Necrotizing fasciitis

QUESTION: Recentty, we had a patient with necrotizing fasciitis (NF) in our OR. None of our staff members had ever cared for a patient with this disease, and we were very concerned about the patient and the possibility of disease transmission to staff members. What is NF and how does it manifest itself? Can it be treated? Is it possible for NF to be transmitted to staff members who are caring for a patient with this disease?

ANSWER: Necrotizing fasciitis also is called a disease of flesh-eating bacteria. It may affect any part of the body, but the most common areas affected are the abdomen, perineum, and extremities. (1) Signs and symptoms of early NF are fever, severe pain and swelling, and redness at a wound site. (2) Erysipelas (ie, bright red, indurated skin lesions) may appear. Injury occurs beneath the skin where pathogens attack the fascia and fatty layers. The pathogens then travel, and injury progresses to the muscle and up through the skin. Most often, NF occurs postoperatively, but it also can occur as a result of external or internal trauma involving breaks in the skin.

There are three types of NF. Each type has its own bacterial sources.

* Type I NF involves both

** aerobic--gram-negative bacteria, including streptococci (ie, other than group A), Escherichia, Enterobacter, Klebsiella, and Proteus species;

** anaerobic--gram-positive bacteria (eg, Peptoccocus species, Clostridium species) and gram-negative bacteria (eg, Bacteroides, Fusobacterium); and

** aerobic to anaerobic--Coryne-bacterium.

* Type II is the most common type of NF. Beta-hemolytic streptococci is the most prevalent bacteria. Less commonly, Staphylococcus aureus and Streptococci B, C, and G have been identified as causes of type II NF.

* Type III involves marine Vibrio that may result from puncture wounds from fish or insects. (2)

Standard precautions should be used when caring for patients with NF. Personal protective equipment (ie, sterile barrier gown, gloves, mask, eye wear) should be used when surgically debriding wounds or when caring for a wound that may require irrigation. It is very important to use aseptic technique when caring for these wounds. (1) Transmission of group A streptococcal disease occurs by person-to-person contact with infectious secretions. (2)

Treatment involves surgical debridement, after which skin and muscle grafting may be required. Initial antimicrobial therapy should include treatment for gram-positive and gram-negative pathogens. If abdominal or perineal areas are affected, the patient may require a colostomy or urinary diversion.

Necrotizing fasciitis is a rare disease, but it causes high mortality rates. Necrotizing fasciitis may be confused with other diseases such as cellulitis. Prompt diagnosis is critical. (1) Use of standard precautions, especially good hygiene practices, can prevent transmission.

QUESTION: The patient surgery waiting lounge at our facility has an area where pediatric patients can pray. These children may be waiting to be called for their surgery, or they may be children of a patient going to surgery. We are not quite sure how to dean the toys kept in this area. Is there a danger of disease transmission from many children playing with the same toys? How should the toys be cleaned? What types of toys are recommended for a surgery waiting Lounge?

ANSWER: There is a risk of disease transmission if many children are allowed to play with the same toys. Toys that are suitable for the hospital setting are toys that can be washed and disinfected between uses. In one study, cultures of some toys isolated coagulase-negative Staphylococcus, Staphylococcus aureus, Serratia marcesens, Streptococcus species, Pseudomonas species, Enterococcus faecalis, and Escherichia coli. (3)

Any toys that a child might place in his or her mouth should be washable. (4) Infants and toddlers should not share toys. Toys should be disinfected between uses (3) and rinsed well. (4) Children who wear diapers should be given only washable toys.

If possible, it is best to wash toys in a dishwasher. (4) If toys are not dishwasher safe, they should be

* washed in warm, soapy water;

* rinsed in clean water;

* submerged in a solution of one part bleach to 10 parts water for 10 to 20 minutes;

* rinsed thoroughly; and

* allowed to air dry. (3)

Toys may be a reservoir for microorganisms and should not be shared. Proper cleaning helps prevent transmission of pathogens from children to the toys and from the toys to other children.

QUESTION: We work in an ambulatory surgery center and perform clean procedures. Our patients are healthy, and we do not have many surgical site infections. Do we need to disinfect the surfaces in ORs after each procedure? What are considered critical and noncritical items?

ANSWER: Disinfecting surfaces is an efficient way to decrease the possibility that patients will acquire surgical site infections. Contaminated surfaces may transmit infectious pathogens to health care workers hands, which then can cause person-to-person transmission. (5)

The Spaulding Classification System has been used for many years to determine what level of disinfection is needed. (6)

* Critical items that enter sterile tissue or the vascular system (eg, sutures, implants) must be sterile.

* Semicritical items that will come in contact with mucous membranes and nonintact skin (eg, bronchoscopes, laryngoscopes) require high-level disinfection.

* Noncritical items that come in contact with intact skin only (eg, blood pressure cuffs, linens, floors) require low-level disinfection. (7)

Disinfectants should be used on noncritical surfaces for the following reasons.

* Epidemiologically important microbes (eg, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, Clostridium difficile) may be present on environmental surfaces and can be transmitted from these surfaces.

* The Occupational Safety and Health Administration requires that surfaces exposed to blood or other body fluids be disinfected because they may be infectious. (8)

* Detergents are not as effective as disinfectants at lowering the microbial load on floors; therefore, use of a disinfectant approved by the US Environmental Protection Agency is recommended. If a detergent is used, solutions should be changed as needed because contaminated detergent may be a reservoir for seeding the area with bacteria.

* The Centers for Disease Control and Prevention (CDC) recommends disinfection of noncritical surfaces for patients who are on isolation precautions. (9)

It simplifies the process for decontamination of floors and equipment when the same disinfectant used in the practice setting is used for orientation of personnel. (5) For example, do not teach new employees to disinfect with a phenol solution if the department they will be assigned to uses quaternary ammonium disinfecting solution. A standard practice of cleaning should be used to prevent surgical site infections and maintain a clean and safe environment.

QUESTION: Perioperative staff members want to update the clinical practice patterns in our hospital We have always used nursing textbooks as a guideline for updating clinical practice patterns. Are there better resources available that we could use?

ANSWER: A better way to update or improve clinical practice patterns is to use evidence-based nursing practice, which uses research to support clinical decisions.(10) Research, which is based on scientific literature, expert opinion, and levels of evidence, is the optimal method of supporting clinical practice.

An example of evidence-based practice in the perioperative area is how ORs are cleaned. In the past, cleaning an OR required mopping the floors from wall to wall. Studies demonstrated that this is not necessary when there is no visible soiling. As a result, AORN's "Recommended practices for environmental cleaning in the surgical practice setting" were adapted to require that a 3-ft to 4-ft perimeter around the OR bed be cleaned after each procedure. (11) The OR bed should be moved to check for visibly soiled areas or debris. (12) According to the CDC, mopping is not required if there are no visible signs of contamination after a procedure is completed. (9,13)

Evidence-based practice provides improved patient outcomes and rapidly is becoming the approach for changing clinical nursing practice. (14) Table 1 provides a variety of evidence-based practice resources.

QUESTION: We have no idea what quality of barrier protection is provided by the gowns and drapes used in our setting. We are concerned that the fever of protection provided may not be appropriate for air the types of surgery performed in every area of our perioperative department. Is there a guideline that we could use for determining what should be used for different levers of protection? What issues should we be concerned about?

ANSWER: The Association for the Advancement of Medical Instrumentation (AAMI) has established a standard that helps facilities select gowns and drapes. This standard, listed under AAMI PB70: 2003, eliminates the need to understand the myriad of industry tests performed on gowns and drapes. The standard uses consistent ratings and terminology when referring to barrier protection. (15)

Additionally, the standard provides information about critical zones on gowns and drapes and how they are defined, which makes it easier to choose products. Critical zones refer to the area on gowns or drapes that come in direct contact with blood, body fluids, and other potentially infectious materials. Critical zones on a gown are the cuff to the elbow, sleeve seams, and the front of the gown. Included on the front of the gown are the areas that have fastenings, such as the belt. Critical zones on drapes are the areas around the openings. Following are the four critical zone levels defined by AAMI. (15)

* Level I--This is the lowest level of protection. Anything below this level does not meet the standard for protection. This level must meet American Association of Textile Chemists and Colorists (AATCC) industry standard #42 for water penetration (ie, < 4.5 gm), which measures water spray and whether it will penetrate fabric in the critical zones (15,16))

* Level II--This level provides more barrier protection than level I. These items must pass two AATCC #42 tests and AATCC industry standard #127 for hydrostatic pressure (ie, > 20 mL/cm), which measures fluid and pressure on fabric in the critical zones. (15-17)

* Level III--Materials at this level are not impervious but do provide better fluid protection. These items must pass two tests for water impact, (ie, < 1 gm) and hydrostatic pressure (ie, > 50 mL/cm). (15-17)

* Level IV--This is the highest level of barrier protection and imperviousness. This protection covers the entire product, including the critical zones. These products must pass the American Society for Testing Materials (ASTM) F1671 test for bloodborne pathogen penetration. (15-18)

The AAMI standard relates to disposable and reusable products. It provides a classification system that can be used by health care personnel to determine barrier properties of gowns and drapes. (15) This standard provides a mechanism to help protect patients and health care providers from bloodborne pathogens and helps protect patients from developing surgical site infections. (13)

NOTES

(1.) C Kessellich, A Bahl, "Necrotizing fasciitis: Understanding the deadly results of the uncommon 'flesh-eating bacteria,'" American Journal of Nursing 104 (September 2004) 51-55.

(2.) "Group A streptococcal (GAS) disease," National Center of Infectious Diseases, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention, (December 2003) http://www.cdc.gov/ncidod/dbmd /diseaseinfo/groupastreptococcal _t.htm (accessed 12 Jan 2005).

(3.) M Avila-Aguero et al, "Toys in a pediatric hospital: Are they a bacterial source?" American Journal of Infection Control 32 (August 2004) 287-290.

(4.) L McFarland, K Kelso, "Child care," in APIC Text of Infection Control and Epidemiology, third ed (Washington, DC: Association for Professionals in Infection Control and Epidemiology, 2002) 7.

(5.) R W Rutala, D J Weber, "The benefits of surface disinfection," American Journal of Infection Control 32 (June 2004) 226-231.

(6.) E H Spaulding, "Chemical disinfection of medical and surgical materials," in Disinfection, Sterilization, and Preservation, eds C Lawrence, S S Block (Philadelphia: Lea & Febiger, 1968) 517-531.

(7.) D Fogg, "Infection prevention and control," in Alexander's Care of the Patient in Surgery 12th ed, J C Rothrock, ed (St Louis: Mosby, 2003) 126-127.

(8.) "Bloodborne pathogens standard 1910.1030," Occupational Safety and Health Administration, http://www.osha.gov/pls /oshaweb/owadisp.show_docu ment?p_table=STANDARDS&p _id=10051 (accessed 12 Jan 2005).

(9.) "Contact precautions," Centers for Disease Control and Prevention, http://www.cdc.gov/ncidod /hip/ISOLAT/contact_prec_excerpt .htm#e (accessed 20 Jan 2005).

(10.) N E Ervin, "Evidence-based nursing practice: Are we there yet?" Journal of the New York State Nurses Association 33 (Fall/Winter 2002) 12.

(11.) "Recommended practices for environmental cleaning in the surgical practice setting," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 275.

(12.) L Sams, M E Gannon, "Evidence-based practice and clinical work assessment," Seminars in Perioperative Nursing 10 (October 2001) 214-221.

(13.) A Mangram et al, "Guideline for prevention of surgical site infection, 1999," Infection Control and Epidemiology 20 (April 1999) 247-280.

(14.) S Beyea, "Evidence-based practice in perioperative nursing," American Journal of Infection Control 32 (April 2004) 97-100.

(15.) J Palomo, J Lenhardt, "Understanding PB70:2003, New AAMI Standard helps balance infection control with cost effectiveness," Association for Infection Control Practitioners News (October 2004) 8-11.

(16.) American Association of Textile Chemists and Colorists (AATCC), Water Resistance: Impact Penetration Test AATCC 42 (Research Triangle Park, NC: AATCC, 2000).

(17.) American Association of Textile Chemists and Colorists (AATCC), Water Resistance: Hydrostatic Pressure Test AATCC 127 (Research Triangle Park, NC: AATCC, 2000).

(18.) American Society for Testing Materials (ASTM) International, Standard Test Method for Resistance of Materials Used in Protective Clothing to Penetration by Blood-Borne Pathogens Using Phi-X174 Bacteriophage Penetration as a Test System (Conshohocken, PA: ASTM West, 2003).

Editor's note: At various times throughout the year, the Recommended Practices Committee seeks review and comment on proposed recommended practices firm members and other interested individuals. When available, these proposed recommended practices appear on AORN Online at http:// www.aorn.org. Interested individuals who do not have access to the Internet may obtain copies of the proposed documents by calling the Center for Nursing Practice, at (800) 755-2676 x 334. Proposed recommended practice documents are available for review and comment for a 30-day period after they are posted. A deadline for comments is indicated with each document. Please check these sources frequently to locate proposed recommended practices. All comments received are considered as the document is finalized. Thank you for your participation.

JOAN BLANCHARD

RN, MAOM, CNOR

PERIOPERATIVE NURSING SPECIALIST

AORN CENTER FOR NURSING PRACTICE

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