Debugging the OR
Hank Hogan
EDEN PRAIRE, MN—Operating rooms, by design, have sterile areas, and keeping such sterile fields clean of biocontaminants is a primary concern. But these biologically clean rooms may have a contamination source inside them that many infection control professionals aren't aware of it.
That is the result of a recently released survey. Conducted on behalf of Augustine Medical (Eden Prairie), the survey examined beliefs about the use of waterbath-based blood/fluid warmers in the operating room. According to the Augustine survey, some 40 percent of infection control professionals don't believe such devices are present in the OR and double that number are not aware that waterbaths are reservoirs for pathogens. However, waterbath-based products are present in 80 percent of operating rooms where fluids are warmed.
“Intuitively, clinicians know that waterbaths in the operating room are a concern, but they may not have made the connection to the risks of waterbath fluid warmers,” says John Carroll, a product manager at Augustine Medical.
Augustine makes a non-fluid based warming product, the Ranger system. According to Carroll, the Ranger takes only minutes to clean, and he notes that there have been no reports of cross-contamination. The Augustine product is in direct competition to the market leader, the SIMS Level 1 (Rockland, MA) HOTLINE. For it's part, Sims Level 1 maintains that either a hydrogen peroxide/distilled water mix or an isopropyl alcohol/distilled water mix is effective as both a decontamination solution and as a maintenance microbicide for the HOTLINE fluid warmer.
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Anecdotal evidence suggests that this may be the case, but the SIMS recommendation is not always being followed. Susan Burns, an infection control specialist at the Henry Ford Health System in Detroit, first became aware of the contamination potential of waterbath-based fluid warmers several years ago. This was due to an outbreak of bloodstream infections following microsurgical procedures.
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According to a study conducted by Burns, no definitive biocontamination culprit was found. However, cultures of the fluid warmers showed that the water had in excess of 100,000 colonies of multiple gram negative organisms. This, notes Burns, is not an isolated finding.
“I have a lot of peers in infection control that have actually cultured the water and found the exact same thing, that it's just loaded with gram negatives,” she says.
Operating room observation by Burns revealed that connecting or disconnecting the waterbath fluid warmer lead to water spraying out through open ports. That, too, has since been confirmed by anecdote to be a common occurrence. Thus, there is potential for contamination of clinicians' hands or the OR environment.
In the study of the Henry Ford hospital outbreak conducted by Burns, none of the organisms found in the water matched those in the patient. So, no definitive link could be established. However, after relocating some activities and changing fluid-bath cleaning guidelines, the problem disappeared.
In changing the guidelines, the hospital enforced the recommended cleaning regimen. With 27 waterbath-based warmers in use, this meant that the hospital had to add a full time employee just to clean the waterbaths. It's this burden that may explain why the contamination problem persists. According to Burns, the manufacturers have procedures and recipes that are effective in controlling the problem.
“A lot of times it's user error because users choose not to use those recipes,” she remarks.
Ultraviolet light illuminates contaminants on an IV-pole that holds a leaking water bath warmer (top). Augustine's blood/fluid warmer system (middle). Waterbath-based blood warmer leaking water (bottom).