improvement. System barriers to compliance were identified in all phases of the perioperative patient care System barriers to compliance were identified in all phases of the perioperative patient care process. System enhancements were identified and implemented to facilitate compliance. These process. System enhancements were identified and implemented to facilitate compliance. These included specific education and training modules developed for all levels of staff, including included specific education and training modules developed for all levels of staff, including physicians. Perioperative isolation practice standards were formally incorporated into the physicians. Perioperative isolation practice standards were formally incorporated into the departmental policy and procedure manual. departmental policy and procedure manual. RESULTS:RESULTS: A unified set of isolation practice standards throughout the perioperative service line was A unified set of isolation practice standards throughout the perioperative service line was established, which mirrored the existing isolation guidelines practiced throughout the rest of the established, which mirrored the existing isolation guidelines practiced throughout the rest of the medical center. System changes included creating electronic case boarding prompts, (Figure 2) to medical center. System changes included creating electronic case boarding prompts, (Figure 2) to actively inquire as to isolation status and type required, as well as electronic reminders to book actively inquire as to isolation status and type required, as well as electronic reminders to book airborne isolation cases at the end of the day. The management of operating room (OR) traffic, airborne isolation cases at the end of the day. The management of operating room (OR) traffic, environmental cleaning, patient transport, supplies and appropriate signage were other key environmental cleaning, patient transport, supplies and appropriate signage were other key elements of concentration identified for practice change. Improved compliance with isolation elements of concentration identified for practice change. Improved compliance with isolation practices was observed soon after implementation. While not directly attributable to the practices was observed soon after implementation. While not directly attributable to the perioperative isolation enhancements (simultaneous interventions were introduced in the critical perioperative isolation enhancements (simultaneous interventions were introduced in the critical care areas) no further HR-ACBA cluster outbreaks were identified (Figure 3). care areas) no further HR-ACBA cluster outbreaks were identified (Figure 3). LESSONS LEARNED: LESSONS LEARNED: Although most staff understood the institution’s isolation mandates for contact, droplet and Although most staff understood the institution’s isolation mandates for contact, droplet and airborne precautions, problems were identified with communication between departments on airborne precautions, problems were identified with communication between departments on patient isolation status and proper practices for transporting patients between perioperative areas patient isolation status and proper practices for transporting patients between perioperative areas and critical care. The concept that the OR environment, with respect to routine practices of sterile and critical care. The concept that the OR environment, with respect to routine practices of sterile and aseptic technique, would inherently prevent cross transmission of organisms from patients in and aseptic technique, would inherently prevent cross transmission of organisms from patients in isolation was deficient as it did not include appropriate practice patterns prior to and after surgery.isolation was deficient as it did not include appropriate practice patterns prior to and after surgery.This intervention project served to increase awareness and education of the perioperative staff This intervention project served to increase awareness and education of the perioperative staff regarding infection prevention and control practices with their isolated patient population. regarding infection prevention and control practices with their isolated patient population. Behavioral changes reflecting improved compliance were influenced by staff collaboration, use of Behavioral changes reflecting improved compliance were influenced by staff collaboration, use of new electronic case boarding prompts and creative methods of communication and education. In new electronic case boarding prompts and creative methods of communication and education. In addition, providing a new, concentrated and standardized process algorithm to guide the units/OR addition, providing a new, concentrated and standardized process algorithm to guide the units/OR staff in preparing for and organizing the isolation patient’s transport, equipment handling and staff in preparing for and organizing the isolation patient’s transport, equipment handling and environment, was a vital tool for quality improvement. These concepts are reproducible for other environment, was a vital tool for quality improvement. These concepts are reproducible for other service areas with similar clinical challenges. service areas with similar clinical challenges.

METHODOLOGY/TRAINING

A unified set of isolation practice standards throughout the perioperative service line was established, which mirrored the existing isolation guidelines practiced throughout the rest of the medical center. System changes included creating electronic case boarding prompts (Fig. 2) to actively inquire as to isolation status and type required, as well as electronic reminders to book airborne isolation cases at the end of the day. The management of operating room (OR) traffic, environmental cleaning, patient transport, supplies and appropriate signage were other key elements of concentration identified for practice change. Simultaneous interventions were introduced in the critical care areas. Key Fundamental Infection Control Concepts Applied:

1. Strict Hand Hygiene adherence2. Strict/Consistent use of PPE for specific precautions3. Appropriate Environmental cleaning/disinfection processes4. Special indications (i.e. for air handling/exchanges for TB)5. Continuous good communication during surgery “booking” process, between the referral/transferring

dept.; the Periop Services regarding patients isolation status6. Highlights and education pertaining to very specific and highly transmittable organisms in the

healthcare environment reviewed

INTRODUCTION

www.mc.vanderbilt.edu/infectioncontrol

Fig. 1Fig. 1

Fig. 2Fig. 2

Fig. 3Fig. 3