Surgical Infections

Existing research regarding design improvements to the operating room (OR) is scarce and emphasizes the compelling need to measure and test new design strategies and interventions.

We propose a conceptual framework for measuring and improving OR physical space design by outlining how two existing measurement schemes can be adapted for ORs. The structure, process, outcomes model described by Donabedian in 1966 is used to show how each of these three measurement approaches can be used to evaluate OR design. In addition, we describe a common design framework that focuses on the end-user experience to highlight the impact different OR stakeholders can have on the prioritization of improvements.

The structure, process, outcomes model has both benefits and drawbacks for measuring OR design quality. For example, these components are easy to measure, highly actionable when deficient, and have high validity as the bottom line. However, they may not necessarily reflect better quality or correlate to better care, and some need risk adjustment to make comparisons fair. The end-user experience model should account for the needs of patients, OR nurses, anesthesiologists, surgeons, facilities managers, hospital administrators, infection control officers, and regulators, among others.

The design quality of ORs influences outcomes and determines the quality of experience for multiple stakeholders. Patients, providers, and hospital staff would benefit directly from efforts to improve OR physical space design. By adapting previously established frameworks, it is possible to measure, evaluate, and improve OR design.

Renovating or building a new intensive care unit (ICU) can be a challenging project. Planning the renovation or rebuild as a quality improvement project will help break down the process into manageable pieces with clear goals.

Literature was reviewed with regards to ICU design and renovation, with specific attention to patient quality improvement, process and structural change, healthcare systems engineering, emerging technology, and infection control.

In any quality improvement initiative, a first step is to create a multidisciplinary change team charged with leading the rebuild process. This team should include frontline providers, administration, architects, infection prevention specialists, and healthcare system engineers. Healthcare system engineers (HSEs) are specialized system and human factors engineers who can assist with data analysis, create mathematical models to anticipate areas of difficulty, and perform simulations to assist with the actual structural changes as well as the process changes aimed at eliminating nosocomial infections. Every aspect of creating a new ICU space should begin with infection control standards of practice ranging from selection of furniture and computer keyboards, to identifying the best location of the soiled utility rooms. There are many infection control products that may be considered during the building process such as tele-tracking hand hygiene stations and heavy-metal–coated surfaces aimed at decreasing surface colonization and subsequent infections.

This article offers suggestions on renovating or rebuilding an ICU aimed at eliminating the preventable harm associated with hospital acquired infections.

Infection is a common complication of burn injury caused by the loss of skin (the primary defense against micro-organisms) as well as burn-induced immunosuppression. Essentially, survival after burn injury is determined by whether wound healing or infection predominates. The purpose of this article is to describe how burn unit structure and design may impact the incidence of infection after burn injury.

This article describes the special considerations for burn unit structure and design based on burn pathophysiology, including burn-related immunosuppression and wound treatment. Particular emphasis is placed on how burn unit design should consider the immunosuppressed state of the burn patient.

Because many of the factors that promote wound healing also promote infection, burn unit design must prioritize infection prevention, including segregation and containment, environment layout and function, room cleaning, and isolation. Burn centers should have dedicated facilities with separation of patients, specialized room environment/equipment, and cleaning and wound care disinfection capabilities, with particular attention paid to surfaces, ventilation, temperature control, and patient movement to the operating room, radiology, and therapy.

Because of the high infection potential associated with burn injury, burn units require meticulous attention to design and function to minimize patient infection risk.

Infection control is a critical aspect in the continuum of surgical care. Much of what is outlined in the literature pertains to hospital-based practice, with only recent attention paid to the more austere environments, particularly those faced during humanitarian or combat operations.

This manuscript provides a brief historical review of the development of infection control practices and further identifies and outlines several aspects necessary to successful program applications in austere environments.

Hand hygiene remains the simplest form of infection control. Use of alcohol-based hand sanitizer is a logistically reasonable option for most circumstances, mitigating the requirement for clean running water to facilitate more traditional “soap and water” methods of hand disinfection. Environmental decontamination, patient cohorting, and patient isolation based on existing colonization/infection also has demonstrated efficacy in controlling cross-contamination and is feasible in most austere environments. Finally, senior leadership engagement with deliberate planning, antimicrobial stewardship, and vigorous quality and process improvement algorithms have resulted in reduced rates of critical infections in these settings.

Basic tenets of infection control can be achieved even in resource-poor environments. Meticulous attention to adhering to these principles, with support from senior medical and operational leadership, facilitates improvements in infection control outcomes. There remains, however, a need for additional robust outcomes data regarding best practices in these environments.

The influenza virus is a pathogenic virus responsible for large numbers of deaths and long-term disabilities worldwide. Although the very young, the very old, and immunocompromised individuals are most susceptible, the effects of the influenza virus can be observed across the entire spectrum of individuals.

Infection with the influenza virus induces a substantial inflammatory and immunologic response and induces marked pulmonary inflammation. Many aspects of influenza affect surgical patients directly. Vaccines are one of the most effective measures aimed at reducing the prevalence and severity of many infectious diseases, including the influenza virus. Vaccination programs remain one of the highest priorities across the spectrum of countries, research institutions such as the National Institutes of Health, international health agencies such as the World Health Organization (WHO), and major non-profit organizations.

This review addresses aspects of the immune and inflammatory response to influenza, with a focus on the elderly population and healthcare providers who may act as reservoirs for virus transmission to the vulnerable surgical population.

The alcohol rub has been proposed as an alternative to the traditional surgical scrub in preparing the hands for surgical procedures. Few reviews have examined critically the evidence that favors or discredits the use of the alcohol rub instead of the traditional scrub.

A review of available published literature was undertaken to define the evidence for the best methods for hand preparation before surgical procedures. The focus of this literature review was to compare the bacteriologic and clinical outcomes of conventional surgical scrubbing of the hands compared with alcohol rubs.

The bacteriologic studies of the hands after the conventional scrub versus the alcohol rub demonstrated consistently comparable or superior reductions in bacterial presence on the hand with the alcohol rub. Only four clinical studies were identified that compared the scrub versus the rub in the frequency of surgical site infections. No difference in surgical site infections were identified.

The alcohol rub appears to have comparable results to the surgical scrub and is a reasonable alternative in preparation of the hands for surgical procedures.

The management of incisions and decisions on closure techniques for surgical wounds are driven by expected incisional morbidity and the severity of the potential morbidity for the patient.

This article reviews current literature on the potential strategies to be considered in closing the skin and fascia of incisions.

The review of the literature indicates that low-risk wounds for infection should be closed primarily with subcuticular suture, and adjunctive local measures should be avoided. Adjunctive measures of irrigation, topical antimicrobial agents, and negative pressure incisional therapy may have a role in high-risk wounds. Surgeons should strongly consider primary closure of contaminated wounds.

The overall literature on adjuncts of wound irrigation, topical antimicrobials, and negative pressure wound therapy have potential to be of benefit but additional investigation is necessary since they do impact cost, patient experience, and antibiotic stewardship.

Abdominal infections following surgery have many severe consequences. Several effective, well-evaluated infection prevention and control processes exist to avoid these infections.

This manuscript reviews and provides supporting evidence for common management strategies useful to avoid postoperative abdominal infection.

Prevention of abdominal infection begins with preparation of the environment using standard infection control practices. Peri-operative use of systemic antibiotics, an antibiotic bowel preparation in colorectal surgery, and effective antiseptic preparation of the surgical site all reduce infection rates. Peri-operative supplemental oxygenation, maintenance of core body temperature, and physiologic euglycemia will reduce both incisional and organ-space infections in the abdominal surgery patient. Strategic use of irrigation and drain placement may be useful in some circumstances.

Specific methods of prevention are documented to reduce intra-abdominal infections. Prevention requires a multi-disciplinary team including the surgeon, anesthesiologist, and all operating room personnel.

Surgical site infection is associated with a substantial healthcare burden and remains one of the most challenging complications to treat. Airborne particles carrying contaminating micro-organisms are responsible for the majority of these infections.

Various operating theater ventilatory systems have been developed to prevent direct airborne bacterial inoculation of the surgical wound. Laminar air flow uses positive pressure air currents through filtration units to direct air streams away from the operative field in order to create an ultraclean zone around the operative site.

Early studies reported lower infection rates with laminar air flow and therefore it became the accepted standard for implant-related surgery. However, more recent evidence has questioned its clinical importance. The purpose of this article is to review contemporary laminar air flow handling systems and the current evidence behind their use.