Suggested Practices for Infection Control in the Invasive Cardiovascular Laboratory

Cardiovascular invasive laboratory personnel are to be commended for their practices and policies outlining infection control in the lab. The data bears witness to their efforts, with very low rates of lab-acquired infection complications. These invasive procedures are varied, and require levels ranging from clean to aseptic to sterile technique to perform them as safely as possible.

The purpose of this document is to provide an update to infection control guidelines for invasive laboratories. One of the most-referenced guidelines on infection control in the invasive lab has been “Infection Control Guidelines for the Cardiac Catheterization Laboratory: Society Guidelines Revisited”, published in 2006 in Catheterization and Cardiovascular Interventions (CCI).¹ This document has been the backbone of guidelines for staff in the lab. 

Charles C. Barbiere, RN, CCRN, RCIS, CCT, CRT, EMT, FSICP, past president of the Society of Invasive Cardiovascular Professionals (SICP), has a long history of helping to develop cath lab professional practices as a founding member of the SICP. The way he organized his approach to infection control practices was clear and easy to understand. He, as well as many others, taught us that to understand any topic, you have to break it down in manageable components. The table within this article strives to do just that. We have compiled an updated list of suggested practices, in an uncomplicated form, as an updated reference for invasive staff and institutions (Table 1). This document is not meant to supersede any state or national regulations, nor override existing institutional policies or procedures in the delivery of patient care. It is also not intended to hold the weight of guidelines, but rather to provide an outline for readers and their respective institutions to use in evaluating their own best practices for infection control. Many wonderful publications have been written on infection control; the few we list here are to identify the excellent quality of the information used to gather the recommendations listed in this document. 

After the 2006 guidelines were published, “Clinical Expert Consensus on Best Practices in the Cardiac Catheterization Laboratory: Society for Cardiovascular Angiography and Interventions” was published in CCI in 2012.² Also published in 2012 was the American College of Cardiology (ACC)/Society for Cardiovascular Angiography and Interventions (SCAI) Expert Consensus Document on Cardiac Catheterization Standards Update.³ These papers were quoted and referenced by many of the hospitals we talked with (Table 2) in the process of compiling our suggested infection control practices. Hospitals also referenced position papers and recommendations from the Centers for Disease Control and Prevention, the Association for periOperative Registered Nurses (AORN), ACC, American Heart Association (AHA), and SICP. The most recent publication has been the SCAI Best Practices 2016⁴, updating the Society’s previous document published in 2012. In a discussion of infection control, the authors note that “infectious complications resulting from cardiac catheterization are exceedingly rare; however, best practices for sterile technique are essential.” 

According to a 2009 Cath Lab Digest editorial by Morton Kern, MD, the cath procedure is a “clean procedure performed outside the operating room; however, with the devices and implants we now have at hand, sterility for those procedures must meet a higher standard for patient protection”.⁵

It bears repeating that there is little data to support the use of masks and caps at the procedure table. The terms associated with the use of those protective pieces of apparel are “it is prudent”, or “reasonable”, or “recommended”, but the use is not data supported, and it is up to each institution and team to decide on their level of apparel. However, a study by Gerberding et al, discussed in the ACC Expert Consensus document, showed 17.5% of gloves developed a perforation during surgery, and by wearing double gloves, the risk of a puncture dropped by 60%.^3,6 So, again, is it prudent, or strongly suggested, to double glove? Perhaps, and each operator and institution can consider using that in their practice.

Acknowledgements. We wish to thank all who provided insight and information, institutional as well as professional. 

References

1. Chambers CE, Eisenhauer MD, McNicol LB, Block PC, Phillips WJ, Dehmer GJ, et al; Members of the Catheterization Lab Performance Standards Committee for the Society for Cardiovascular Angiography and Interventions. Infection control guidelines for the cardiac catheterization laboratory: society guidelines revisited. Catheter Cardiovasc Interv. 2006 Jan; 67(1): 78-86.
2. Naidu SS, Rao SV, Blankenship J, Cavendish JJ, Farah T, Moussa I, et al; Society for Cardiovascular Angiography and Interventions. Clinical expert consensus statement on best practices in the cardiac catheterization laboratory: Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2012 Sep 1;80(3):456-464.
3. Bashore TM, Balter S, Barac A, Byrne JG, Cavendish JJ, Chambers CE, et al; ACCF Task Force Members. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine. J Am Coll Cardiol. 2012 Jun 12; 59(24): 2221-2305.
4. Naidu SS, Aronow HD, Box LC, Duffy PL, Kolansky DM, Kupfer JM, Latif F, Mulukutia SR, Rao SV, Swaminathan RV, Blankenship JC. SCAI expert consensus statement: 2016 best practices in the cardiac catheterization laboratory: (endorsed by the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencionista; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d’Intervention). Catheter Cardiovasc Interv. 2016 May 2. doi: 10.1002/ccd.26551. [Epub ahead of print]
5. Kern M. Do I need to wear a hat and mask in the cath lab? Cath Lab Digest. 2009 Mar; 17(3). Available online at www.cathlabdigest.com/articles/Do-I-Need-Wear-a-Hat-and-Mask-Cath-Lab. Accessed September 7, 2016.
6. Gerberding JL, Littell C, Tarkington A, Brown A, Schecter WP. Risk of exposure of surgical personnel to patients’ blood during surgery at San Francisco General Hospital. N Engl J Med. 1990 Jun 21; 322(25): 1788-1793.
7. Kohut K. Infection prevention in the interventional settings. Personal communication via klkohut@gmail.com.

Marsha Holton, CCRN, RCIS, FSICP, can be contacted at marshasicp@aol.com.