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Friday, December 23, 2005

QUESTION: Are waterborne infections a common concern in health care facilities? Can our water supply contribute to infection transmission? How does the transmission occur? What types of microbes cause waterborne infections? Which patients are most at risk? How can health care facilities reduce the risk of waterborne infections?

ANSWER: Water supplies can contribute to infection transmission. Microbe survival in a hospital's water supply was first identified more than 30 years ago. (1) The water supply also is one of the most controllable sources of nosocomial microbes in health care settings. (1) Health care providers and administrators may believe they do not have a problem in their facility, but they may not be performing the correct type of sampling and culturing of their water. (2)

Waterborne infections transmission comes from the buildup of biofilm on and corrosion of water supply lines and lining of the water tank. Increased water use or construction during summer months increases the possibility that stagnant water in the lines will loosen organisms from biofilm, which then enter the water supply. (1) Water tap aerators that have become corroded also can collect biofilm. (3)

Exposure can occur when a patient showers, bathes in, or drinks the water. Transmission also may occur via equipment that becomes contaminated with the tap water used to rinse or wipe equipment or by health care workers contacting contaminated equipment. (1) Aerosolization of contaminated water sources also may be a means of waterborne infection transmission. (2)

Gram-negative bacilli identified as causing waterborne infections are

* Acinetobacter species,

* Burkholderia cepacia,

* Chryseobacterium species,

* Ewingella species,

* Legionella species,

* Pseudomonas species,

* Serratia marcescens, and

* Stenotrophomonas maltophilia.

Pseudomonas aeruginosa, a well-known pathogen that causes nosocomial outbreaks, (4) does well in moist and humid environments where it can grow in large numbers with hardly any sustenance. (3) For example, Pseudomonas aeruginosa can grow in endoscopes and spray bottles.

Fungi also can cause hospital-acquired infections that may be linked to a hospital's water supply. Examples of fungi cultured from shower heads include Aspergillus species and Fusarium. These fungi also can be transmitted to patients via aerosolization. Aspergillus fumigatus can cause pneumonia and, in certain circumstances, surgical site infections.

Mycobacterium species, excluding Mycobacterium tuberculosis, may be found in the water supply. Some Mycobacterium species can survive and grow in water temperatures greater than or equal to 45[degrees]F (7.2[degrees]C). Nontuberculous mycobacterium has caused infections in cardiac and procedures, as well as dialysis and injection sites. Nontuberculous mycobacterium are resistant to some disinfectants, including chlorine, glutaraldehyde, and formaldehyde. (4)

Immunosuppressed or immunocompromised patients are at higher risk for contracting waterborne infections. Patients who may be reasonably immune and who exposed to water that has microbes with a high level of virulence also may be at risk. These patients may have had an invasive or diagnostic procedure (eg, laparoscopy, colonoscopy, endoscopy). (5)

One step in preventing waterborne infections is using filters that remove bacteria. The Centers for Disease Control and Prevention recommends that the water filters have 0.2 micrometer filtration capability. Filters are successful in filtering bacteria and can be placed easily on faucets and showers. (2) Cleaning of faucets and aerators should include removing corrosion, although this may not be an effective method for decreasing buildup of microbes. (5) An alternative method would be to remove the aerators and place a filter on the faucets. (2) Chemical disinfection (eg, adding chlorine to the water) can be used but may change the taste of the water and possibly could lead to development of multiple resistant strains of microbes. Running water that is heated to 75[degrees]F (24[degrees]C) for 60 minutes may be another measure for filtration but is difficult to accomplish in a health care setting. (5)

Waterborne infections are a serious concern. Protecting patients from acquiring a waterborne infection is key to decreasing the potential for infection. Good environmental cleaning and use of water filtration systems helps provide a barrier to transmission of waterborne infections.

QUESTION: Frequently, we have to take cultures of the surgical wound during surgery. We usually use a cotton swab to collect drainage or fluid present in the wound. Is this an appropriate method for obtaining a wound culture? Does this give an accurate report of what is growing in the wound? What are some identified problems with specimen collection? What are essential steps for safe handling of specimens?

ANSWER: Using a cotton swab is not always the appropriate method for collecting a wound culture. Anaerobic cultures should be collected by aspirating the fluid using a sterile syringe and needle to ensure that atmospheric oxygen does not come in contact with the specimen. Surface lesions must be cleaned and then opened to obtain a sample of the margin. When collecting aspirated material or material with a needle and syringe, the specimen should not be placed on a swab.

Collected aspirates should be placed in a sterile tube or vial. (6)

Specimens should be chosen that reflect the disease process occurring in the patient. Specimens frequently arrive in the laboratory mislabeled or without appropriate labeling. Following are a few examples of errors that can occur during specimen collection and labeling.

* Wound specimens--Identifying a specimen as "wound" is inadequate. The actual wound site should be specified. The paperwork should state whether the culture was taken at the superficial level or deeper. Exudate by itself does not give an accurate culture result because it may only show contaminants.

* Ear specimens--These specimens usually are obtained from patients with otitis media. Swabbing material from the ear canal is not appropriate. The fluid should be obtained by using a small-gauge needle and syringe. Swabbing a specimen should only be performed if the tympanic membrane has ruptured.

* Sputum specimens--These specimens very often are contaminated with oropharyngeal flora. A bronchoalveolar lavage or a transtracheal aspirate would provide a more appropriate sample for culturing. (6)

The essentials for safe handling of specimens include

* using an appropriate container for the specific type of specimen being collected;

* labeling specimen containers correctly on and off the field;

* identifying the patient, tissue, and specimen source correctly;

* verifying the type of specimen and appropriate patient information before transferring the specimen off the sterile field;

* handing the specimen off the sterile field safely;

* transferring the specimen safely to the point of use;

* ensuring that a tracking mechanism for the specimen is in place and used correctly;

* documenting verbal and written instructions on the laboratory form and patient record and within the tracking system;

* ensuring appropriate storage and maintenance of specimens before they are sent to the laboratory; and

* transferring specimens to the laboratory safely. (7) Using the correct method to obtain a wound culture should provide an accurate culture result.

QUESTION: We have seen the ambulatory National Patient Safety Goats from the Joint Commission on Accreditation of Healthcare Organizations. We have heard that there are new hospital National Patient Safety Goals. What is new for 2006 and how will the new goats work in the perioperative areas?

ANSWER: Two new 2006 hospital National Patient Safety Goal requirements will involve perioperative patient care.

* Requirement 2E--Implement a standardized approach to "hand-off" communications, including an opportunity to ask and respond to questions. (8) An example of hand-off communications is the report given by the circulating nurse to the postanesthesia care unit (PACU) nurse when the patient is taken to the PACU after the surgical procedure is completed. This includes discussing

** a baseline assessment of the patient;

** the patient's skin condition and position during the procedure;

** the patient's skin condition and placement site for electrodes;

** irrigating fluids used in the wound;

** medications or dyes used during the procedure;

** types, numbers, and sites of implants, transplants, or explants;

** drains, stents, and dressings;

** any other information relevant to the patient's care; and

** family members and others present and their locations. (9)

* Requirement 3D--Label all medications, medication containers (eg, syringes, medication cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings. (8) AORN's guidance statement, "Safe medication practices in perioperative practice settings," addresses the need for labeling medications on and off the sterile field. (10) The essentials for safe medication practice include

** verifying that medication labels are accurate;

** delivering medications onto the sterile field in an aseptic manner;

** labeling medications on and off the sterile field and confirming each label;

** communicating the type of medication, strength, and dosage as the medication is passed to the person who will administer the medication; and

** knowing the dose limits and monitoring the patient for any untoward reactions to the medications. (10)

AORN's "Recommended practices for safe care through identification of potential hazards in the surgical environment" also addresses medications delivered to the sterile field. (11) As a precaution, all medication containers should remain available until the procedure is completed. (10) AORN has developed a Safe Medication Administration Tool Kit that offers a comprehensive approach for safely administering medications to promote good patient outcomes. The tool kit includes a CD ROM; a conversions and calculations pocket guide; and an herbal and dietary supplement poster that presents common indications, side effects, and herbal and dietary supplement medication interactions. For more information on the medication tool kit, call AORN at (800) 755-2676 x 1.

QUESTION: Our hospital is concerned about postoperative sternal infections after open heart surgery. The heart surgeon is using a vancomycin paste on the edges of the sternum before the sternum is wired closed at the end of the procedure. The vancomycin vial is sterilized by steam sterilization or by ethylene oxide sterilization and then placed on the sterile field where a paste is made of the contents and applied to the edges of the sternum. Is this an appropriate method of using vancomycin? Is this an appropriate method of achieving antibiotic prophylaxis?

ANSWER: Sternal infections after open-heart surgery are a concern. Vancomycin is not approved for topical use. It is only approved for use via oral and IV routes of administration. (12) The vancomycin material safety data sheet states that it can be irritating to eyes, mucous membranes, and the respiratory tract. Furthermore, vials should be stored at room temperature (59[degrees]F to 86[degrees]F [15[degrees]C to 30[degrees]C]) before they are reconstituted. (13)

The Centers for Medicare and Medicaid Services National Surgical Infection Prevention Project prophylaxis recommendations for cardiothoracic surgery is cefazolin or cefuroxime, 30 to 60 minutes before the incision is made. Vancomycin or clindamycin can be used if the patient has an allergy to beta lactams. If vancomycin is used, it should be administered two hours before the incision is made. (14) Vancomycin should be used according to the manufacturer's guidelines and the appropriate route should be used for prophylaxis.

QUESTION: We are concerned about vaginal prep solutions. What is AORN's recommendation for selecting a skin preparation product? Should chlorhexidine be used for vaginal preps?

ANSWER: AORN's Recommended practice for product selection," provides criteria to be used during product selection. These include

* safety,

* quality,

* effectiveness,

* purpose and use,

* ease of use,

* compatibility with other products,

* appropriate clinical outcomes, and

* efficacy. (15)

Evaluation should be performed with each new product selected. (15) AORN's "Recommended practices for skin preparation" states that the antiseptic agent selected should be used according to the manufacturer's guidelines. (16) Guidelines provided by the Association for Professionals in Infection Control and Epidemiology and the US Food and Drug Administration should be reviewed when selecting antiseptics.

Chlorhexidine gluconate may cause allergic reactions including irritation and sensitization when used in the genital areas. (16) After a product is selected, follow the manufacturer's guideline and AORN's "Recommended practices for skin preparation," when performing vaginal preps. (16,17)

QUESTION: We use disposable, cordless, battery-operated electrocautery hand pieces for some small surgeries. These are disposed of in the trash. Is there a potential fire hazard from disposing of them in this manner?

ANSWER: There is a potential for starting a fire if the tip of the cordless electrocautery hand piece is not removed and the cap is not replaced before it is put in the trash. The weight of trash placed on top of the electrocautery hand piece could activate the unit if the on/off switch is in the on position. This could cause the electrocautery wire to heat. It is important that all staff members be instructed in proper disposal of cordless electrocautery hand pieces. (18)

The safest practice when using a cordless electrocautery hand piece is to dispose of the electrocautery hand piece in a fire-rated sharps disposal container after the tip is removed and the cap is replaced. For additional resources on fire prevention, see the AORN "Position statement on fire prevention," at /about/positions/pdf/Final%20PS %20on%20Fire%20Prevention .pdf and the "Guidance statement on fire prevention in the operating room" at http://www TI-2e-firesafety.pdf.

Editor's note: At various times throughout the year, the Recommended Practices Committee seeks review and comment on proposed recommended practices. from members and other interested individuals. When available, these proposed recommended practices appear on AORN Online at Interested individuals who do not have access to the Internet may obtain copies of the proposed documents by calling, the Center for Nursing, Practice at (800) 755-2676 x 334. Proposed recommended practice documents are available for review and comment for a 30-day period after they are posted A deadline for comments is indicated with each document. Please check these sources frequently to locate proposed recommended practices. All comments received are considered as the document is finalized. Thank you for your participation.


(1.) E Anaissie et al, "The hospital water supply as a source of nosocomial infections: A plea for action," Archives of Internal Medicine 162 (July 8, 2002) 1483-1492.

(2.) J Schraag, "Waterborne pathogens: What's lurking in your facility's pipes?" Infection Control Today 9 (July 2005) 14-19.

(3.) M Trautmann et al, "Ecology of Pseudomonas aeruginosa in the intensive care unit and the evolving role of water outlets as a reservoir of the organism," American Journal of Infection Control 33 Suppl 1 (June 2005) S1-S49.

(4.) G Orotolans et al, "Hospital water point-of-use filtration: A complementary strategy to reduce the risk of nosocomial infection," American Journal of Infection Control 33 Suppl 1 (June 2005) S1-S19.

(5.) C Squier et al, "Waterborne nosocomial infections," Current Infectious Disease Reports 2 (December 2000) 490-496.

(6.) J M Miller, A Guide to Specimen Management in Clinical Microbiology, second ed (Herndon, Va: American Society of Microbiology Press, 1999) 5-6.

(7.) "Safe specimen identification, collection, and handling in perioperative practice settings," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 205-207. Also available at /pdf/SECTI-2e-spechandling .pdf (accessed 20 July 2005).

(8.) "2006 critical access hospital and hospital National Patient Safety Goals," Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho .org/accredited+organizations/patient +safety/06_npsg/06_npsg_cah_ hap.htm (accessed 20 July 2005).

(9.) N Phillips, Berry & Kohn's Operating Room Technique, 10th ed (St Louis: Mosby, 2004) 585.

(10.) "Safe medication practices in perioperative practice settings," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 196-198.

(11.) "Recommended practices for safe care through identification of potential hazards in the surgical environment," Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 389-390.

(12.) G Spratto, A Woods, PDR Nurse's Drug Handbook (Clifton Park, NY: Thomson Delmar Learning, 2004) 1225-1227.

(13.) "Vancomycin hydrochloride for injection," Eli Lilly and Company, /msds/msds_vancomycin_hydrochlo ride_for_injection.html (accessed 21 July 2005).

(14.) D Bratzler, P Houck, "Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project," Clinical Infectious Diseases 38 (June 15, 2004) 1706-1715.

(15.) "Recommended practices for product selection in the perioperative practice setting," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 433-436.

(16.) "Recommended practices for skin preparation of patients," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 445-451.

(17.) "Hibiclens antiseptic/antimicrobial skin cleanser," Regent Medical, (accessed 25 July 2005).

(18.) S Beumer, "Potential fire threat at medical offices," (memorandum to Aurora, Colo, Fire Department personnel) Aurora, Colo, June 29, 2005.





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