Leech storage; surgical site: infection study; national patient safety goals; eating on instrument prep tables; razor shaving - Clinical Issues

AORN Journal, Feb, 2004 by Joan Blanchard

QUESTION: We use leeches for venous circulation therapy. One surgeon has requested that we keep the leeches in the OR for easy access; however, leeches were kept in the pharmacy at another facility in which I worked. Is it appropriate to keep leeches in the OR medication refrigerator? Should we be concerned that this practice might contribute to infection?

ANSWER: Leech therapy is useful for tissue that has impaired venous circulation. The disadvantages are few; however, infection, allergy, blood loss, and patient rejections have been cited as adverse effects. Aeromonas hydrophilia is normal flora in leeches' guts that aids in digestion of blood from patients' wounds, but it has been identified as a source of infection as well. Patients receiving leech therapy may need to receive prophylactic antibiotics for this therapy. (1)

The OR medication refrigerator probably would not be the best area to maintain your supply of leeches. A better choice for storing leeches would be laboratory or pharmacy refrigerators. Leeches arrive specifically packaged to keep them healthy during transport. They must be removed immediately from the packaging material to ensure their survival. Laboratory or pharmacy departments generally are responsible for receiving, preparing, storing, and distributing leeches. Laboratory or pharmacy personnel are responsible for preparing distilled water with hirudo salt to create an aquatic environment for the leeches to live in until they are used. Leeches must be housed and stored in a container with a tight-fitting lid before use. The container used to deliver leeches to the area of use should be able to contain them. Leeches are very elastic, which allows them to squeeze through small cracks and even air holes punched in containers. (2)

With proper handling and storage of leeches, there should be minimal risk of infection before use. It is best to store them in the laboratory or the pharmacy for point of use delivery. Application of leeches usually occurs in the nursing unit for postoperative patients. The OR is not an appropriate storage area because of the required preparation nor should OR personnel act as distributors of leeches.

QUESTION: We would like more information on the surgical site infections (SSIs) study being performed by the Centers for Medicaid and Medicare Services (CMS). Are SSIs a significant concern, and should we be involved in this project?

ANSWER: Surgical site infections are the second most common cause of health care-acquired (ie, nosocomial) infections in the United States. Morbidity, mortality, and increased health care costs related to SSIs are of considerable concern. (3) Approximately 27 million people have surgery annually, and it is estimated that 500,000 of these people will acquire a health care-acquired infection. (4) An estimated 40% to 60% of SSIs are preventable. (3) The CMS and the Centers for Disease Control and Prevention (CDC) formed a national collaborative in 2002 to develop the new CMS/CDC Surgical Infection Prevention (SIP) project. (3)

The mission of this collaborative effort is to create systems that decrease surgical infection rates. Hospitals can prevent infections by implementing a system-wide model of care. Identified personnel will collaborate and help each hospital achieve this mission and its specific goals. (5) One goal within the CMS/CDC SIP project is to decrease morbidity and mortality associated with postoperative infections in the Medicare patient population by promoting the appropriate selection and timing of administration of prophylactic antibiotics. A panel of multidisciplinary experts, including AORN members, developed three performance measures for national surveillance and quality improvement. These measures include patients

* who received prophylactic antibiotics within one hour before the surgical incision,

* who received prophylactic antibiotics consistent with current recommendations, and

* whose prophylactic antibiotics were discontinued within 24 hours after surgery.

The outcome indicators are to

* double the number of surgical procedures between SSI occurrences,

* reduce preventable SSIs by 90%, and

* achieve 100% compliance with appropriate selection and timing of prophylactic antibiotic administration. (3)

The Quality Improvement Organization (QIO), formerly known as Peer Review Organization, in each state will work with hospitals to improve these SSI prevention practice indicators. Hospitals are responsible for providing high quality care. The QIO helps with this responsibility by educating, analyzing data, providing quality improvement tools and techniques, and facilitating hospital compliance with the guidelines to enhance patient care and safety.

Hospitals may select other prevention practices, such as normothermia, glucose control, oxygenation, hair removal with clippers, and other infection prevention procedures. The procedures to be tracked are those procedures commonly performed on Medicare patients. These include coronary artery bypass grafting; other open chest surgery; vascular surgery, including aneurysm repair; thromboendarterectomy and vein bypass procedures; hip and knee total joint arthroplasty, excluding revision surgery; general abdominal colorectal surgery; and abdominal and vaginal hysterectomy.