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Strict management, medical protocols contribute to 18,000 consecutive cases without endophthalmitis
Maintenance of equipment, use of hospital-grade germicide and cleaning log helped one ambulatory surgical center remain endophthalmitis-free for 10 years.
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Strict adherence to cleaning procedures and management practices at an ambulatory surgery center in Arkansas have most likely contributed to the site’s 10 years and 18,000 surgeries without any incidence of endophthalmitis, according to Randall E. Cole, MD.
| Image: Cole RE |
Dr. Cole, medical director at the Boozman-Hof Eye Surgery & Laser Center in Rogers, Ark., said surgeons at the center perform mostly cataract procedures, but their 18,000 endophthalmitis-free cases also included filtering surgeries, repair of penetrating injuries, penetrating keratoplasties and secondary lens implants. Of those, 17,800 were cataract surgeries and about two-thirds were clear corneal no-stitch cataract surgery. Seven surgeons have conducted those surgeries at the center since it opened in April 1996, showing that the accomplishment was not because of only one gifted surgeon, Dr. Cole said.
“When we opened, we decided we wanted to use every measure that we could to try to prevent infection. We had a goal right up front,” he said in a telephone interview with Ocular Surgery News. “We were going to take every precaution that we could to try to prevent endophthalmitis. And so we developed a comprehensive prophylaxis strategy.”
The prophylaxis system that they developed consisted of two parts: a medical component and a management component. Dr. Cole said it was important to develop both a strategy and a way to carry it out.
“It’s creating as many barriers as you can and making those barriers as tall or high as safely as one can to try to kill bacteria all along the process,” he said.
While the center maintained its no-endophthalmitis record, the rate of endophthalmitis across the country rose, Dr. Cole noted. A study published by researchers at the Wilmer Eye Institute at Johns Hopkins showed that endophthalmitis incidence was higher from 1998 to 2001 than in the 4 years preceding that period, he said.
“There have been a lot of studies that seem to indicate that the use of clear corneal no-stitch surgery is causing a two-, three-, even four-times increased risk of endophthalmitis. So, in light of the trend for increasing infections, one wants to look at what sort of measures that we can take to lower the rate of infection and reverse that trend,” he said.
Medical components
 Donna Acord, surgery center director, and Diana Trotter, RN, escort a preoperative patient into surgery. The Boozman-Hof Eye Surgery and Laser Center is equipped with two fully operational surgical suites. Image: Cole RE |
The ASC has a medical advantage over hospitals, Dr. Cole said, in that the ASC does not treat patients with untreated ocular or systemic infections. They also make an effort to keep the blood sugar levels of diabetic patients below 250 mg/dL prior to surgery.
As part of the center’s medical strategy, pre- and postoperative prophylaxis with antibiotic drops is seen as crucial to the process, according to Dr. Cole. He said starting 3 days before surgery, either gatifloxacin or moxifloxacin topical fluoroquinolone antibiotics are administered to the operative eye four times a day. Patients are also required to wash their faces with antibacterial soap for 3 days before surgery.
The day of surgery, after topical anesthetic is applied in the preoperative area, a drop of 2.5% povidone-iodine solution is put in each eye, Dr. Cole said. Patients are also prepped with 10% povidone-iodine solution swab sticks. Vancomycin 10 mg, gentamicin 4 mg and epinephrine 0.1 mg are added to each 500-ml bottle of balanced salt solution used for intraocular irrigation. The irrigation solutions are disposed of following surgery.
After surgery, gatifloxacin or moxifloxacin are prescribed for patients to use four times a day for 1 week then twice a day for a second week.
The center’s staff members start each day with a 3-minute scrub and use a 62% alcohol foam scrub between patients. Staff members are required to wash their hands regularly and to wear long-sleeved garments, surgical hats and shoe covers at all times. In the surgical area they must wear hats, shoe covers, scrub suits and masks. They wear sterile gloves and gowns during surgery, changing if necessary.
Patients receive an adhesive incise drape covering the lid margin, a full body drape and a hair drape, according to Dr. Cole.
Management components
Maintaining the high standards at the center is not easy, Dr. Cole said. Personnel work diligently on a daily basis to clean and sterilize, and to ensure that patients, staff and surgical areas are as clean as possible, he said. Personnel are mostly licensed registered nurses, which has been helpful in standardizing protocol on a multitude of levels, he said.
“The difficult part is how to get people to do this, day in and day out, one patient after another, one year after another for 18,000 operations,” Dr. Cole said. “That’s where management comes in. It’s a discipline to get people to understand that those fundamentals are important.”
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Image: Cole RE |
The center’s personnel take the cleaning protocols seriously, he said. Personnel have been terminated in the past because of broken protocols, he said. Not only must the nursing staff understand the importance of the protocol, but the doctors must also know the necessity for not “cutting corners” and operating on patients with high blood sugar levels or fevers.
“Some people will say this is overkill, and I wouldn’t argue with that,” Dr. Cole said. “Our whole point is, we’re trying to kill bacteria over and over again. In fact, we refer to this as germ warfare. We’re trying to keep bacteria out of the entire environment – we’re trying to keep it out of the operating room and out of the patient’s eye.”
The center has an infection and control policy that provides staff with a strict cleaning protocol including a specific cleaning schedule, Dr. Cole said. Staff uses a cleaning log that details which rooms and areas have been cleaned and when.
Sterilizers are monitored weekly for adequate sterilization parameters and monitored daily and on a load-to-load basis, Dr. Cole said.
“Epidemics of infections often come from sterilizers that are not operating correctly or are not getting to temperature for long enough, or they have reservoirs that are not changed,” he said.
He said it is also important to have vacuum sterilizers that pull the air out of the lumens of phacoemulsification tubes to kill bacteria.
Care of instruments is also of key importance, Dr. Cole said. Cannulas must be irrigated, diamond blades must be wiped, cleaned and steamed, and phaco handpieces and irrigation and aspiration handpieces must be steamed and disassembled.
“Instrument care and sterilization is important for both prevention of infection and prevention of toxic anterior segment syndrome,” he said.
For Your Information:
- Randall E. Cole, MD, can be reached at Boozman-Hof Eye Surgery & Laser Center, P.O. Box 1353, 3737 W. Walnut, Rogers, AR 72757-1353; 479-246-1700; e-mail: dreyerecole@aol.com; Web site: http://www.boozmanhof.com.
Reference:
- West ES, Behrens A, et al. The incidence of endophthalmitis after cataract surgery among the U.S. Medicare population increased between 1994 and 2001. Ophthalmology. 2005;112(8):1388-1394.
- Erin L. Boyle is an OSN Staff Writer who covers all aspects of ophthalmology.