Infection prevention strategies are documented in the Qur’an, Old Testament, and the Torah, and forward throughout history (Cule, 1987; Forder, 2007; Miller, Rahimi, & Lee, 2005). Holmes (infection transmission), Semmelweis (hand hygiene), Pasteur (germ theory), Nightingale, Lister, and Keen (surgical sterility), Bergmann (steam sterilization), Neuber, Mikulicz, and Halstead (personal protective equipment), Fleming (penicillin), and Haley (infection prevention discipline) have built on previous knowledge culminating in a compendium of infection prevention strategies, which, if applied, can reduce the risk of infection in hospitalized patients to nearly zero. Unfortunately, infection continues to plague the hospitalized patient (Brennan et al., 1991), though not as widespread today as the historic 50% mortality potential for a soldier undergoing surgical intervention during the mid-19th century Crimean or Civil Wars.

In 1995, Hecht estimated that by 2000, approximately 75% of all surgical procedures in the United States would be performed in an out-of-hospital environment, such as in an ambulatory or same-day setting (Hecht, 1995). National statistics for 2006 demonstrate that this prediction was optimistic (Cullen, Hall, & Golosinskiy, 2009; DeFrances, Lucas, Buie, & Golosinskiy, 2008), with more than 50% of all surgical procedures performed as ambulatory procedures (Maki & Crnich, 2005). The significance of this phenomenon is the potential to miss an untoward event, such as the development of surgical site infections (SSI), as patients may be lost to follow-up in the ambulatory setting (see Table 10 - 1).

In 1999, the Institute of Medicine (IOM) released its report, To Err is Human: Building a Safer Health System, which reported that up to 98,000 people die each year because of medical errors, and wound infections were the second most common adverse event to occur to hospitalized patients after drug complications (John & Donaldson, 1999). Two to five percent of surgical procedures are complicated by SSIs each year (Institute for Healthcare Improvement [IHI], 2008; Magill et al., 2014), with rates up to 11% for some procedures (Cruse, 1994). That percentage represents an estimated 157,500 SSIs per year in the United States. However, according to the 2013 Centers for Disease Control and Prevention (CDC) National and State HAI Progress Report, acute care hospitals experienced a 19% reduction in SSIs compared to 2008 (CDC, 2015). Each SSI is estimated to increase a hospital stay by 7 to 10 days, and add more than $11,000 to $35,000 in charges, an estimated annual national cost of $3 to $10 billion (Scott, 2009).

Legislative mandates and reimbursement limits designed to accelerate healthcare facilities’ implementation of infection risk-reduction strategies are now in effect in many states in the United States. In California, for example, the requirement to report deep and organ space infections as the result of select surgical procedures was effected in 2009. The state department of health is required to publicly report statewide data for SSIs annually. In response to the federal Deficit Reduction Act of 2005, the Centers for Medicare and Medicaid Services [CMS] (2007) instituted their Value-Based Purchasing initiative, intended to link “payment more directly to the quality of care provided, [as] a strategy that can help to transform the current payment system by rewarding providers for delivering high quality, efficient clinical care.” Legislative and reimbursement decisions have spurred healthcare facilities to implement strategies with demonstrated positive outcome effects, as well as unproven risk-reduction strategies (Chavez et al., 2005; Mangram, Horan, Pearson, Silver, & Jarvis, 1999). This chapter will provide the reader with strategies for demonstrated positive outcome effects.

Table 10-1 Surgical Procedure Volume, United States, 2006

1.What are the basic critical elements of infection and prevention?

Answer

2.What is a written functional program?

Answer

3.What are important aspects of the physical layout of a PACU that should be considered to reduce infection risks?

Answer

4.What air handling (airflow and air exchange) is necessary to protect both patients and personnel in the PACU?

Answer

5.What workflow elements in the PACU should be considered to reduce infection risks?

Answer

6.How can storage in the PACU support workflow and reduce infection risks?

Answer

7.What hospital finishes are appropriate for a PACU?

Answer

8.What are the important elements to include in a cleaning policy and who should be involved in developing such a policy?

Answer

9.What information is important to include in a hand hygiene policy?

Answer

10.What personal protective equipment (PPE) should be used in the PACU?

Answer

11.Many PACUs are designed with open bays. What isolation precautions can be used in that type of PACU arrangement?

Answer

12.What considerations should be given to occupational health?

Answer

13.What attire should PACU nurses wear and what personal appearance practices should PACU personnel keep?

Answer