Theatre practice on AMROs affecting patient access

Some patients colonised or infected with antimicrobial-resistant organisms (AMROs) experience multiple operation cancellations as they are placed last on procedure lists, despite this practice not being necessary, the HSE National Clinical Lead on healthcare-associated infections and antimicrobial resistance has warned hospitals.

In a memo in late 2018 to hospital managers, Prof Martin Cormican wrote that he believed some hospitals implemented a programme of “exceptional measures” in the theatre in advance of procedures on patients colonised or infected with an AMRO.

“I understand that exceptional cleaning of the operating theatre/procedure room may be performed after performing a procedure on such a patient, resulting in significant disruption to patient flow. As an unintended consequence of such practice, the patients concerned are frequently placed last on procedure lists.”

According to Prof Cormican, these patients are disproportionately likely to have their procedure postponed in the event of delays and he had been informed that some patients may experience “multiple cancellations”.

He outlined that AMROs — such as  carbapenemase-producing Enterobacteriaceae (CPE); extended-spectrum beta-lactamases (ESBL); methicillin-resistant Staphylococcus aureus (MRSA); and vancomycin-resistant Enterococci (VRE) — are “transmitted by contact” and the “standard procedures” that apply to operative and other invasive procedures are designed to prevent transmission of organisms by contact.

It was important that standard procedures were applied consistently with respect to all patients.

“These procedures are important, for example, because up to one-in-three patients and healthcare workers carry methicillin-susceptible Staphylococcus aureus (MSSA), which is an important cause of surgical site infection. In all probability, some patients and some healthcare workers carry one or more AMRO but are not known to do so because they have not been tested. Good surgical practice is intended to manage these risks.”

Prof Cormican concluded that patients colonised or infected with an AMRO should not be placed last on theatre or procedure lists. “Specifically, there is no requirement for additional cleaning beyond that required after every case after the patient’s procedure. There is however a requirement that the patient who is known to be colonised with [an] AMRO should not be in close proximity to other patients (for example in recovery).”