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Infection rates ignite after OR alcohol ban
Balancing fire risks and infection prevention
A hospital that restricted the use of alcohol-based skin preps (ABSPs) in operating rooms due to concerns about surgical fires saw infection rates flame up in very short order. "In our hospital, we noted that there was a high neurosurgery infection rate that occurred during the time period of restricted alcohol use," said Marion Pkrywka, MS, CIC, an infection control professional at the University of Pittsburgh Medical Center. "So we think there was a likely association between the increase in those infections and removing the alcohol skin prep."
Surgical fires have prompted some state safety officials to ban use of ABSPs on patients in the operating room if cautery or lasers will be used. According to The Joint Commission, the fire triangle — heat, fuel, and oxygen — must be present for a fire to start. If the three elements come together in a hospital's surgical suite, the results can be disastrous. Though they are considered rare occurrences in the health care environment, The Joint Commission reported that there are approximately 100 surgical fires each year, resulting in up to 20 serious injuries and one or two patient deaths annually.1
"Surgical fires are very significant events and certainly can be devastating," Pkrywka recently said in Baltimore at the annual conference of the Society for Healthcare Epidemiology of America (SHEA). In addition to lasers and cautery devices, a spark can arise from the use of high-speed drills or fiber optic cables, she noted. "What can burn in the OR? Almost anything: sponges, drapes, towels, hoods, masks, anesthesia circuits, multiple types of dressings, and also some ointments and flammable solutions, in particular alcohol prep solutions," Pkrywka added.
And therein, literally, lies the rub, because applying the alcohol to kill pathogens at the surgical site brings fuel to a potential fire. On the other hand, ABSPs help prevent surgical-site infections, one of the most prevalent and costly nosocomial complications. "This presents a problem for those of us in infection control," Pkrywka said. "Certainly, alcohol-containing preps rank among the most rapid [acting] and also the most effective agents for preventing infections. But they are flammable, even in concentrations as low as 4%."
As a result, the National Fire Protection Association (NFPA) 1999 Standard on Healthcare Facilities dictated that liquid germicides and antiseptics, used in anesthetizing locations where electrocautery or laser is in use, shall be nonflammable. However, given the infection-reduction benefits of the alcohol preps, the American Society of Hospital Engineers (ASHE) prompted the NFPA to write a Tentative Interim Amendment (TIA) to the standard in 2005. Nevertheless, the Pennsylvania Department of Health did not immediately recognize the TIA and banned the alcohol products. Pkrywka's hospital complied for a brief period before working out a solution with the state, but she was curious about what effect the ban had on infection rates when it was in effect.
The surgical-site infection (SSI) rate in a neurosurgical service, in which 70% alcohol had been used routinely as part of a three-part surgical prep, was monitored for potential impact. The SSI rate during the period in August 2006 when alcohol was banned was compared to SSI rates during historical and successive time periods. The August 2006 neurosurgery SSI rate was 3.0 (10 SSIs/323 procedures) vs. 0.9 (38 SSIs/4,088 procedures) in the preceding 12 months and 1.2 in the next two months (nine SSIs/754 procedures).2
"We tripled our infection rate," Pkrywka said. "This was quite a shock to our infection control committee." The results were somewhat complicated by some use of alcohol preps despite the ban, but the overall findings suggested a direct relationship between the policy and the infection rate rise. "The change in the standard skin prep was the only change detected and was likely responsible for the increased SSI rate," she said.
The state health department decided to grant hospitals an exemption to the ban if they adopted safe-use policies such as calling a timeout to allow the solution to dry before applying surgical drapes over the patient. "We established a very definite protocol for timeout, we limited the application of the products, and we provided a lot of staff education," Pkrywka reported. "Alcohol products were reintroduced the next month. The neurosurgery infection rate went down and it stayed down, returning essentially to baseline. Guidelines are certainly available out there for the safe use of alcohol products in the OR."
Those include those issued by the Emergency Care Research Institute (ECRI).3 Rather than prohibiting specific products to reduce the risk of fire, the ECRI guidance offers ways that the risk of surgical fires can be mitigated through effective management of each of the key patient care elements that could contribute to fires: