Minimizing The Risk Of Perioperative Infection In Patients With Wounds
What is your protocol on hand hygiene between patients?
As for hand scrubs, Dr. Suzuki follows the hand hygiene guide from the Centers for Disease Control and Prevention. He uses antibacterial chlorhexidine soap scrubs for the hands in the morning or for the first case of the day. Dr. Suzuki follows this with alcohol hand gel for the subsequent cases or when entering and exiting the patient’s room in the hospital, or in the wound care center. Before applying gloves to treat the first patient, Dr. Bell always washes his hands and uses a hand sanitizer, either alcohol or iodine-based. He repeats this process immediately after seeing patients.
In between patients, Dr. Bell always washes his hands thoroughly. Likewise, between surgeries, Dr. Armstrong will use a gel prep.
As for hospital or long-term facility patients, before starting any patient contact, Dr. Bell uses a hand sanitizer as soon as he can find the nearest dispenser. Dr. Suzuki’s facility has a Purell dispenser outside each patient’s room, noting there is no excuse for staff not to use them.
“Since the hospitals are held accountable by the CMS for hospital-acquired infection these days, I’ve seen people written up for not complying with this hand hygiene protocol,” says Dr. Suzuki.
At the end of the day, Dr. Bell will repeat the washing and hand sanitizing ritual.
“It becomes second nature and sometimes feels a bit obsessive-compulsive, but you must do all you can to prevent from being the transmitter of bacteria between patients, your family and yourself,” emphasizes Dr. Bell.
Which solutions and devices do you use for wound irrigation and cleansing?
Dr. Suzuki and Dr. Bell use normal sterile saline. Dr. Suzuki will use saline in a 30 mL plastic container (Saljet Rinse, Winchester Laboratories). He calls this “a nice alternative” to a syringe and a big 500 mL saline bottle, saying the larger bottle can be cumbersome and possibly cross-contaminated if one is using the same bottle on more than one patient.
If his patients are changing their dressings at home, Dr. Suzuki encourages them to use tap water to irrigate the wound unless they have deep wounds that penetrate into bone or joints. He cites studies that drinkable, municipal tap water is clean enough for wound irrigation, and tap water does not increase the infection rate any more than using a sterile saline bottle, a prescription item that may be costly to some patients.3
In regard to irrigation in the OR, Dr. Bell says sometimes a bulb syringe is adequate but in many instances in which a deep infection is present, he most often uses pulsed lavage.
Dr. Armstrong uses Pulsavac (Zimmer) and Versajet (Smith and Nephew) for nearly all cases. If one uses the Versajet deftly, Dr. Armstrong says it can be enormously helpful in debulking flaps, removing non-viable tissue cleanly and preparing wounds for split thickness skin grafts. Dr. Bell has also found the Versajet to be an exceptional way to debride and clean wounds in the OR, where significant necrotic tissue is present. He also cites significant time savings in using the device.
Dr. Suzuki uses the Qoustic Wound Therapy System (Arobella Medical), a 35 kHz ultrasound debridement device that uses a bag of sterile normal saline (0.9% sodium chloride solution).4 He notes this device can achieve “excellent” wound cleansing and debridement as well as physically destroying the wound surface bacteria.
Dr. Armstrong is a Professor of Surgery at the University of Arizona College of Medicine in Tucson, Ariz. He is the Director of the Southern Arizona Limb Salvage Alliance (SALSA).
Dr. Bell is a board certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.