BASIC ASEPSIS: A CRITICAL ELEMENT IN BREAKING THE CHAIN OF INFECTION

Standard Precautions and basic asepsis - Implementation of "Standard Precautions" is the primary strategy for successful prevention of healthcare associated infections of not only health care workers but also our patients. It contains the fundamental practices of infection control for the care of all individuals, regardless of their diagnosis or presumed infectious status. Effective use of personal protective equipment (PPE) can protect the health care worker from the patient’s infectious agents and vice versa. Since the development of Universal Precautions, there has been an emphasis on protecting the health care worker but we have forgotten message that these same practices can also protect the patient from infection if done correctly.

Surgical Conscience (Four Components): Optimal patient care during invasive procedures requires the sound practice of asepsis coupled with surgical conscience. Surgical conscience incorporates knowledge of aseptic principles, perpetual attention to detail and experience. Open and honest communication is crucial for acknowledgement of questionable breaks in technique or risks to patient safety. Surgical conscience recognizes the intimate contact between the patient and the surgical team and includes attention to personal hygiene health. Employees should feel comfortable to call-in if they are ill. (Editorial in Annals of Surgery, 1950 pp315-18. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1616565/pdf/annsurg01395-0161.pdf) • Caring o Care enough to take care of yourself, know when to stay home. o Care enough to educate yourself and peers on the institution’s policies and procedures. o Care enough about your patients to develop a strong surgical conscience. • Conscience o Ability to see and correct breaks in technique. o Inner guide to do what is right, not what it is the easiest, fastest, or fear of retaliation. • Discipline o To follow policies and procedures that are in place. o To teach and mentor staff. o Always take the high road. • Technique o Assimilation of all these values with the knowledge of aseptic principles that develop over time. o Techniques evolve through time, trial, and error / quality improvement studies. o Be open-minded. o Seek out evidence-based practice to challenge or implement changes.

Basic Asepsis Page 1

Aseptic technique - Aseptic technique is the effort taken to keep patients as free from hospital micro-organisms as possible (Crow 1989). • Sterile technique or surgical asepsis - A technique that restricts any microorganisms in the environment, on equipment and supplies from contaminating the wound or vascular system. It is the required technique for the use of critical items that enter sterile tissue or the central vascular system. At a minimum, sterile technique involves meticulous hand hygiene, use of a sterile field, sterile gloves for application of a sterile dressing and sterile instruments. Sterile technique may be expanded to include the use of clean attire, sterile surgeon gowns, surgical masks, hair covering and a controlled environment • Clean technique or medical asepsis - A technique that places emphasis on the prevention of cross contamination or transfer of microorganisms to the involved body site, other body sites of the patient, between patients or the environment. It requires the use of Standard Precautions for the protection of the employee from the patient’s body fluids, secretions, and excretions. It is appropriate for the use of semi-critical items that have contact with intact mucous membranes. Clean technique includes meticulous hand hygiene, a clean environment including a clean field, use of clean gloves, sterile instruments, and prevention of direct contamination of materials and supplies.

Spaulding classification scheme Body Contact Disinfection Requirements FDA Device Class sterile body cavity sterilization critical mucous membranes high level semi-critical intact skin low level non-critical

• Critical items - A category assigned to items that present a high risk of infection if the item is contaminated with any microorganisms, including bacterial spores. This category includes surgical instruments, cardiac catheters and indwelling urinary catheters, implants, and needles. Most of the items in this category should be purchased sterile or be sterilized. • Semicritical items - A category assigned to items that come in contact with mucous membranes or with skin that is not intact. These items must be free of all microorganisms, with the exception of high numbers of bacterial spores. Intact mucous membranes are generally resistant to infection by common bacterial spores but are susceptible to other organisms, such as tubercle bacilli and viruses. Respiratory therapy and anesthesia equipment, endoscopes, and diaphragm fitting rings are included in this category. Semicritical items generally require high-level disinfection with the use of wet pasteurization or chemical germicides (i.e. gluteraldehydes, chlorine). Terminal sterilization of instruments

Basic Asepsis Page 2

is done to remove all pathogenic organisms before use on the next patient although items may be handled using clean technique during the procedure. • Noncritical items- A category assigned to items that come in contact with intact skin but not with mucous membranes. Intact skin acts as an effective barrier to most microorganisms. Examples of noncritical items include blood pressure cuffs, exam tables, electronic thermometers and furniture. Most items can be effectively cleaned with a hospital-grade disinfectant.

Traffic patterns • Good traffic control patterns protect personnel, patients, supplies, and equipment from potential sources of cross-contamination. The practice setting should be designed to facilitate movement of patients and personnel into, through, and out of defined areas within procedure areas. • Movement of personnel is kept to a minimum while invasive or noninvasive procedures are in progress. Movement not only includes movement in an out of the procedure room but also movement within the procedure area. • The flow of clean and sterile supplies and equipment is separated from contaminated supplies, equipment, and waste by: o Space, o Time, or o Traffic patterns. • The surgical suite has three distinct areas defined by the activities that are performed in each area. o Unrestricted area: serves as the central control point established to monitor the entrance of patients, personnel, and materials. Street clothes may be worn in this area. o Semi-restricted area: is the peripheral support area that has storage areas for clean and sterile supplies, work areas and corridors leading to the restricted areas. Traffic is limited to authorized personnel and patients. Personnel are required to wear clean attire and cover all hair. No food or drink is allowed in this area. o Restricted area: includes the procedure/operating rooms, the clean core, and the scrub sink areas. Clean attire and hair covering is required. No food or drink is allowed in this area. Masks are required where open sterile supplies or scrubbed persons are located.

Hygiene • Standard Precautions, a consistent method of taking precautions with body substances, should be applied to all patients at all time, irrespective of the diagnosis, in order to prevent the transmission of infectious agents. • All healthcare workers, visitors, and patients should have good hygiene practices.

Basic Asepsis Page 3

o Hands with intact skin - Healthy skin is less apt to harbor potentially dangerous organisms. o Free from upper respiratory illnesses - Sneezing, coughing and talking may contribute to the spread of organisms that may inhabit the upper respiratory tract. o All health care workers should be immunized against influenza to not only prevent the spread of influenza but also the spread of other common organisms from the upper respiratory tract, such as Staph aureus. • Respiratory Hygiene/Cough Etiquette: Targets patients and visitors with undiagnosed transmissible respiratory infections, and apply to persons with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a healthcare facility. Elements include: o Education of healthcare facility staff, patients and visitors. o Posted signs, in language(s) appropriate to the population served, with instructions to patients and visitors. o Source control measures (e.g., covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated and appropriate). o Hand hygiene after contact with respiratory secretions. o Spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible. o Vaccination against respiratory illnesses as appropriate including influenza, pertussis, and pneumonia. • Hand hygiene o Alcohol based gels ƒ Gel in and Gel out- Waterless, alcohol-based hand rubs are now the preferred products for routine hand hygiene in healthcare settings, unless hands are visibly soiled. The CDC recommends that healthcare workers be provided with a readily available alcohol-based hand rub product at the entrance to each patient care room, at the patient’s bedside, or at other convenient locations. ƒ Recommendations for increased use of waterless hand hygiene products do not negate the need for hand washing sinks. The efficacy of alcohol-based products or soap and water depends on the technique of the user. o Artificial fingernails or nail extenders are prohibited for those having direct contact with patients especially those at high risk (e.g. NICU. ICU, OR). o Soap - Hands should be washed with soap and water when visibly soiled with dirt or proteinaceous contaminates such as blood, other body fluids, secretions, and excretions, as soon as possible. Hands should also be washed with soap and water before eating and after using the restroom. Hands should be washed with soap and water (with or without gloves) if exposed (suspected or proven) to Bacillus anthracis,

Basic Asepsis Page 4

Clostridum difficile, and some viral organisms such as Norovirus, Norwalk virus or Rotovirus. ƒ Antimicrobial ƒ Surgical scrub agents ƒ Bar soap o Lotions – should be provided. Personal hand lotions are discouraged in the patient care area. Outbreaks have been traced back to contaminated lotion. o 5 Moments for Hand Hygiene from the World Health Organization includes Human Factors Engineering principals. It focuses on principals –not tasks and offers what we should do and the rationale. (See Hand Hygiene presentation for more information.) 1. Before patient contact- prevents organisms of the healthcare environment (including the worker) from contaminating the patient or their environment Example – shaking hands 2. Before aseptic task- immediately before touching site to be protected will prevent any organisms (patient’s or healthcare environment’s) from contacting the aseptic area. Examples: medication administration, IV line care, food prep 3. After exposure to body fluids - protects self and environment from contamination. Examples: oral care, emptying urinals. 4. After patient contact 5. After contact with patient surroundings Items 4 & 5 above protects healthcare environment from patient contaminants. Examples: adjusting blanket of patient in hallway, adjusting IV flow rate. o Hand hygiene is the corner stone of infection prevention and control and is identified as the first step of Standard Precautions. o Ayliffe (1978) developed the Seven step hand washing technique 1. Palms 2. Backsides 3. Between fingers 4. Back of fingers 5. Thumbs 6. Fingertips 7. Wrists Ayliffe SA et al (1978) A Test for Hygienic Hand Disinfection. Journal of Clinical Pathology. Vol 31, p 923. o Alcohol-based rubs - follow the manufacturer’s recommendation for use; ƒ Dispense an appropriate amount of product (2.5 grams) into one hand ƒ Spread over both hands to wrists, interlace fingers and spread under fingernails, and rub into skin until dry (approximately 15-30 seconds) ƒ Wash hands with soap and water after 8-10 applications of alcohol gel to remove accumulated emollients. o Soap (plain lotion soap) and water instructions are as follows:

Basic Asepsis Page 5

ƒ Wet hands with water ƒ Apply soap products per manufacturer’s recommendations, usually 1-2 pumps from the dispenser or 3-5 mL. ƒ Rub hands together vigorously, covering all skin surfaces and under rings ƒ Rinse thoroughly ƒ Dry hands with a disposable towel that is then used to turn off the water faucet. o Remember - Clean hands are the corner stone of standard and transmission-based precautions.

Gloves • Purpose o Prevent exposure to healthcare worker o Protect the patient from hand contamination by the health care worker • Type o Vinyl ƒ Not appropriate for tasks longer than 15-20 minutes in duration ƒ No fit ƒ Tear easily with stretching o Latex ƒ Provides better protection than vinyl ƒ Better fit ƒ More elastic than vinyl ƒ Sensitivity may develop with repeated exposure o Nitrile ƒ Able to tolerate wider temperature variances ƒ Better fit than vinyl o Others • One pair or double glove? o Need a set to remove the old dressing o A fresh pair of gloves is donned just prior to a procedure to prevent contamination of the field and procedure area. Gloves are promptly removed after removing contaminated items from the field, including the clean drape. o Double glove when tearing or puncturing of glove can be anticipated during the task (e.g. caring for trauma victim) o Extra gloves should not be stored in pockets with other personal items. • Clean or sterile o Hands should be cleaned before reaching into glove box. o Sterile gloves are:

Basic Asepsis Page 6

ƒ Recommended when doing dressing change on a fresh surgical wound that is not completely healed. ƒ Required if inserting a sterile catheter or needle in deep tissue or body fluids, usually to obtain fluid or instill therapeutic agent. ƒ Worn if handling instruments/supplies used for invasive procedures of sterile body cavities. ƒ Selected based on a number of factors, including size, the task has to be performed, anticipated contact with chemicals, and chemotherapeutic agents, and latex sensitivity.

Gowns • Impervious gowns (isolation gown, lab coat or non-sterile surgeon gown) are: o Worn when it is likely that personal clothing will be soiled with any patient's body fluids. o Laundered by the institution. • The need for and type of gown selected is based on the nature of the patient interaction including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. Gowns may be worn not only to protect the clothing of the health care worker but may also provide clean/sterile attire. • Impervious gowns used for personal protection should not be worn outside of the area where the exposure was anticipated (e.g. blue lab coats should not be seen in the hallways). • AAMI Level 1 gown is typically used for isolation gowns or standard precautions. There is a consistent level of barrier protection throughout the gown – no reinforced areas.

Basic Asepsis Page 7

Masks • Mask are used for three primary purposes in healthcare settings: • Placed on healthcare personnel to protect them from contact with infectious material from patients (e.g., respiratory secretions and sprays of blood or body fluids, consistent with Standard Precautions). • Placed on healthcare personnel when engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents carried in a health-care worker’s mouth or nose.

Basic Asepsis Page 8

• Placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others (see Respiratory Hygiene/Cough Etiquette, CDC’s Guideline for Isolation Precautions). • Procedural masks are the least effective and are not appropriate in a surgical setting. • Surgical masks are tie masks and provide better protection than procedure masks (ear-loop masks)

Respiratory Protection • To protect the health care worker – should be worn consistently with bronchoscopy procedures • Primarily designed to protect the health care worker ffrom droplet nuclei but some designs may also protect the patient from aerosols from the health care worker

Eye Protection • Worn to protect the eye and face from infectious materials. • The degree of protection required depends upon the circumstances of exposure, other PPE used, and personal vision needs. • Personal eyeglasses and contact lenses are not considered adequate for eye protection.

Basic Asepsis Page 9

All Personal Protective Equipment (PPE) should be promptly removed after completing the procedure or when there is no longer a risk of exposure. PPE should not be seen in the hallway or outside of the procedure area.

Dressing changes for patients with chronic wounds

Minor invasive procedures • Must do o PPE – sterile gloves o Skin prep o Sterile drape • Remove hair only if necessary – seldom necessary. Do not use a razor but clip. Consider implementation with IV starts, electrode placement on patients anticipated to require heart surgery, etc. • Prepare skin o Approved scrub agent o Select based on location and patient’s sensitivity o Follow instructions • Drape

Basic Asepsis Page 10

• Sterile items – check processing and package integrity o Peel packs • Package integrity • Not wet • Completely sealed • Not punctured • Check for outdates • Flip technique to place on field o Wrapped • Inspect package • Ensure integrity o Instrument pans: • Locks • Filter in place • Tracking tag in place o High level disinfection • Monitor field once sterile items are opened

Clean Technique (Medical Asepsis) • Supplies, Instruments and Utensils: o Have established protocols for handling all supplies and instruments o Manually remove debris from instruments with damp gauze or flush with water immediately after use to facilitate cleaning o Place grossly soiled instruments in a rigid leak resistant container with appropriate soaking solution and cover. o Hands are never used to retrieve objects from opaque solution since liquid may obscure reusable sharps. o Rinse grossly soiled utensils and place in designated soiled receiving area for future processing, which is to be ideally done by Central Services. o Use processing solutions which are approved by the Infection Control Committee and for their intended use only. • Equipment: o Surfaces should be cleanable o Clean equipment with a disinfectant before use by another patient, i.e., cautery unit, etc. o Items are cleaned with a disinfectant before return to central storage area, and before repairs or preventative maintenance. o Large equipment returned to CS is wiped down before transport. • Trash o Bag all trash and disposable items to prevent leakage.

Basic Asepsis Page 11

o Gather trash at the end of the procedure by personnel wearing gloves. Trash is typically removed with the liner but small amounts from non-patient care areas may be dumped into another larger container. Trash is never removed by reaching into containers by hand. o Place all infectious waste in biohazard labeled red bags. o A biohazard bag is available in patient care areas to use during procedures. o Drainage units that have a drain port are emptied in the Decontamination area in Central Services using engineering controls or not emptied at all. Place emptied drainage units in infectious waste container for disposal. Every attempt must be made to use available engineering controls to empty drainage units. This may include use of closed drainage systems or hopper shields. If Engineering Controls are not available, the appropriate personal protective equipment must be worn.

Room cleaning: • Daily and terminal cleaning of the exam/procedure room is performed consistently, including prompt cleanup of body substances and/or spills by gloved personnel using an EPA approved disinfectant. • Daily disinfect frequently touched surfaces with an EPA approved hospital disinfectant.

There is a continuum between clean technique and sterile technique.

Surgical Asepsis (Sterile technique) • Assessed prior to the procedure - Patients are assessed prior to the procedure for any signs or symptoms of an infectious process. The following are reported to the surgeon and anesthesiologist for final decision if the patient is a surgical candidate: o Core temperature > 38.5 Celsius o Productive cough, runny nose, sore throat, and any other symptoms of a respiratory infection. o Pyuria > 10 WBCs/hpf o Elevated WBC o Diarrhea with abdominal pain o Any purulent material or lesion of the skin or subcutaneous tissue in proximity to the operative site. This includes any abraded or burned skin o Any recent exposure to communicable disease that may lead to subsequent disease (e.g., chickenpox exposure to those w/o immunity). • Skin preparation o The patient is instructed to bathe the night before and/or the morning of surgery according to an established protocol. o Pre-surgical scrubs and clips are preformed only if necessary and then according to individual surgeon preference for that specific procedure.

Basic Asepsis Page 12

o Consider decolonization of patient with known methicillin resistant Staphylococcal aureus (MRSA) colonization or infection. • Patients requiring transmission based precautions o Established protocols for patients with a multiple drug resistant organism (MDRO) or any other infection requiring Contact or Droplet Precautions o Place patients with uncontrolled drainage from wounds in Contact Precautions. o Patients requiring Airborne Infection Isolation (AII) Precautions should be scheduled in surgical suite with a negative pressure anteroom and recovered in the same operating room or in another Airborne Infection Isolation (AII) room. Staff must wear the appropriate personal protective equipment during isolation. Respiratory protection should not have an exhalation valve or exhausted without a filtration system in place to protect the patient from pathogens from the health care workers upper respiratory tract. o Regardless of isolation status – all patients entering the surgical suite should have freshly laundered linens donned after their evening/morning shower or bag bath. Hair will be covered just prior to entering surgery. Trend to make a slight revision for Ophthalmology patients. They may wear their street clothes from the waist down and a clean patient gown if they are cocooned in freshly laundered linens. This only applies if the patient will remain on the eye cart throughout the surgical procedure. o All patient contact requires Personal Protective Equipment (PPE), typically gown and gloves. It is important that hands are washed after removing the gown, gloves, and other PPEs. Mask and goggles should be added with anticipated contact with blood or body fluids with possible splash, splatter or spray to the face or eyes.. o After the patient is draped in the OR, the circulator does not have to wear the isolation gown and gloves. Anesthesia should continue to wear gown and gloves when in direct contact with the patient. o Avoid contaminating items in surgery suite while wearing gown and gloves.

Surgery Scrub – Hand Antisepsis • Wash hands at the beginning of the shift prior to and after performing the procedure, prior to entry into semi-restricted or restricted areas, and on exit of semi-restricted or restricted areas. • No artificial fingernails or nail extenders • Remove jewelry, don eye and face protection and do a final check to be sure all hair is secured. • Clean nails under running water • Apply antiseptic per posted manufacturer recommendations. Specific manufacturer instructions are to be posted by the scrub sink for easy reference. • Dry with sterile towel completely before gloving • When using an alcohol-based surgical hand rub product (with persistent activity), the hands and forearms should be pre-washed with plain lotion soap and dried completely.

Basic Asepsis Page 13

Clean Attire • Before donning surgical attire, all persons entering the perioperative suite should wash their hands with soap and water, antiseptic and water, or an antiseptic hand rub if visible soil is not present upon arrival. • Facility-approved, clean, and freshly laundered surgical attire should be donned in a designated dressing area of the perioperative suite before entry or reentry into the semirestricted and restricted area. • All individuals who enter the semirestricted and restricted areas of the perioperative setting should wear freshly laundered or disposable surgical attire intended for use within the perioperative setting. • All non-scrubbed personnel should wear a long-sleeved jacket snapped closed with the cuffs pulled down to the wrists • All attire is changed daily or more often whenever they become visibly soiled or wet. The two piece pant suit should be sized appropriately to prevent pant legs from dragging and provide adequate coverage. The top should fit snuggly at the hips or be tucked in to the pants. • Wearing clean attire is limited to the inside of the institution. This does not include the grounds of the institution or residential housing. Clean attire should be completely covered with clean jumpsuit if worn outside during the course of job-related duties (e.g. walking from hospital to pack room, etc.). • Duty shoes are kept clean and not worn outside. Shoe covers are only worn with reasonable anticipation of exposure to blood or potentially infective material. Shoe covers are removed following the procedure upon leaving the room. Shoe covers should not be worn as a substitute to having duty shoes. Hose or socks are worn. • Long sleeved jackets or warm-up jackets should be worn by all non-scrubbed personnel in the central core or the operating room. Long sleeved jackets should be snapped close and changed daily or whenever possible contamination may have occurred. Clothing that cannot be covered by the clean surgery attire should not be worn. • All jewelry is contained within scrub attire. • All possible head and facial hair, including sideburns and neckline, should be covered. A hood is worn if scrub caps do not cover hair. Reusable hair coverings should be laundered after each use by an accredited laundry services. Single use hair covering is discarded at the end of the shift. • Surgical attire helps contain bacterial shedding and promotes environmental control. An individual sheds millions of skin squames daily. Five percent to 10% of skin squames have bacteria. • Surgical attire that has been worn during one shift has higher bacterial colony counts at the end of the work shift when scrub clothing is removed, or when stored in a locker and used again. Worn surgical attire should be placed in an appropriately designated container for laundering and should not be hung or placed in a locker for wearing at another time.

Basic Asepsis Page 14

• Wearing the warm-up jacket snapped closed prevents the edges of the front of the jacket from contaminating a skin prep area or the sterile surgical field. Long-sleeved attire contains skin shedding from bare arms. When in the semirestricted or restricted areas, all non- scrubbed personnel should wear a long-sleeved jacket snapped closed with the cuffs pulled down to the wrists. • Surgical attire should be laundered in a health care-approved or accredited laundry facility. • Surgical attire should not be washed in the home. • Wash hands after removing gown and gloves or any personal items. • Shoe covers should be changed whenever they become torn, wet, or soiled and discarded in a designated container before leaving the surgical area. • Protective shoes must be worn in the perioperative environment. Shoes should have closed toes, low heels, and non-skid soles. • Shoes worn within the perioperative environment should be cleaned regularly and have no visible soiling.

Masks • The need and the type of mask selected (e.g. surgical, PAPR, N95 respirators, HEPA) should be selected based on the infectious agent involved and the anticipated level of exposure. Medical PAPRs typically are not approved for use in a surgical setting with an open sterile field. • Masks are worn during invasive procedures or when the sterile items are open. • Masks are worn to completely cover the nose and mouth and secured to prevent venting at the sides. • Masks are either on or off; they are not to be tucked into a pocket or worn hanging around the neck. • Masks are generally changed between cases. Exceptions can be made for supervising staff or others that are in several rooms for brief periods of time. • Masks are worn by staff cleaning between cases due to the short turn-around time of rooms. • When removing the mask, touch only the strings to reduce contamination of the hand from the nasopharyngeal area.

Health care workers should know their status for possible infection with Blood Borne Pathogens (BBP) if they are at risk of exposure All surgeons and surgery staff that scrub-in should know their baseline status for Hepatitis B (HBV), Hepatitis C (HCV) and human immune-deficiency virus (HIV) infection. All possible exposures to blood borne pathogens should be promptly reported. It is not uncommon to have a dual exposure during a surgical procedure whereby the patient becomes exposed to the health care worker's blood. There should be a system in place to handle dual exposures. Surgeons and surgery staff with known HBV, HCV or

Basic Asepsis Page 15

HIV infection should consult with an advisory panel for ongoing follow-up. (Reference: Infection Control and Hospital Epidemiology March 2010, Vol. 31, No. 3)

Skin Prep • The operative site and surrounding areas should be cleaned before entry into procedure room (i.e., pre-op shower & shampoo). • Hair should be removed prior to transport to operative/procedure area. Hair removal should be done only with a clipper or a chemical depilatory and only when absolutely necessary to facilitate wound closure and dressing. Hair removal should occur as close to incision time as possible. • There should be a documented assessment of the operative site, which notes the presence of skin lesion. • The operative site and the surrounding area should be prepped with an approved surgical scrub agent. • Surgical scrub agents should be selected based on patient sensitivity, incision location, and skin condition. • Surgical scrub agents should be used according to the manufacturer’s recommendations. • Skin lesions or open areas should be prepped according to established protocols. • Antimicrobial agents should be applied using sterile supplies and sterile gloves. Scrub jackets should be worn during the prep as long as this does not contaminate the prepped area. The antimicrobial agent should be applied proceeding from the incision site to the periphery with the exception of Chloraprep. Surgical scrub agents should not be allowed to pool under patient. • Documentation of the skin prep should include assessment of the skin integrity, hair removal process, area prepped, solutions used, abnormal reaction to prep, and name of person(s) performing the task.

Sterile Gown • Sterile gowns and gloves should be worn by scrubbed personnel. • Sterile gowns should be available with various levels of protection. The standard surgeon gown is classified per ANSI/AAMI PB270:2003 standard as a Level 2 Barrier. Level 2 barrier gowns are appropriate for short procedures with little or no anticipated exposure to blood or body fluids. As the length and physical contact of the procedure increases there should be consideration to select a gown with greater barrier properties. • Scrubbed personnel should don a sterile gown and sterile gloves from a sterile field other than the instrument table.

Basic Asepsis Page 16

AAMI Classification Levels of Barrier Performance Level Test Result Exposure Risk

1 Impact Penetration <4.5 g Minimal

2 Impact Penetration <1.0 g Low Hydrostatic Pressure > 20.0 cm 3 Impact Penetration <1.0 g Moderate Hydrostatic Pressure > 50.0 cm 4 ASTM F1670 (Drapes) Pass High ASTM F1671 (Gowns) Pass

• Strikethrough while wearing a sterile gown should be reported for possible exposure. Strikethrough indicates that a gown with better barrier protection should be worn. The ASTM F1670 determines the ability of a material to resist the penetration of synthetic blood under constant contact. The test sample is mounted on a cell separating the synthetic blood challenge liquid and a viewing port. The time and pressure protocol specifies atmospheric pressure for 5 minutes, 2.0 psi for 1 minute and atmospheric pressure for 54 minutes. The test is terminated if visible liquid penetration occurs before or at 60 minutes. The ASTM F1671 determines the ability of a material to resist the penetration of a microorganism under constant contact using a method which has been specifically designed for modeling penetration of HBV, HCV, and HIV. The sterile gown with barrier protection has reinforced protection in the front and lower half of the sleeve. • Sterile gowns are considered sterile in front from chest to the level of the sterile field, and the sleeves are considered sterile from two inches above the elbow to the cuff. • The front of the surgical gown should be considered sterile from the chest to the level of the sterile field, and the sleeves should be considered sterile from two inches above the elbow to the top edge of the cuff. • The area of sterility in the front of the gown extends to the level of the sterile field because most scrubbed personnel work adjacent to a sterile table. Surgical gown sleeves up to two inches above the elbow must remain sterile because the arms of scrubbed personnel must move across sterile fields. The neckline, shoulders, axilla, back, and cuffed portions of the gown sleeves are areas of friction; therefore, these areas should be considered ineffective microbial barriers (i.e., unsterile). The backs of surgical gowns cannot be under constant supervision by scrubbed personnel and, therefore, should be considered contaminated. • After the sterile gloves are donned, the gown cuffs should be considered contaminated because as the scrubbed hand passes through the gown cuff, the cuff becomes contaminated.

Basic Asepsis Page 17

Gloves • Gloves are inspected after donning. • Double gloving is recommended for most procedures. • Blue indicator polyisoprene surgical gloves are available as the under glove when double gloving. The blue indicator glove allows for easier detection of holes in the outer surgeon glove. Perforation indicator systems results in significantly more innermost glove perforations being detected during surgery. • It is generally recommended to change the outer glove every two hours. • Double gloving may reduce the rate of surgical site infections if perforations are detected sooner or the barrier remains intact.

Draping • Inspect for holes as establishing the sterile field • Handle as little as possible • During the draping the process the sterile drape is held folded and compact above the operative area, then placed and unfolded from the operative site to the periphery starting with the side closest. • Cuff drape over hands during draping process

Sterile field • All items used within the sterile field should be sterile. • All items presented to the sterile field should be checked for proper processing and package integrity. • Items introduced onto a sterile field are opened, dispensed, and transferred by methods that maintain sterility and integrity. • Wrapped supplies should be opened by un-scrubbed personnel by opening the wrapper farthest from them first and the nearest wrapper flap last. • All wrapper edges are secured when supplies should be presented to the sterile field to prevent contamination. • Tables are sterile only at table level. o Anything over the edge should be considered unsterile, such as a suture or the table drape. o Should use non-perforating device to secure tubing and cords to prevent them from sliding to the floor. • Sterile items should be presented to the scrubbed person or placed securely on the table. • Objects that are sharp, heavy or difficult to handle should be presented to the scrubbed person or opened on a separate surface. • Solutions should be dispensed by: o Pouring the entire contents into the receptacle or the remainder is discarded.

Basic Asepsis Page 18

o The receptacle is placed near the edge of the table or held be the scrubbed person, and the fluid is poured slowly to avoid splashing. • The sterile filed should be constantly monitored, once unguarded it should be considered contaminated • Opened instruments should not leave room of intended use. • Do not cover sterile field to save until later because it is difficult to remove drape without contaminating the sterile filed. • Once the patient enters surgical suite, all items should be considered contaminated to that case • Scrubbed persons should keep their arms and hands within the sterile area at all times • Movement around the sterile field should be done in a manner to maintain the integrity of the sterile field. • Conversation should be kept to a minimum once the sterile items have been opened. There should be no gum chewing under the mask.

Sanitation • Patients should be provided with a safe, clean environment free from dust and organic debris. • Cleaning should be done on a scheduled basis to prevent cross-contamination. • Furniture, lights, and equipment should be damp dusted with approved disinfectant before the first scheduled case. • The area should be visually inspected before the instruments are brought into the room. • External packing containers used during shipping should be removed before materials are transported into the procedure/operating room. The integrity of all packages should be maintained. • Equipment from outside the procedure room should be damp dusted with an EPA approved germicidal agent prior to entry into the procedure/operating room. This includes but is not limited to items stored in outer corridor. • Patients should be brought into the procedure/operating room with freshly laundered linens and gown. • During the procedure, all activities should be directed at confining and containing contamination. • There should be a prompt clean-up of contaminated surfaces with an approved disinfectant. • Spray bottles should not be used during the procedure or set up. • The patient's bed from the nursing unit should be cleaned with an approved disinfectant and freshly laundered linen should be applied. • Items that come in contact with the patient and/or sterile field are considered contaminated. • Disposable items with squeezable, dripable, pourable blood are placed in closeable, leak- proof containers or red bags that are labeled with the biohazard symbol. Used/unused or soiled disposable items are placed in the properly defined disposal receptacles.

Basic Asepsis Page 19

• Gowns and gloves should be removed in a manner that contains contamination and gowns and gloves placed in the proper receptacle prior to leaving the procedure/operating room. • Contaminated linen should be handled as little as possible. Linen from any open packs, whether soiled or not, should be placed in linen hampers for the laundry. • Instruments should be placed by the gloved scrub person directly into instrument trays and placed in case cart. • Disposable suction containers should be sealed and either sent to central processing area for disposal or emptied in designated soiled area by an individual wearing the appropriate PPE. • All needles, sponges, instruments should be counted when there is a likelihood of items to be retained before disposal. • Sponges should be discarded into or onto impervious surface for counting. • Personnel should use gloves in handling sponges, organic material, and specimens.

Between Case Cleaning • All surfaces should be disinfected between cases – know wet contact time claim • Clean from the top to bottom (cleanest to dirtiest) • Disinfect all surfaces that could be possibly contaminated o Includes area for circulator o Lead aprons/shields o Keyboards o Door panels o Phone • Remove all debris from floor before mopping/wet vac (includes bone chips) • The area mopped is dependent upon the likelihood of contamination. Some procedures are minimally invasive and there is no blood loss therefore floor disinfection is not necessary. Floors are cleaned with an approved disinfectant. A mop- head is used only once and not double dipped. It may require several mopheads to clean the floor. • Scrub sinks should be cleaned after the scrub for each case

Term cleaning • Terminal/daily cleaning of the procedure/operating room should be done at the conclusion of the day’s schedule. • The areas to be cleaned include; lights, ceiling mounted equipment, all furniture including the wheels and casters, handles and pushes plates, face plates and vents, all horizontal surfaces, the entire floor, kick buckets, and scrub sinks. • Thermostats should be set at 72 degrees Fahrenheit or warmer. Terminal/daily cleaning is also done in the related locker rooms, corridors, rest-rooms, workrooms and storage areas. • Break rooms should be cleaned at least daily but typically need to be cleaned more often to keep trash to a minimum. Doors to break rooms should be kept closed at all times.

Basic Asepsis Page 20

Weekly/Monthly Cleaning • Weekly damp dusting should be done for refrigerators, crash carts, supply carts, med carts, desks, tables, and case carts in the restricted areas.. • Monthly cleaning of clean storage areas/shelves should be done with monthly checks for outdated supplies. This includes refrigerators, freezer, crash cart, etc. and med cart. The following should be cleaned monthly: gas tracks, light fixtures, and the vents in the clean storage areas and corridors.

Ventilation • The surgical area should have positive ventilation pressure in relationship to the adjacent area • There should be a minimum of 4 outside air changes per hour • There should be a minimum of 20 air changes per hour • The relative humidity should be 30-60% • There should be no air recirculation unity in the procedure room • The temperature control should be 68-75 degrees Fahrenheit. • Guidance ASHREA/ASHE Standard Ventilation of Health Care Facilities o Check for duct cleanliness o Check for balance of the ventilation system.

Syringes, Needles and Disposables • Safety devices should be used whenever appropriate and available (blunt suture needles, blunt needle system, safety syringes, etc.). • Safety device should be activated before disposal. • Sharps may be place in a rigid, plastic leak-resistant, with a closable container. • Needles should not be broken, bended, or recapped before disposal. • Sharps containers should be sealed when two-thirds full and placed in designated area for pick up.

Injection Safety • Injection safety includes practices intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare worker and also to prevent harms such as sharp injuries.

Laboratory Specimen • All blood, body fluids and tissue specimens should be placed in a clean impervious container for transport. • Specimens from all patients are handled with care. • The outside of a soiled specimen container is cleaned with a disinfectant.

Basic Asepsis Page 21

• All specimens must be bagged in a clean leak-proof clear bag for transportation to the lab. Any specimen that is not in recognizable standard specimen container needs a biohazardous label before transport. Visibly soiled containers may be rejected by the laboratory. All specimens leaving the institution need a biohazard label. • Specimens that require other precautions in addition to Standard Precautions are labeled (i.e. AFB/ Airborne Infection Precautions on lung tissue from a known/suspect TB case). • Hands are washed after transporting specimens to the laboratory. • Specimens sent through the tube system should be sealed and double bagged. Liquid specimens are sealed in containers with a screw-on lid and bagged. • No specimens should be given directly to the patient. All requests for specimens should be processed following the approved protocols and the physician before being allowed to leave the institution. • Amputated limbs, appendages or fetus are not considered infectious waste although they do need to be handled with precautions. Limbs should be placed in an orange bag for special handling by Pathology or Central Services.

Care of Instruments • Immediate use sterilization should not be used as a substitute for sufficient instrument inventory or late delivery of loaner sets. • Instruments should be used only for the specific purpose for which they were designed. • Instruments should be kept free of gross soil during the procedure. • A sponge moistened with sterile water should be used to wipe debris from the instrument during the procedure. • Lumens should be kept patent by sterile water irrigation. • All items in contact with the patient and/or sterile field should be considered contaminated to that specific case. This includes but is not limited to: instruments, sponges, drapes, suture, equipment, and furnishings. All contaminated items should be cleaned at the end of the case. If the case cart has been assigned to a specific case, it should be used to return the contaminated items back to the central processing area. Suction canisters should be secured in a manner in the case cart to prevent spills during transit (e.g. place canister in basin). Laundry and trash bags should be removed from procedure room through the outer corridor. Transit should not occur through sterile storage areas. • Reuse of single use devices is prohibited unless reprocessing is done by an FDA approved facility. Open and unused items should be kept to a minimum but may be reprocessed by an FDA approved facility. • The decontamination process should begin immediately after completion of the invasive procedure. Disinfection practices outside of the central processing area should be consistent with practices within the central processing area. • Personal protective equipment (PPE) should be used during the decontamination process.

Basic Asepsis Page 22

• Manual cleaning should be done in a manner to limit aerosolization and splashing of infectious material. Spray bottles of disinfectant should not be used during the case although disinfectant wipes may be used. • Prolonged soaking of dirty instruments should be avoided to prevent damage of instrument surfaces. Enzymatic soaking of instruments is generally considered safe for several hours. • Decontamination should be done in a designated soiled area. • Manufacturer’s written instructions should be followed for the detergent selection and the proper use, care, and maintenance of the instruments. • Instruments with movable parts should be lubricated after every cleaning and according to the manufacturer’s written instructions. • Instruments should be inspected and prepared for storage and/or sterilization following the cleaning process. • Instruments should be checked for cleanliness, proper functioning and alignment, freedom from defects, sharpness of cutting edges, looseness of pins, and chipping of surfaces. • Instruments should be dried and then stored. • Instruments with removable parts are should be disassembled and placed in trays designed for sterilization. Ring-handled instruments should be secured in a manner that retains an open position. • Delicate sharp instruments should be protected during the decontamination process.

Endoscope Reprocessing (See presentation on Endoscope Reprocessing for more details.) • Endoscopes should be inspected, tested, and processed according to design and type and manufacturer’s written instructions. • Endoscopes should be handled so as to prevent damage to lenses and fiberoptic components. • Endoscopes should be disassembled, thoroughly cleaned manually, and dried before sterilization or high level disinfection. • Disinfected endoscopes should be thoroughly rinsed with sterile water and dried before storage. • Accessories should be decontaminated, cleaned, and sterilized according to the manufacturer’s written instructions. • The disinfected endoscope should be rinsed again immediately before use.

Powered Instruments • Powered surgical instruments should be decontaminated, cleaned, and sterilized according to the manufacturer’s written instructions. • Powered surgical instruments should be inspected, tested, and used according to the manufacturer’s written instructions. • Powered surgical instruments should be packaged and sterilized before use according to the manufacturer’s written instructions.

Basic Asepsis Page 23

• Exposure times for steam and EtO sterilization of powered surgical instruments should be done according to the manufacturer’s written instructions.

References Perioperative Standards and Recommended Practices, 2011 Edition by AORN

Basic Asepsis Page 24

Policy

Subject Basic Asepsis Index Number GL‐9710 Section Infection Control Subsection General Category Corporate Contact Pfaff, Bridget L

References CDC. (2007) Guidelines for Isolation Precautions: Preventing transmission of Infectious Agents in Healthcare Setting.

WHO Guidelines for Hand Hygiene in Health Care. Applicable To All employees of Gundersen Clinic, Ltd. and Gundersen Lutheran Medical Center, Inc. Detail It is the policy of Gundersen Lutheran: • To provide consistent infection control practices within all areas of the institution performing invasive procedures. • To prevent the transmission of nosocomial infections to patients, personnel, and visitors. • To provide a consistent method of barrier precautions in direct and indirect patient care situations. • To provide a basis for the orientation of personnel.

Implementation of "Standard Precautions" is the primary strategy for successful prevention of healthcare associated infections of not only health care workers but also our patients. It contains the fundamental practices of infection control for the care of all individuals, regardless of their diagnosiis or presumed infectious status. Effective use of personal protecttive equipment (PPE) can protect the health care worker from the patient’s infectious agents and vice versa. Optimal patient care during invasive procedures requires the sound practice of asepsis coupled wiith surgical conscience. Surgical conscience incorporates knowledge of aseptic principles, perpetual attention to detail and experience. Open and honest communication is crucial for acknowledgement of questionable breaks in technique or risks to patient safety. Surgical conscience recognizes the intimate contact between the patient and the surgical team and includes attention to personal hygiene health. Employees should feel comforrtable to call‐in if they are ill.

DEFINITIONS: Clean technique or A technique that places emphasis on the prevention of cross contamination or medical asepsis transfer of microorganisms to the involved body sitte, other body sites of the patient, between patients or the environment. It requires the use of Standard Precautions for the protection of the employee from the patient’s body fluids, secretions, and excretions. It is appropriate for the use of semi‐critical items tthat have contact with intact mucous membranes. Clean technique includes meticulous hand hygiene, a clean environment including a clean field, use of clean gloves, sterile instruments, and prevention of direct contamination of materials and supplies.

Page 1 of 17

Policy

Sterile technique A technique that restricts any microorganisms in the environment, on equipment or surgical asepsis and supplies from contaminating the wound or vascular system. It is the required technique for the use of critical items that enter sterile tissue or the central vascular system. At a minimum, sterile technique involves meticulous hand hygiene, use of a sterile field, sterile gloves for appllication of a sterile dressing and sterile instruments. Sterile technique may be expanded to include the use of clean attire, sterile surgeon gowns, surgical masks, hair covering and a controlled environment Critical items A category assigned to items that preseent a high risk of infection if the item is contaminated with any microorganisms, including bacterial spores. This category includes surgical instruments, cardiac catheters and indwelling urinary catheters, implants, and needles. Most of the items in this cattegory should be purchased sterile or be sterilized with ethylene oxide, peracetic acid (Steris System) or by steam under pressure. Semicritical items A category assigned to items that come in contact with mucous membranes or with skin that is not intact. These items must be free of all microorganisms, with the exception of high numbers of bacterial spores. Intact mucous membranes are generally resistant to infection by common bacterial spores but are susceptible to other organisms, such as tubercle bacilli and viruses. Respiratory therapy and anesthesia equipment, endoscopes, and diaphragm fitting rings are included in this category. Semicritical items generally require high‐level disinfection with the use of wet pasteurization or chemical germicides (i.e. gluteraldehydes, chlorine). Terminal sterilization of instruments iss done to remove all pathogenic organisms before use on the next patient although items may be handled using clean technique during the procedure. Noncritical items A category assigned to items that come in contact with intact skin but not with mucous membranes. Intact skin acts as an effective barrier to most microorganisms. Examples of noncritical items include blood pressure cuffs, exam tables, electronic thermometers and furniture. Most items can be effectively cleaned with a hospital‐grade disinfectant.

Implementation TRAFFIC PATTERNS A. Good traffic control patterns protect personnel, patients, supplies, and equipment from potential sources of cross‐contamination. B. The practice setting should be designed to facilitate movement of patients and personnel into, through, and out of defined areas within procedure areas. C. Movement of personnel is kept to a minimum while invasive or noninvasive procedures are in progress. Movement not only includes movement in an out of the procedure room but also movement within the procedure area. D. The flow of clean and sterile supplies and equipment is separated from contaminated supplies, equipment, and waste by space, time, or traffic patterns.

Page 2 of 17

Policy

1. Supplies prepared for procedures are stored in arreas designated for sterile or clean equipment to maintain cleanliness and to prevent physical daamage. 2. Infection Control is consulted when construction//renovation causes a change in traffic patterns or storage of sterile supplies. E. The surgical suite has three distinct areas defined by the activities that are performed in each area. 1. Unrestricted area: serves as the central control ppoint established to monitor the entrance of patients, personnel, and materials. Street clothes may be worn in this area. 2. Semi‐restricted area: is the peripheral support area that has storage areas for clean and sterile supplies, work areas and corridors leading to the restricted areas. Traffic is limited to authorized personnel and patients. Personnel are required to wear clean attire and cover all hair. No food or drink is allowed in this area. 3. Restricted area: includes the procedure/operating rooms, the clean core, and the scrub sink areas. Clean attire and hair covering is required. No food or drrink is allowed in this area. Masks are required where open sterile supplies or scrubbed persons are located.

CLEAN TECHNIQUE (MEDICAL ASEPSIS) WITH STANDARD PRECAUTIONS

A. Standard Precautions, a consistent method of taking precautions wwith body substances, should be applied to all patients at all time, irrespective of the diagnosis, in order to prevent the transmission of infectious agents. B. All healthcare workers, visitors, and patients should have good hygiene practices. 1. Hands with intact skin ‐ Healthy skin is less apt to harbor potentially dangerous organisms. 2. Free from upper respiratory illnesses ‐ Sneezing, coughing and talking may contribute to the spread of organisms that may inhabit the upper respiratory tract. All health care workers should be immunized against influenza to not only prevent the spread of influenza but also the spread of other common organisms from the upper respiratory tract, such as Staph aureus. C. Respiratory Hygiene/Cough Etiquette: Targets patients and visitors with undiagnosedtransmissible respiratory infections, and apply to persons with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a healthcare facility. Elements include: 1. Education of healthcare facility staff, patients and visitors. 2. Posted signs, in language(s) appropriate to the population served, with instructions to patients and visitors. 3. Source control measures (e.g., covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated and appropriate). 4. Hand hygiene after contact with respiratory secretions. 5. Spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible. 6. Vaccination against respiratory illnesses as appropriate including influenza, pertussis, and pneumonia. D. Hand washing:

Page 3 of 17

Policy

1. Waterless, alcohol‐based hand rubs are now the preferred products for routine hand hygiene in healthcare settings, unless hands are visibly soiled. The CDC recommends that healthcare workers be provided with a readily available alcohol‐based hand rub product at the entrance to each patient care room, at the patient’s bedsiide, or at other convenient locations. 2. Artificial fingernails or nail extenders are prohibited for those having direct contact with patients especially those at high risk (e.g. NICU. ICCU, OR). 3. Recommendations for increased use of waterless hand hygiene products do not negate the need for hand washing sinks. The efficacy of alcoohol‐based products or soap and water depends on the technique of the user. 4. Hands are washed with soap and water when vissibly soiled with dirt or proteinaceous contaminates such as blood, other body fluids, secretions, and excretions, as soon as possible. Hands should also be washed with soap and water before eating and after using the restroom. Hands should be washed with soap and water (with or without gloves) if exposed (suspected or proven) to Bacillus anthracis, Clostridum difficile, and some viral organisms such as Norovirus, Norwalk virus or Rotovirus. 5. Hand hygiene is done with alcohol‐based rubs (preferred) or soap and water for situations such as: • Before and after direct patient contact • Before donning sterile gloves • After removing sterile or non‐sterile gloves • Before an aseptic task such as inserting invasive devices • After contact with body fluid • After contact with patient’s intact skin (e.g. taking pulse or blood pressures) • After contact with objects and equipment in the patient’s immediate vicinity • When moving from a contaminated body site to a clean body site during patient care 6. Standard hand‐hygiene techniques for using alcohol‐based rubs are as follows. It is important to follow the manufacturer’s recommendation for use; • Dispense an appropriate amount of product (2.5 grams) into one hand • Spread over both hands to wrists, interlace fingers and spread under fingernails, and rub into skin until dry (approximately 15‐30 seconds) • Wash hands with soap and water after 8‐10 applications of alcohol gel to remove accumulated emollients. 7. Standard hand‐hygiene techniques for using soap (plain lotion soap) and water are as follows: • Wet hands with water • Apply soap products per manufacturer’s recommendations, usually 1‐2 pumps from the dispenser • Rub hands together vigorously, covering all skin surfaces and under rings • Rinse thoroughly • Dry hands with a disposable towel that is then used to turn off the water faucet. E. All personal protective equipment (PPE) used for infection control precautions are supplied by the institution at no cost to the employee and are impervious or of a repellent fabric. This includes the following articles: 1. Gloves, which are used to prevent contamination of healthcare personnel hands when:

Page 4 of 17

Policy

a. Anticipating direct contact with blood or body fluids, mucous membranes, non‐intact skin and other infectious materials. b. Having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route (e.g. VRE, MRSA, Norovirus and RSV). c. Handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces. d. The selection of glove type for non‐surgical use is based on a number of factors, including sizing, the task that is to be performed, anticipatted contact with chemicals and chemotherapeutic agents, and latex sensitivity. e. A fresh pair of gloves is donned just prior to a procedure to prevent contamination of the field and procedure area. Gloves are promptly removed after removing contaminated items from the field, including the clean drape. Extra gloves should not be stored in pockets with other personal items. 2. Sterile gloves are: a. Required if inserting a sterile catheter or needle in deep tissue or body fluids, usuallly to obtain fluid or instill therapeutic agent. b. Worn if handling instruments/supplies used for invasive procedures of sterile body cavities. c. Selected based on a number of factors, including size, the task has to be performed, anticipated contact with chemicals, and chemotherapeutic agents, and latex sensitivity. 3. Impervious gowns (isolation gown, lab coat or nonsterile surgeon gown) are: a. Worn when it is likely that personal clothing wwill be soiled with any patient's body fluids. b. Laundered by the institution. c. The need for and type of gown selected is based on the naature of the patient interaction including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. Gowns may be worn not only to protect the clothing of the health care worker but may also provide clean/sterile attire. d. Impervious gowns used for personal protectiion should not be worn outside of the area where the exposure was anticipated (e.g. blue lab coats should not be seen in the hallways). 4. Mask are used for three primary purposes in heaalthcare settings: a. Placed on healthcare personnel to protect them from contact with infectious material from patients (e.g., respiratory secretions and sprays of blood or body fluids, consistent with Standard Precautions). b. Placed on healthcare personnel when engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents carried in a health‐care worker’s mouth or nose. c. Placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others (see Respiratory Hygiene/Cough Etiquette, CDC’s Guideline for Isolation Precautions). d. The need and the type of mask selected (e.g.. procedural, surgical, PAPPR, N95 respirators, or HEPA) should be selected based on the anticipated level of exposure to the health care worker and the patient. Proceedural masks are the least effective and are not appropriate in a surgical setting. 5. Goggles/Face Shields: a. Worn to protect the eye and face from infectious materiaals.

Page 5 of 17

Policy

b. The degree of protection required depends upon the circumstances of exposure, other PPE used, and personal vision needs. c. Personal eyeglasses and contact lenses are not considered adequate for eye protection. 6. For minor invasive procedures that require the use of the above PPE with a skin prep and use of a sterile drape: a. Sterile gloves are to be worn by individuals having contact with sterile items or wound. b. Prepare patient as for a standard invasive procedure. c. Hair removal is done only with a clipper or a chemical depilatory and only when absolutely necessary to facilitate wound closure and dresssing. Hair removal occurs as close to incision or procedure time as possible. d. Prepared the procedure site and the surrounding area with an approved surgical scrub agent. Surgical scrub agents are selected based on patient sensitivity, incision location, and skin condition and used according to the manufacturer’s recommendations. e. Apply surgical scrub agents using sterile supplies and steriile gloves proceeding from the incision site to the periphery taking care to avoid skin contact with sterile gloves. f. Follow manufacturer instructions for application of scrub agents. Chloroprep does not require application by concentric circles. See attached skin prep protocol. g. Drape patient as for a standard operating procedure. i. Use sterile drapes to establish a sterile field. ii. Place sterile drapes on the patient and on all furniture/equipment to be included in the sterile field. h. Use sterile items within the sterile field. Check all items prresented to the sterile field for proper processing and package integrity. i. Items introduced onto a sterile field are opened, dispensed, and transferred by methods that maintain sterility and integrity. This field is constantly monitored and maintained and prepared as close as possible to the time of use. 7. Instruments for an endoscopic procedure are sterilized or receeive high level disinfection since they are classified as critical items and may enter sterilee body cavities (including specimen collection).

CLEAN TECHNIQUE (MEDICAL ASEPSIS) AND THE ENVIRONMENT A. Supplies, Instruments and Utensils: 1. Handle all supplies and instruments according to Practice Guidelines for Clean/Sterile Supplies & Instruments. 2. Place grossly soiled instruments in a rigid leak resistant container with appropriate soaking solution. Hands are never used to retrieve objects from opaque solution since liquid may obscure reusable sharps. 3. Rinse grossly soiled utensils and place in designated soiled receiving area for future processing, which is to be ideally done by CS. 4. Use processing solutions which are approved by tthe Infection Control Committee for the intended use. B. Equipment: 1. Clean equipment with a disinfectant before use by another patient, i.e., cautery unit, etc. Items are cleaned with a disinfectant before return to central storage area, and before

Page 6 of 17

Policy

repairs or preventative maintenance. Large equipment returned to CS is wiped down before transport. C. Trash: 1. Bag all trash and disposable items to prevent leakkage. 2. Gather trash at the end of the procedure by perssonnel wearing gloves. Trash is typically removed with the liner but small amounts may be dumped intto another larger container. Trash is never removed by reaching into containers by hand. 3. Place all infectious waste in biohazard labeled red bags. See Policy ‐ General and GL‐9091 Hazardous Materials: Hazardous Substance and Waste Management Control Program for specifics of trash disposal. • A red bag is provided in each Standard Precaution basket for MD's etc., to use during procedures. • Drainage units that have a drain port are empptied into a hopper or sink in soiled receiving area. This is typically done in the Decontaminatiion area in Central Services. • Place emptied drainage units in infectious waste container for disposal. Every attempt must be made to use available engineering coontrols to empty drainage units. • This may include use of closed drainage systems or hopper shields. If Engineering Controls are not available, the appropriate personal protective equipment must be worn. • Infectious waste containers are available throughout clinic based on need and on the loading dock. D. Room cleaning: 1. Daily and terminal cleaning of the exam/procedure room is performed consistently, including prompt cleanup of body substances and/or spills by gloved personnel using an EPA approved disinfectant. 2. Daily disinfect frequently touched surfaces with an EPA approved hospital disinfectant.

STERILE TECHNIQUE (SURGICAL ASEPSIS) A. Patient Care 1. Patients are assessed prior to the procedure for any signs or symptoms of an infectious process. The following are reported to the surgeon and anesthesiologist for final decision if the patient is a surgical candidate: a. Core temperature > 38.5 Celsius b. Productive cough, runny nose, sore throat, and any other symptoms of a respiratory infection. c. Pyuria > 10 WBCs/hpf d. Elevated WBC e. Diarrhea with abdominal pain f. Any purulent material or lesion of the skin or subcutaneouus tissue in proximity to the operative site. This includes any abraded or burned skin g. Any recent exposure to communicable disease that may leead to subsequent disease (e.g., chickenpox exposure to those w/o immunity).

2. Skin preparation

Page 7 of 17

Policy

a. The patient is instructed to bathe the night before and/or the morning of surgery according to handbook instructions, pre‐op phone call or MD instructions. b. Pre‐surgical scrubs and clips are preformed according to individual surgeon preferences. c. Consider decolonization of patient with known methicillin resistant Staphylococcal aureus (MRSA) colonization or infection. See MRSA Decolonization Protocol . 3. Patient Placement a. Patients with a multiple drug resistant organism (MDRO) oor any other infection requiring Contact or Droplet Precautions shall follow the protocols in Isolation Precautions, GL‐ 9100. See also Contact Isolation Guidelines for Perioperative Areas 0050 PACU does not have any private and therefore will place patients requiring Contact or Airborne Precautions in their predesignated isolation bay. b. Place patients with uncontrolled drainage from wounds in Contact Precautions. c. Patients requiring Airborne Infection Isolation (AII) Precautions will be scheduled in OR 12 with the negative pressure anteroom and recovered in the same operating room or in another AII room (e.g. ICU Room 7, CCU Room 12, etc.). Staff must wear the appropriate personal protective equipment during isolation. See the TB Control Plan for additional information. d. Patients entering the surgical suite shall have freshly laundered linens donned after their evening/morning shower or bag bath. Hair will be covered just prior to entering surgery. However Ophthalmology patients may wear their street clothes from the waist down and a clean patient gown if they are cocooned in freshly laundered linens. This only applies if the patient will remain on the eye cart throughout the surgical procedure. B. Personnel: 1. Wash hands at the beginning of the shift prior to and after peerforming the procedure, prior to entry into semi‐restricted or restricted areas, and on exit of semi‐restricted or restricted areas. Artificial fingernails or nail extenders are prohibited for those having direct contact with patients especially those at high risk (e.g. ICU, OR). Hand antisepsis is accomplished with an antimicrobial soap product and water or with an alcohol‐based surgical hand rub product. a. When using an antimicrobial soap product and water: • Hand and arm jewelry should be removeed • Use a nail cleaner under running water to remove debris from underneath fingernails using a nail cleaner under running water • Soap applied; hands and forearms are scrubbed for the length of time recommended by the manufacturer, usually 2 to 6 minutes. Specific manufacturer instructions are to be posted by the scrub sink for easy reference. • Hands and forearms should be dried completely before donning gloves b. When using an alcohol‐based surgical hand rub product (with persistent activity): • Hand and arm jewelry should be removeed • Debris should be removed from underneath fingernails using a nail cleaner under running water. • At a minimum, hands and forearms shouuld be pre‐washed with plain lotion soap and dried completely. The most common praactice is to do the first scrub of the day with a brush and surgical scrub agent following the specific manufacturer instructions and then use the alcohol based surgical rubs for subsequent scrubs.

Page 8 of 17

Policy

• Alcohol‐based surgical hand rub product should follow, using manufacturer’s instructions for surgical hand antisepsis • Hands and forearms must be dried completely before donning sterile gloves. 2. All personnel entering a semi‐restricted and restricted area require appropriate clean attire and hair covering. Clean attire consists of scrub pants, scrub top, and optional warm‐up jacket, which have been laundered and delivered by the hospital laundry. No clean attire is laundered at home. Parents or other supportive individuals may accompany the patient to surgery after donning the appropriate attire and provided the necessary instructions. Parents/supportive individuals will be escorted from the area when the patient has been sedated. Parents or other supportive individuals may enter secondary recovery areas based on patient situation. Generally visitors are not allowed in recovery areas. a. All attire is changed daily or more often whennever they become visibly soiled or wet. The two piece pant suit should be sized appropriately to prevent pant legs from dragging and provide adequate coverage. The top should fit snuggly at the hips or be tucked in to the pants. b. Wearing clean attire is limited to the inside of the institution. This does not include the grounds of the institution or residential housing. Clean attire should be completely covered with clean jumpsuit if worn outside dduring the course of job‐related duties (e.g. walking from hospital to pack room, etc.). c. Duty shoes are kept clean and not worn outside. Shoe covers are only worn with reasonable anticipation of exposure to blood or potentially infective material. Shoe covers are removed following the procedure upon leaving the room. Shoe covers should not be worn as a substitute to having duty shoes. Hose or socks are worn. d. Long sleeved jackets or warm‐up jackets shouuld be worn by all non‐scrubbed personnel in the central core or the operating room. Long sleeved jackets should be snapped close and changed daily or whenever possible contamination may have occurred. Clothing that cannot be covered by the clean surgery attire should not be worn. e. All jewelry is contained within scrub attire. f. All possible head and facial hair, including sideburns and neckline, should be covered. A hood is worn if scrub caps do not cover hair. Reusable haiir coverings should be laundered after each use by Laundry services. Single use hair covering is discarded at the end of the shift. g. The need and the type of mask selected (e.g.. surgical, PAPR, N95 respirators, HEPA) should be selected based on the infectious agent involved and the anticipated level of exposure. Medical PAPRs are not approved for use in a surgical setting with an open sterile field. • Masks are worn during invasive procedurres or when the sterile items are open. • Masks are worn to completely cover the nose and mouth and secured to prevent venting at the sides. • Masks are either on or off; they are not to be tucked into a pockett or worn hanging around the neck. • Masks are generally changed between cases. Exceptions can be made for supervising staff or others that are in several rooms for brief periods of time. • Masks are worn by staff cleaning between cases due to the short turn‐around time of rooms.

Page 9 of 17

Policy

• When removing the mask, touch only the strings to reduce contamination of the hand from the nasopharyngeal area.

3. All surgeons and surgery staff that scrub‐in shoulld know their baseline status for Hepatitis B (HBV), Hepatitis C (HCV) and human immune‐deficiency virus (HIV) infection. All possible exposures to blood borne pathogens should be promptly reported. It is not uncommon to have a dual exposure during a surgical procedure whereby the patient becomes exposed to the health care worker's blood. Employee Health Service (EHS) will consult with Infection Control in the event of a dual exposure. Surgeons and surgery staff with known HBV, HCV or HIV infection should consult with EHS for ongoing follow‐up. (Reference: Infection Control and Hospital Epidemiology March 2010, Vol. 31, No. 3) C. Surgical Skin Prep (See attached : Surgical Skin Preparation, Practiice Guideline for further details) 1. The operative site and surrounding areas are cleaned before entry into procedure room (i.e., pre‐op shower & shampoo). 2. Hair is removed prior to transport to operative/procedure area. Hair removal is done only with a clipper or a chemical depilatory and only when absolutely necessary to facilitate wound closure and dressing. Hair removal occurs as close to incision time as possible. 3. There is a documented assessment of the operative site, which notes the presence of skin lesion. 4. The operative site and the surrounding area are prepped with an approved surgical scrub agent. a. Surgical scrub agents are selected based on patient sensitivity, incision location, and skin condition. b. Surgical scrub agents are used according to the manufacturer’s recommendations. c. Skin lesions or open areas are prepped according to established protocol. d. Antimicrobial agents are applied using sterile supplies and sterile gloves. Scrub jackets are worn during the prep as long as this will not contaminate the prepped area. The antimicrobial agent is applied proceeding from the incision site to the periphery with the exception of Chloraprep. Surgical scrub agents are not allowed to pool under patient. 5. Documentation of the skin prep includes assessment of the skin integrity, hair removal process, area prepped, solutions used, abnormal reaction to prep, and name of person(s) performing the task. D. Sterile field: 1. Sterile gowns and gloves are worn by scrubbed personnel. a. Sterile gowns are available with various levells of protection. The standard surgeon gown (ComPel from Standard Textile ) are classified per ANSI/AAMI PB270:2003 standard as a Level 2 Barrier. Level 2 barrier gowns are appropriate for short procedures with little or no anticipated exposure to blood or body fluids. As the length and physical contact with the procedure increases there should be consideration too select a gown with greater barrier properties. Greater protection may be obtained frrom the ComPel XTR gown from Standard Textile although this gown was not submitted for barrier testing. The greatest level of protection is from the disposable MicroCool KC400 meets Level 4 Barrier standards. Gown strike‐through places not only the healthcare worker at risk to blood‐ borne pathogens but also may increase risk to the patient for developing a surgical site

Page 10 of 17

Policy

infection. Strike‐through may indicate a problem with reprocessing of reusable gowns or may indicate that a higher level of protection is needed. Any incident of strike‐through should be reported for evaluation and possible exposure follow‐up. b. Scrubbed personnel should don a sterile gown and sterile gloves from a sterile field other than the instrument table. c. Sterile gowns are considered sterile in front from chest to the level of the sterile field, and the sleeves are considered sterile from twwo inches above the elbow to the cuff. d. Gloves are inspected after donning. Double gloving is recommended for most procedures. Blue indicator polyisoprene surgical gloves are available as the under glove when double gloving. The blue indicator glove allows for easier detection of holes in the outer surgeon glove. It is generally recommended to change the outerr glove every two hours. 2. Sterile drapes are used to establish a sterile field. a. Sterile drapes are placed on the patient and on all furniture/equipment to be included in the sterile field. b. Sterile drapes should be handled as little as possible. c. During the draping the process the sterile drape is held folded and compact above the operative area, then placed and unfolded from the operative site to the periphery starting with the side closest. d. The sterile gloves are protected during the drraping process by cuffing the draping material over the hands. 3. Items used within the sterile field should be steriile. All items presented to the sterile field are checked for proper processing and package integrity. 4. Items introduced onto a sterile field are opened, dispensed, and transferred by methods that maintain sterility and integrity. a. Wrapped supplies opened by un‐scrubbed personnel by opening the wrapper farthest from them first and the nearest wrapper flap last. b. All wrapper edges are secured when supplies are presenteed to the sterile field to prevent contamination. c. Sterile items are presented to the scrubbed person or placed securely on the table. d. Objects that are sharp, heavy or difficult to handle are presented to the scrubbed person or opened on a separate surface. e. Solutions are dispensed by: • Pouring the entire contents into the receptacle or the remainder is discarded. • The receptacle is placed near the edge of the table orr held be the scrubbed person, and the fluid is poured slowly to avoid splashing. 5. The sterile field is constantly monitored and maintained. a. Sterile fields are prepared as close as possible to the timee of use. • Opened instruments from delayed cases in Labor & Delivery are allowed to be set up for four hours before take‐down provided that room access is limited and set up is monitored. • Opened instruments are not transported outside of the intended room of use. b. Sterile fields should not be covered since it is difficult to reemove the drape without contamination although there is conflicting research. c. Once the patient enters the room, all supplies are considered contaminated to that case. The set‐up may not be used on another patient.

Page 111 of 17

Policy

d. Unguarded sterile fields are considered contaminated. e. Every team member is responsible for observing events that may contaminate the sterile field. f. Conversation is kept to a minimum in the procedure/operating room. There is no gumchewing in the procedure/operating rooom. g. Non‐sterile equipment brought into or over the sterile field is draped with a sterile material or covering so that only sterile items are touching sterile items. 6. Movement around the sterile field is done in a manner to maintain the integrity of the sterile field. a. Scrubbed people remain close to the sterile field and do not leave the room. b. Scrubbed persons keep arms and hands within the sterile area at all times and do not drop them below the sterile level. c. Scrubbed personnel should avoid changing levels to prevent exposure to the un‐sterile portion of the gown. d. Un‐scrubbed persons maintain a safe distance from sterile areas. E. Sanitation 1. Patients are provided with a safe, clean environment free from dust and organic debris. a. Cleaning is done on a scheduled basis to prevent cross‐contamination.. b. Furniture, lights, and equipment is damp dusted with approved disinfectant before the first scheduled case. c. The area is visually inspected before the instruments are bbrought into the room. d. External packing containers used during shipping are removed before materials are transported into the procedure/operating rooom. The integrity of all packages will be maintained. e. Equipment from outside the procedure room is damp dusted with an EPA approved germicidal agent prior to entry into the procedure/operating room. This includes but is not limited to items stored in outer corridor. f. Patients are brought into the procedure/opeerating room with freshly laundered linens and gown. 2. During the procedure, activities are directed at confining and containing contamination. a. There is a prompt clean‐up of contaminated surfaces with an approved disinfectant. b. Spray bottles are not used during the proceddure or set up. c. The patient's bed from the nursing unit is cleean with an approved disinfectant and freshly laundered linen is applied. 3. Items that come in contact with the patient and/or sterile field are considered contaminated. a. Disposable items with squeezable, dripable, ppourable blood are placed in closeablee, leakproof containers or red bags that are labeled. Used/unused or soiled disposable items are placed in the properly defined disposal receptacles. b. Gowns and gloves are removed in a manner tthat contains contaminatiion and gowns and gloves placed in the proper receptacle prior to leaving the procedure/operating room. c. Contaminated linen is handled as little as possible. Linen from any open packs, whether soiled or not, is placed in linen hampers for the laundry. d. Instruments are placed by the gloved scrub person directly into instrument trays and placed in case cart.

Page 12 of 17

Policy

e. Disposable suction containers are sealed and either sent to CS for disposal or emptied in designated soiled area by an individual wearing the appropriate PPE. f. All needles, sponges, instruments are counted when there is a likelihood of items to be retained before disposal. g. Sponges are discarded into or onto imperviouus surface for counting. h. Personnel use gloves in handling sponges, orrganic material, and specimens. 4. Cleaning between cases (turnover) is done jointly by Operating Room staff and Environmental Services. Environmental Services iis ultimately responsible for all terminal cleaning. See Operating Room Cleaning document for further details. a. Equipment and furniture used during the surgical procedure are cleaned with friction and an approved disinfectant. Manufacturer recommendations are followed for the necessary wet contact time needed for surface disinfection. Cleaning is done in a sequence from clean to dirty (e.g. overhead lights, gowning table, prep stand, back table to OR table). All surfaces that may have been contaminated during the procedure are disinfected. This includes but is not limited to ring stands, Mayo stand, desk, lead aprons, lead shields, etc. b. All debris must be removed from the floor before mopping with an approved disinfectant. This includes any item that mayy potentially result in a puncture wound of laundry personnel. The area mopped is depeendent upon the likelihood of contamination. Some procedures are minimally invasive and there is no blood loss therefore floor disinfection is not necessary. c. Floors are cleaned with an approved disinfectant. The mop‐head is changed after each patient's procedure and not dipped back into mop‐bucket after use. Several mopheads may be required to clean a heavily soiled floor. The wet vac system is used to a clean heavily soiled floor in areas where it is available. d. Patient transport vehicles are cleaned with an approved disinfectant. 5. Terminal/daily cleaning of the procedure/operatiing room is done at the conclusion of the day’s schedule. The areas to be cleaned include; lights, ceiling mounted equipment, all furniture including the wheels and casters, handlles and push plates, face plates and vents, all horizontal surfaces, the entire floor, kick buckets, and scrub sinks. Thermostats are set at 72 degrees Fahrenheit or warmer. Terminal/daily cleaning is also done in the related locker rooms, corridors, rest‐rooms, workrooms and storage areas. Break rooms should be cleaned at least daily but typically need to be cleaned more often to keep trash to a minimum. Doors to break rooms should be kept closed at all times. 6. Weekly damp dusting is done for refrigerators, crash carts, supply carts, med carts, desks, tables, and case carts in the Central Core. Step stools are sent to Central Services weekly for cleaning. 7. Monthly cleaning of clean storage areas/shelves needs to be done with monthly checks for outdated supplies. This includes refrigerators, freezer, crash cart, etc. and med cart. The following should be cleaned monthly: gas tracks, light fixtures, and the vents in the clean storage areas and corridors.

SYRINGES, NEEDLES, AND DISPOSABLE SHARPS A. Personnel take precautions to prevent injuries caused by scalpels and other shharp instruments. 1. A hands‐free technique is used whenever possible and practical instead of hand‐to‐hand passing of sharps between physician and assistant.

Page 133 of 17

Policy

2. All syringes, needles and other sharp objects are placed immediately into rigid plastic leakproof, closeable sharps container immediateely after use to prevent secondary handling. 3. Used needles are not broken off, purposely bent, or recapped before disposal (due to increased injury when needles are recapped). Exception: If proocedure requires the contaminated needle be recapped and no alternative is feasible, the only acceptable method is a one‐handed scoop technique. 4. Sharps are not removed from instrument by hand (i.e. needlees are removed from syringes with forceps, etc.). 5. Safety devices are used whenever appropriate and available (blunt suture needles, blunt needle system, safety syringes, etc.). B. All sharps are disposed of safely and according to regulations. 1. Sharps containers should be sealed when 2/3 full and placed in designated area for pickup by Housekeeping. 2. Biohazard labeling is used on all sharps containers. 3. Broken glass is not picked up with bare hands, but swept up with a broom. If small amount ‐ place in sharps container. If large amount ‐ page Environmental Services for pickup.

INJECTION SAFETY Injection safety includes practices intended to prevent transmission of inffectious diseases between one patient and another, or between a patient and healthcare worker and also to prevent harms such as sharp injuries. A. Aseptic technique is used to avoid contamination of sterile injectioon equipment. Aseptic technique pertains to the handling of all supplies used for injections and infusions, including syringes, needles and intravenous tubing. Proper hand hygiene should be performed before handling medications. The rubber septum should be disinfected with alcohol prior to piercing it. Designated medication areas should be clean and free from potentially contaminated items. Personnel preparing drugs for dispensing or administration should not be interrupted during the process to prevent possible oversights in aseptic technique. B. Medications should never be administered from one syringe to multiple patients (including jet injectors) even if the needle or cannula on the syringe is changed. Needles, cannulaes and syringes are considered single use items. They should never be reused for another patient nor to access medication or solution that might be used for a subsequent patient. C. Fluid infusion and administration sets (i.e. intravenous bags, tubing and connectors) are to be used for one patient only and disposed of appropriately after use. Bags or bottles or intravenous solutions should not be used as a common source of supply for multiple patients. Needles / cannulas are considered contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set. D. Once a needle or syringe is used on a patient, it shouuld be promptly discarded into a sharps container. E. Single‐dose vials instead of multidose vials are used whenever posssible. Single‐use vials should be used for only one patient, for one procedure, using a new (clean) needle and new (clean) syringe. Any medication remaining in the vial at the end of the procedure must be discarded and may not be used on additional patients. Never administer medications from a single dose vial/ampule to multiple patients or combine leftovers for later use. This includes but is not limited to contrast dye, propofol, botox or lidocaine.

Page 14 of 17

Policy

F. If multi‐dose vials must be used, both the needle or cannula and syringe used to access the multi‐dose vial must be sterile. Although multi‐dose vials may contain bacteriostatic agents, these agents are not effective against common blood borne pathogens nor are they effective at killing pathogens introduced into the vial with poor aseptic technique. Multi‐dose vials should not be stored in the immediate patient treatment area. This includdes carts or totes brought to the patient bedside during the procedure. Multi‐dose vials accessed at the patient's bedside or in the exam room will be considered single patient use vials and discarded at the end of the procedure. Multi‐dose vials stored in the designated medication area are dated with the beyond use date. The standard beyond use date for multi‐dose vials is 28 days. The beyond use date is the date that occurs 28 days after the initial entry into the multi‐dose vial. The manufacturer's instructions supersede the standard of 28 days (e.g. the beyond use date for vaccines is the expiration date). Pre‐drawn medications must be labbeled with the name of the medication, and concentration or amount. Pre‐drawn medications must be stored in a secured environment and used within one hour. G. Multi‐dose premixed vaccine vials contain bacteriostatic agents that prevent the growth of bacteria. CDC has indicated that these vaccines may bbe used until the expiration date on the vial if aseptic technique was used to access the vials. Ideally the person giving the vaccine should be the one drawing up the vaccine. Only draw up from one vial at a time. H. Surgical masks are worn when placing a catheter or injecting material into the spinal canal or subdural space (e.g. during myelograms, lumbar punctures and spinal or epidural anesthesia). I. Blood glucose monitoring devices are disinfected between patients. Only single use finger stick devices that permanently retract are used by the healthcare worker. Insulin pens are considered single patient use items.

LABORATORY SPECIMENS A. All blood, body fluids and tissue specimens should be placed in a clean impervious container for transport. 1. Specimens from all patients are handled with care. 2. The outside of a soiled specimen container is cleaned with a disinfectant. 3. All specimens must be bagged in a clean leak‐proof clear bag for transportation to the lab. Any specimen that is not in recognizable standard specimen container needs a biohazardous label before transport. Visibly soiled containers may be rejectted by the laboratory. All specimens leaving the institution need a biohazard label. B. Specimens that require other precautions in addition to Standard Precautions are labeled (i.e. AFB/ Airborne Infection Precautions on lung tissue from a known/suspect TB case). C. Hands are washed after transporting specimens to the laboratoryy. D. Specimens sent through the tube system are sealed and double bagged. Liquid specimens are sealed in containers with a screw‐on lid and bagged. E. No specimens are given directly to the patient. All requests for specimens are pprocessed through the Laboratory and physician before being allowed to leaave the institution. See Return of Pathology Specimens to Patients Lab‐5593 for greater detail. F. Amputated limbs, appendages or fetus are not considered infectious waste although they do need to be handled with precautions. Place limb in orange bag for special handling by Pathology or Central Services.

Page 155 of 17

Policy

CARE OF INSTRUMENTS, SCOPES, AND POWERED SURGICAL INSTRUMENTS A. Flash sterilization should not be used as a substitute for sufficient instrument inventory or late delivery of loaner sets. Flash sterilization should not bbe used for implantable devices except in cases of an emergency. See Flash Sterilization PeriOp‐0120 and Requirements for Vendor Representatives in Patient Care Areas GL‐0345 for additional details. B. Instruments are used only for the specific purpose for which they were designed. C. Instruments are kept free of gross soil during the procedure. 1. A sponge moistened with sterile water is used too wipe debris from the instrument duringthe procedure. 2. Lumens are kept patent by sterile water irrigationn. D. All items in contact with the patient and/or sterile field will be considered contaminated. This includes but is not limited to: instruments, sponges, drapes, suture, equipmentt, and furnishings. All contaminated items will be cleaned at the end of the case. If the case cart has been assigned to a specific case, it may be used to return the contaminated items back to Central Services. Secure suction canisters in a manner in the case cart to prevent spills during transit (e.g. place canister in basin). Place laundry and trash bags on top of case cart and remove from procedure room through the outer corridor. Avoid transit through sterile storage areas. E. Reuse of single use devices is prohibited unless they are reprocessed by an FDA approved facility. Open and unused items should be kept to a minimum but may be reprocessed by an FDA approved facility. See Reprocessing Single Use Devices (SUDS) GL‐9040 for further details. F. Decontamination process begins immediately after completion of the invasive procedure. Disinfection practices outside of CS are consistent witth practices within CS. 1. PPE is used during the decontamination process. 2. Manual cleaning is done in a manner to limit aerosolization and splashing of infectious material. Spray bottles of disinfectant should not be used during the case although disinfectant wipes may be used. 3. Prolonged soaking of dirty instruments is avoided to prevent damage of instrument surfaces. Enzymatic soaking of instruments is safe for several hours. 4. Decontamination is done in a designated soiled area. 5. Manufacturer’s written instructions are followed for the detergent selection and the proper use, care, and maintenance of the instruments. G. Instruments with movable parts are lubricated after every cleaning and according to the manufacturer’s written instructions. H. Instruments are inspected and prepared for storage and/or sterilization following the cleanning process. 1. Instruments are checked for cleanliness, proper functioning and alignment, freedom from defects, sharpness of cutting edges, looseness of pins, and chiipping of surfaces. 2. Instruments are dried and then stored. 3. Instruments with removable parts are disassembled and placed in trays designed for sterilization. Ring‐handled instruments are secureed in a manner that retains an open position. 4. Delicate sharp instruments are protected during the decontamination process. I. Endoscopes are inspected, tested, and processed according to design and type and manufacturer’s written instructions. 1. Endoscopes are handled so as to prevent damage to lenses and fiberoptic components.

Page 16 of 17

Policy

2. Endoscopes are disassembled, thoroughly cleaned manually, and dried before sterilization or high level disinfection. 3. Disinfected endoscopes are thoroughly rinsed with sterile water and dried before storage. 4. Accessories are decontaminated, cleaned, and stterilized according to the manufacturer’s written instructions. 5. The disinfected endoscope is rinsed again immediately before use. J. Powered surgical instruments are decontaminated, cleaned, and sterilized according to the manufacturer’s written instructions. K. Powered surgical instruments are inspected, tested, aand used acccording to the manufacturer’s written instructions. L. Powered surgical instruments are packaged and sterilized before use according to the manufacturer’s written instructions. M. Exposure times for steam and EO sterilization of powered surgical instruments are done according to the manufacturer’s written instructions.

RELATED POLICIES/PRACTICE GUIDELINES • AIIR Control Plan, GL‐9900 • Bloodborne Pathogens, GL‐9067 • Employee Illness or Injury, HR‐415 • Flash Sterilization PeriOp‐0120 • General Infection Control Policy, GL‐9060 • Isolation Precautions, GL‐9100 • Occupational Exposure, GL‐9502 • Reprocessing Single Use Devices (SUDS) GL‐9040 • Requirements for Vendor Representatives in Patient Care Areas GL‐0345 • Return of Pathology Specimens to Patients Lab‐5593 • Sterile Supply Preparation, Practice Guideline • Sterilization and Sterility Assurance, GL‐9705

Page 17 of 17