비뇨기과 수술 관련 감염의 예방: 위생 및 교육

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129

• 교신저자：심봉석, 이화여자대학교 의과대학 비뇨기과학교실 서울시 양천구 목동 911-1 ^우 158-710

Tel: 02-2650-2863, Fax: 02-2654-3682 E-mail: bonstone@ewha.ac.kr Received: July 28, 2011

Accepted: August 8, 2011

비뇨기과 수술 관련 감염의 예방: 위생 및 교육

이화여자대학교 의과대학 비뇨기과학교실

심 봉 석 [Abstract]

Prevention of Infections Associated with Urological Surgery:

Hygiene and Education Bong-Suk Shim

From the Department of Urology, School of Medicine, Ewha Womans University Hospital, Seoul, Korea

The safety of the patient depends upon a clean environment in the wards and operating theatre. Good hospital hygiene is an integral and important component of a strategy for preventing hospital acquired infections. The hospital environment must be visibly clean, free from dust and spoilage, acceptable to the patients, their family and visitors and to the staff. Each hospital should have rules and recommendations for maintaining a clean environment with scheduled routines. All staff must maintain good personal hygiene. Appropriate hospital clothing is recommended in conjunction with all patient contact in the wards, the out-patient departments and operating area. Careful hand washing and disinfection and appropriate clothing are key measures to limit cross-contamination and each hospital must have written policies and procedures for these matters. Regular teaching and training of staff in infection control is required to reach the aims of reducing health acquired infections. (Korean J UTII 2011;6:129-139)

Key Words: Hospital environment, Personal hygiene, Hand washing, Education, Infection control

SUMMARY OF RECOMMENDATIONS

Note that most recommendations are of grade (GoR)

B or C based on available literature. Nonetheless, they merit a strong recommendation grade A, because no weaknesses in the maintenance of cleanness and hygiene are acceptable for a safe environment.

Hospital environment hygiene

1. The hospital environment must be visibly clean, free from dust and spoilage, and acceptable to patients, their visitors and staff (GoR C).

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Operating room hygiene

• Cleaning

2. All surfaces kept clean, free from dust and spoilage (GoR B).

3. Regular schedule for cleaning and disinfection of the operating theatre (GoR B):

• Every morning before any intervention: cleaning of all horizontal surfaces.

• Between procedures: cleaning and disinfection of horizontal surfaces and all surgical items (e.g. tables, buckets).

• At the end of the working day: complete cleaning of the operating theatre using a recommended disinfectant cleaner.

• Once a week: complete cleaning of the operating room area, including all annexes such as dressing rooms, technical rooms, cupboards.

4. Perform routine cleaning of these surfaces to re-es- tablish a clean environment after each operation (GoR B).

5. Wet vacuum the operating room floor after the last operation of the day or night with an Environmental Protection Agency-approved hospital disinfectant (GoR B).

• Ventilation

6. Maintain positive-pressure ventilation in the operating room with respect to the corridors and adjacent areas (GoR B).

7. Maintain a minimum of 15 air changes per hour, of which at least 3 should be fresh air (GoR B).

8. Filter all air, re-circulated and fresh, through the appropriate filters per the American Institute of Architects’ recommendations (GoR B).

9. Introduce all air at the ceiling, and exhaust near the floor (GoR B).

10. Limit the number of personnel entering the operating room to necessary personnel (GoR C).

• Surgical attire

11. All persons entering the surgical theatre must wear surgical attire restricted to being worn only within the surgical area (GoR C).

12. Wear a cap or hood to fully cover hair on the head and face when entering the operating room (GoR B).

13. Wear a surgical mask that fully covers the mouth and nose when entering the operating room if an operation is about to begin or is already under way, or if sterile instruments are exposed. Wear the mask throughout the operation (GoR B).

14. Full body, fluid repellent gowns should be worn where there is a risk of extensive splashing of blood, body fluids, secretions and excretions, with the exception of sweat, onto the skin of health care practitioners (GoR B).

15. Do not wear shoe covers for the prevention of SSI (GoR B).

16. Gloves must be worn for invasive procedures, contact with sterile sites, and non-intact skin, mucous membranes, and all activities that have been as- sessed as carrying a risk of exposure to blood, body fluids, secretions and excretions; and when handling sharp or contaminated instruments. (GoR B).

17. Gloves should be worn as single use items. Put gloves on immediately before an episode of patient contact or treatment and remove them as soon as the activity is completed. Change gloves between caring for different patients, or between different care/treatment activities for the same patient (GoR B).

18. Powdered and polythene gloves should not be used in health care activities (GoR B).

• Sampling

19. Do not perform routine environmental sampling of the operating room. Perform microbiologic sampling of operating room environmental surfaces or air only as part of an epidemiologic investigation

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(GoR B).

Personal hygiene

20. All staff must maintain good personal hygiene.

Nails must be clean and kept short. False nails should not be worn. Hair must be worn short or pinned up. Beard and moustaches must be kept trimmed short and clean (GoR C).

Hand hygiene

21. Hands must be decontaminated immediately before each and every episode of direct patient contact and care and after any activity or contact that potentially results in hands becoming contaminated (GoR B).

22. Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material must be washed with liquid soap and water (GoR B).

23. Apply an alcohol-based hand rub or wash hands with liquid soap and water to decontaminate hands between caring for different patients, or between different caring activities for the same patient (GoR B).

24. Remove all wrist and ideally hand jewellery at the beginning of each clinical shift before regular hand decontamination begins. Cuts and abrasions must be covered with waterproof dressings (GoR C).

25. Effective hand washing technique involves three stages: preparation, washing and rinsing, and drying. Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial preparation. The hand wash solution must come into contact with all the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10-15 seconds, pay- ing particular attention to the tips of the fingers, the thumbs and the areas between the fingers.

Hands should be rinsed thoroughly prior to drying

with good quality paper towels (GoR C).

Disposal of sharps

26. Sharps must not be passed directly from hand to hand and handling should be kept to a minimum (GoR C).

27. Used sharps must be discarded into a sharps con- tainer at the point of use. These must not be fil- led above the mark indicating that they are full.

Containers in public areas must not be placed on the floor and should be located in a safe position (GoR C).

Education

28. All staff involved in hospital hygiene activities must be included in education and training related to the prevention of hospital-acquired infection (GoR C).

INTRODUCTION

The aim of prophylaxis in urological intervention is to prevent infectious complications resulting from diag- nostic and therapeutic procedures, as defined in the introduction to the chapter. A clean, hygienic environment is one of the essential pillars of surgical practice. A clean environment aims at reducing bacterial burden and risk of contamination in the clinical and surgical environment. For urological intervention, the same rules are applied as in hygiene for prevention of nosocomial infections. Risk factors for perioperative infections are related, among others, to the patient, the health-care workers and the environment in the wards and operating rooms.^1-4 Patient related risk factors such as advanced age, malnutrition, diabetes, smoking, obesity, infections at sites other than the surgical sites, deficiency of the immune status and a long preoperative hospital stay, are reviewed in this chapter in the section on “preparation

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of the patient”. Healthcare worker factors are contaminated hands and poor hygiene of personal protective equipment such as working clothes, shoes, caps, masks and gloves. Environmental risk factors are inappropriate skin preparation, preoperative hair removal, prolonged operation time, inappropriate antimicrobial prophylaxis, poor controlled operating room ventilation system, in- adequate sterilization of surgical instruments, foreign body use in operation, inappropriate drain use, and inappropriate surgical techniques. Good hospital hygiene is thus an integral and important component of a strategy for preventing hospital-acquired infections. The environment should be maintained in accordance with the hospital hygiene team’s recommendations.

METHODS

A standard search of the literature including available guidelines and expert opinions was performed with the following key words: infection, hygiene, hospital, environment, and education one by one, using only English language papers with the abstract available. A total number of 600 publications were found, which were screened and reviewed by title and abstract and finally 60 publications were included into this review. No randomised controlled trials were found which are usually not appropriate for the present topic. The present review is based on available literature, established praxis and recommendations by manufacturers. Case reports or oral presentations are not included. The studies were rated according to the level of evidence (LoE) and the grade of recommendation (GoR) using ICUD standards (for details see Preface).^5-6

HOSPITAL HYGIENE

1. Hospital environmental hygiene

Good hospital hygiene is an integral and important

component of a strategy for preventing hospital-acquired infections.⁷ Hospital environmental hygiene encompasses a wide range of routine activities that are generally considered to be central to the prevention of hospital-acquired infection (LoE 3).^8-9 Routine cleaning is necessary to ensure a hospital environment which is visibly clean, and free from dust and soil. 90% of microorganisms are present within visible dirt, and the purpose of routine cleaning is to eliminate this dirt. Neither soap nor detergents have antimicrobial activity, and the cleaning process depends essentially on mechanical action. There must be a hospital policy and recommendations specifying the frequency of cleaning and cleaning agents used for walls, floors, windows, beds, curtains, screens, fix- tures, furniture, baths and toilets, and all reused medical devices. Bacteriological testing of the environment is not recommended except in selected circumstances such as 1) epidemic investigation where there is a suspected environmental source, 2) dialysis water monitoring for bacterial counts, as required by standards, 3) quality control when changing cleaning practices (LoE 1b).⁹

OPERATION ROOM HYGIENE

1. Operating room environment

In the operating room environment, airborne bacteria must be minimized, and surfaces kept clean (LoE 1b). A recommended schedule for cleaning and disinfection of the operating theatre is⁹:

• Every morning before any intervention: cleaning of all horizontal surfaces

• Between procedures: cleaning and disinfection of horizontal surfaces and all surgical items (e.g. tables, buckets)

• At the end of the working day: complete cleaning of the operating theatre using a recommended disinfectant cleaner

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• Once a week: complete cleaning of the operating room area, including all annexes such as dressing rooms, technical rooms, cupboards.

2. Ventilation

Operating rooms should be maintained at positive pressure with respect to corridors and adjacent areas.¹⁰ Positive pressure prevents airflow from less clean areas into cleaner ones. All ventilation or air con- ditioning systems in hospitals, including those in operating rooms, should have two filter beds in series, with the efficiency of the first filter bed being >30%

and that of the second filter bed being >90%.¹¹ Operating room ventilation systems produce a minimum of about 15 air changes of filtered air per hour, three (20%) of which must be fresh air. Air should be introduced at the ceiling and exhausted near the floor.^12,13Laminar airflow has been suggested as additional measures to reduce surgical site infections (SSI) risk for certain operations. Laminar airflow is designed to move particle-free air (called ultraclean air) over the aseptic operating field at a uniform velocity (0.3 to 0.5 µm/sec), sweeping away particles in its path. Laminar airflow can be directed vertically or horizontally, and recirculated air is usually passed through a high efficiency particulate air (HEPA) filter.^14,15HEPA filters remove particles >0.3µm in di- ameter with an efficiency of 99.97% (LoE 1b).^12,14,16

3. Environmental surfaces

Environmental surfaces in operating rooms such as tables, floors, walls, ceilings, lights, are rarely im- plicated as an important source of pathogens in the development of SSIs. Nevertheless, it is important to perform routine cleaning of the surfaces to restore a clean environment after each operation.^12,14 There are no data to support routine disinfecting of environmental surfaces or equipment between operations in

the absence of contamination or visible soiling (LoE 3-4).

Wet-vacuuming of the floor with a hospital disinfectant should be performed routinely after the last operation of the day or night. Care should be taken to ensure that medical equipment left in the operating room be covered so that solutions used during cleaning and disinfecting do not contact sterile devices or equipment.¹⁷

4. Microbiologic sampling

Because there are no standardized parameters by which to compare microbial levels obtained from cul- tures of ambient air or environmental surfaces in the operating room, routine microbiologic sampling cannot be justified. Such environmental sampling should only be performed as part of an epidemiologic investigation LoE 2b).¹

5. Operating room activities

Operating room air may contain microbial-laden dust, lint, skin squamae, or respiratory droplets. The microbial level in operating room air is directly pro- portional to the number of people moving about in the room.¹⁸ Therefore the number of persons entering the theatre during an operation should be minimized.

And unnecessary movement or conversation should be avoided (LoE 3).

PERSONAL HYGIENE

Staff can normally wear a personal uniform or street clothes covered by a white coat in hospital.

However, in view of the increasing number of re- sistant bacterial strains, most hospitals nowadays rec- ommend wearing only short sleeved working clothes and disposable aprons in all contact with the patients.

The working outfit must be made of a material which

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is easy to wash and decontaminate. If possible, a clean outfit should be worn each day. An outfit must be changed after exposure to blood or if it becomes wet through excessive sweating or other fluid exposure (LoE 3).⁹

All staff must maintain strict personal hygiene.

Nails must be clean and kept short. False nails should not be worn.

Hair must be worn short or pinned up. Beards and moustaches must be kept trimmed short and clean (LoE 4).

HAND HYGIENE

There must be written policies and procedures for hand washing. There are several levels of hand cleaning according to the needs. In summary (LoE 2b):

• Routine care and contact: Hand washing with non-antiseptic soap or hygienic hand disinfection with alcoholic based solution;

• Antiseptic hand cleaning in the care of infected patients: hygienic hand washing with antiseptic soap following the manufacturer’s instructions or, as a minimum, hand disinfection as above;

• Surgical hand and forearm preparation:

◦ Surgical hand and forearm washing with antiseptic soap for sufficient time and duration of contact, usually 3-5 minutes (manufacturer’s in- struction)

◦ Surgical hand and forearm washing with standard soap for same period of time, followed by drying and two applications of a hand disinfectant until dryness or according to the product’s recommendations

1. Patient contact

Hand hygiene is considered the primary measure to reduce the transmission of nosocomial pathogens (LoE 2b).^19,20 The importance of hands in the transmission

of hospital infections has been well demonstrated, and can be minimized with appropriate hand hygiene. The consistent practice of adequate hand hygiene, either by washing the hands with soap and water or disinfecting them with an antiseptic solution,²¹is considered to be the single most important intervention to prevent nosocomial infections.²⁰

Patients are put at potential risk of developing a hospital-acquired infection when a health care practitioner caring for them has contaminated hands. Hands must be decontaminated before every episode of care that involves direct contact with patients’ skin, their food, invasive devices or dressings. Hands need to be decontaminated after completing an episode of patient care to minimize cross contamination of the environment.^21-23 The preparations for the decontamination of hands include washing with plain soap and water, antimicrobial hand wash, and alcohol hand rub. In general, effective hand washing with a liquid soap will remove transient microorganisms and render the hands socially clean. This level of decontamination is sufficient for general social contact and most clinical care activities. The use of an antimicrobial liquid soap preparation will reduce transient microorganisms and resident flora, and result in hand antisepsis^21,22,24 The effective use of alcohol-based hand rubs on contaminated hands will also result in substantial reduc- tions of transient microorganisms, although alcohol is not effective at removing dirt and organic material.²⁴ However, alcohol hand rubs offer a practical and acceptable alternative to hand washing when the hands are not grossly soiled and are increasingly being recommended for routine use.^22,24

The duration of hand decontamination, the exposure of all aspects of the hands and wrists to the preparation being used, the use of vigorous rubbing to create friction, thorough rinsing in the case of hand washing, and ensuring that hands are completely dry are key factors in effective hand hygiene and the maintenance of skin integrity.^21,22

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2. Hand washing before surgery

The preparation of hand asepsis before surgery is well established and each hospital has to have clear rules. It includes washing of the hands and wrists and forearms for a defined period of time, clean short cut nails, rubbing with soap or antiseptic soap, thorough rinsing, drying and application of a disinfectant solution. Procedures will vary with the patient risk assessment.⁹

3. Jewells

Jewellery must be removed before washing.

SURGICAL ATTIRE

The term surgical attire refers to scrub suits, caps/hoods, shoe covers, masks, gloves, and gowns.

All persons entering the surgical theatre must wear surgical attire restricted to being worn only within the surgical area. The design and composition of surgical attire should minimize bacterial shedding into the environment. The use of surgical attires seems pru- dent to minimize a patient’s exposure to the skin, mucous membranes, or hair of surgical team members, as well as to protect surgical team members from exposure to blood and blood borne pathogens.^25-27 All personnel entering in the operating suite must remove any jewellery; nail polish or artifi- cial nails must not be worn.

1. Surgical caps or hoods

Surgical caps/hoods reduce contamination of the surgical field by organisms shed from the hair and scalp. SSI outbreaks have occasionally been traced to organisms isolated from the hair or scalp (S. aureus and group A Streptococcus), even when caps were

worn by personnel during the operation and in the operating suites.^28-29 All head and facial hair, including sideburns, and neckline, must be covered.⁹

2. Masks

The wearing of surgical masks during operations to prevent potential microbial contamination of incisions is a long-standing surgical tradition.³⁰ The efficacy and cost-benefit of surgical masks in reducing SSI risk are inconclusive. Nevertheless, wearing a mask can be beneficial since it protects the wearer’s nose and mouth from inadvertent exposures (i.e. splashes) to blood and other body fluids. There should be full coverage of the mouth and nose area with a surgical mask for everyone entering the operating suite.³¹ Masks of cotton wool, gauze, or paper are ineffective. Paper masks with synthetic material for fil- tration are an effective barrier against microorganisms.⁸

• Masks are used in various situations; mask require- ments differ for different purposes.

• Patient protection: staff must wear masks to work in the operating room, to care for immuno-compro- mised patients, and to puncture body cavities. A surgical mask is sufficient.

• Staff protection: staff must wear masks when caring for patients with airborne infections, or when per- forming bronchoscopies or similar examination. A high-efficiency mask is recommended. Masks with additional transparent face and eyes shields are used in case of patients with blood borne infectious diseases.

• Patients with infections which may be transmitted by the airborne route must use surgical masks when outside their isolation room.

3. Grown and apron

Protective clothing should be worn by all health care practitioners when blood, body fluids, secretions, and excretions (with the exception of sweat), or close

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contact with the patient, materials or equipment may lead to contamination of the clothing with microorganisms.²⁴

Plastic aprons are recommended for general use.¹⁵ Full body gowns need only be used where there is the possibility of extensive splashing of blood, body fluids, secretions or excretions, and these should be fluid repellent.³²

4. Shoe cover

The use of shoe covers has never been shown to decrease SSI risk or to decrease bacteria counts on the operating room floor.^33,34 Shoe covers may, however, protect surgical team members from exposure to blood and other body fluids during an operation.

5. Surgical gloves

Operating staff must wear sterile gloves. The use of gloves protect hands from contamination with organic matter and microorganisms and reduce the risks of transmission of microorganisms to both patients and staff.³⁰The reported occurrence of glove punctu- res ranges from 11.5% to 53% of procedures,³⁵ and double gloving is recommended when operating on patients known to be infected with blood borne pathogens such as the human immunodeficiency virus (HIV), hepatitis B, or hepatitis C.³⁶Gloves should be changed immediately after any accidental puncture.

Gloves must be discarded after each care activity for which they were worn in order to prevent the transmission of microorganisms to other sites in that individual or to other patients.^35,37

Cornstarch powder, used to assist in the donning of gloves, is harmful and is associated with adhesions, latex allergy, and increasing risks of infection associated with invasive devices contaminated with cornstarch powder.³⁸ As a consequence, powdered gloves should not be used in healthcare.³⁹

DISPOSAL OF SHARP ITEMS

The safe handling and disposal of needles and other sharp instruments should form part of an overall strategy of clinical waste disposal to protect staff, patients and visitors from exposure to blood borne pathogens. In general clinical settings, sharps injuries are predominantly caused by needle devices and associated with blood vessel puncture, administration of medication via intravascular lines and recapping of needles during the disassembly of equipment.^40-42

EDUCATION

Infection prevention and control personnel must be specifically trained in methods of SSI surveillance.

They must have knowledge of and the ability to pro- spectively apply the Centre for Disease Control and Prevention definitions of SSI. Also, they should pos- sess basic computer and mathematical skills, and be adept at providing feedback and education to healthcare personnel when appropriate.¹

It is essential to regularly provide education to the surgeons and operating room staff through continuing educational activities focusing on minimizing the SSI risk through implementation of recommended process measures. Several educational components can be combined into concise, efficient, and effective recommendations that are easily understood and remem- bered.⁴³ This also includes feedback on the outcome of implemented preventive measures from patients¹⁴ families, surgeons, and associated staff.

FURTHER RESEARCH

The evidence concerning the control of perioperative infections in the urological field are limited.

Hygiene refers to practices associated with ensuring good health and cleanliness. Existing study designs

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for hygiene are inherently weak. Unfortunately, appropriate prospective randomised studies are missing for most urological procedures. At present, most studies are poorly designed. Further studies for additional evidence, particularly specific to urological intervention, are necessary to make these guidelines more appropriate. Alternative precautions for high risk procedures are also required.

Education is one of the cornerstones for improvement within hygiene practices. Hygiene education must be promoted at all levels of experience to maintain good hygiene and aseptic techniques.

CONCLUSIONS

Good hospital hygiene is an integral and important component of a strategy for preventing hospital-acquired infections, therefore hygiene for both environment and personnel should be carried out. This includes hospital environment hygiene, hand hygiene and the use of personal protective equipment.

Education should regularly be provided to physicians and perioperative personnel through continuing educational activities.

ACKNOWLEDGEMENT

This article has been published earlier in the book of Urogenital Infection, edition 2010 by European Association of Urology - International Consultation on Urological Diseases.

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