IT'S ALIVE Your surface disinfection regimen needs to be able to handle bacteria, fungi and viruses.

We must remain vigilant in the fight against such infectious microorganisms as Clostri-dium difficile, Staphylococcus, Acinetobacter and Pseudomonas. To take down these invisible enemies, to prevent them from colonizing, you first have to know them. This quick, 3-question quiz drills down to deliver the answers on key infectious organisms that could be lurking in your facility.

1. Choose the microorganism set that correctly lists the organisms from most resistant to disinfectants to least resistant to disinfectants.

1. prions, bacterial spores, fungi, vegetative bacteria
2. vegetative bacteria, prions, bacterial spores, fungi
3. bacterial spores, prions, fungi, vegetative bacteria
4. prions, fungi, bacterial spores, vegetative bacteria

Answer: a. prions, bacterial spores, fungi, vegetative bacteria
The correct order is prions (such as Creutzfeldt-Jakob Disease), bacterial spores (such as C. difficile) fungi (such as Candida), vegetative bacteria (such as Staphylococcus and Pseudomonas).1 There are others on the resistance spectrum, but prions are the most difficult to kill. The good news? You can rest easy: Surfaces and the environment don't play a role in prion transmission.²

2. A patient has explosive diarrhea upon entry to the OR. You discover from the patient's record that an assay for Clostridium difficile is pending. What chemical disinfectant would you ask the housekeeper to use to clean the room after the case?

1. quaternary ammonium compound
2. a hospital-grade, EPA-approved disinfectant
3. 1:10 bleach-based product
4. 70% isopropyl alcohol

Answer: c. 1:10 bleach-based product.
C. difficile is an anaerobic, gram-positive bacterium that can persist for extended periods on a variety of surfaces in the environment because it is spore-forming. According to the Guide to the Elimination of Clostridium difficile in Healthcare Settings, "The term 'hypersporulation' has been used to denote the propensity of the bacterium to move from the vegetative form to the spore form with increased rapidity. The term has also been used to note that contact with some germicides stress the bacterium, so it more readily transitions to the spore form."³ That is, using the wrong disinfectant can actually make C. diff more difficult to eradicate.

The guide, published by the Association for Professionals in Infection Control and Epidemiology (APIC) further states that, "[a]lthough many EPA-registered germicides kill vegetative C. difficile, only chlorine-based disinfectants and high-concentration, vaporized hydrogen peroxide kill spores." With vaporized hydrogen peroxide still emerging as an option for outpatient facilities, this leaves the Centers for Disease Control-recommended regime: "The recommended approach to environmental infection control with respect to C. difficile is meticulous cleaning followed by disinfection using hypochlorite-based germicides." That is, bleach-containing disinfectants.⁴

3. What is the leading cause of surgical site infections in the United States?

1. methicillin-resistant Staphylococcus aureus
2. C. difficile
3. vancomycin-resistant Enterococcus
4. norovirus

Answer: a. methicillin-resistantS. aureus
S. aureus is the leading cause of surgical site infections (SSIs) in the United States.⁵ Antimicrobial prophylaxis is the main strategy to prevent methicillin-resistant S. aureus (MRSA), but it's important to note that surface disinfection also plays a role. Evidence is accumulating that contaminated surfaces contribute to transmission of all the answer options as well as Acinetobacter baumannii and Pseudomonas aeruginosa, and that improved environmental decontamination helps to prevent and control outbreaks.6 MRSA can live for months on surfaces.⁷

It's important to note that norovirus is the leading cause of outbreaks of infection in the United States. Last winter, norovirus was frequently in the headlines for causing many outbreaks, giving it timely significance for surgical facilities.⁸ A recent survey found that medical/surgical units represented 25.7% of 386 outbreak investigations reported by 289 hospitals over 24 months.8 Unfortunately (although perhaps not surprisingly), norovirus is "relatively resistant to the most common surface disinfectants."⁹

REDUCE CASE COSTS
5 Easy Ways to Save on Surgical Supplies

BASIN SET It's more economical to use basin sets than to stock each individual item.

Next to staffing, surgery's biggest cost is supplies. Unlike staffing, supplies are the one true variable in the fixed-cost business of surgery. Supplies typically account for 19% of case costs. The per-case supply cost will vary, but the industry average is about $300. Here at Golf Surgical Center, we incentivize our employees to find ways to reduce our case costs. Some of our best ideas:

1. Use basin sets. We switched from opening individual items to less-expensive basin sets. Basin sets include a sterile basin, 2 light handles, needle counter, ROPs (radio-opaque pads), quart bowl, kidney basin and sterile towels.

2. Prune your procedure packs. We pulled unused supplies from our packs and replaced pricey items with less expensive options. For example, our packs came with a pack of medication labels and a marker. We weren't using the $1 marker, so we asked to have it removed.

3. Reprocess. Our carts would typically include all sorts of supplies that were opened but went unused, such as shaver blades and phaco tips. We now send those items to a reprocessor so we're not wasting them. We also switched from disposable 7515 blades for cataract procedures to diamond blade knives.

4. Stretch those drapes. If our physicians agree, we use drapes out of sterile packs that weren't used or touched on the field for other "clean" procedures, such as ENT cases, where we can use "clean" drapes instead of sterile because they're not sterile procedures.

5. Switch from brand to generic drugs. We saved a lot when we switched to generic pharmaceuticals, including going from Marcaine to generic bupivacaine and from Ocuflox to generic ofloxacin. We also switched to vials of medications that need to be reconstituted instead of pre-mixed.

Rachel Shulkin, RN, BS
Golf Surgical Center, Des Plaines, Ill.
[email protected]