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Infection Prevention and Control Guidelines for Anesthesia Care

1. Non Critical Device an infection risk category of medical devices or surfaces that carry the least risk of gory y disease transmission This category also includes environmental surfaces Nosocomial Infection refers to any infection that develops during or as a result of an admission to an acute care facility hospital Personal Protective Equipment PPE a variety of barriers used alone or in combination to protect mucous membranes skin and clothing from contact with infectious agents PPE includes but is not limited to gloves masks respirators goggles face shields and gowns Respiratory Hygiene Cough Etiquette a combination of preventative measures designed to minimize the transmission of respiratory pathogens via contact droplet or airborne transmission in healthcare 129 30 settings Semi Critical Device an infection risk category of medical devices or instruments that come into contact with mucous membranes and do not ordinarily penetrate body surfaces Spaulding Classification a classification system of medical devices and environmental surfaces based upon the degree of infection risk involved in their use System includes critical semi critical and non critical devices The system also establishes three levels of germicidal activity for disinfection high intermediate and low 13457128 27 Standard Precautions a group of infection prevention practices that apply to all
2. e Facilities should develop an infection control policy and a method for monitoring compliance that specifies appropriate disinfection and sterilization protocols for anesthesia equipment gt e Facilities should select disinfectants or detergents registered with the U S Environmental Protection Agency EPA and follow manufacturer recommendations regarding use exposure time and disposal e Anesthesia equipment should be adequately cleaned prior to disinfection and sterilization e The amount of personal equipment e g stethoscopes and belongings e g jackets backpacks bags purses personal electronic devices brought into the operating room and or patient care areas should be minimized The Spaulding Disinfection and Sterilization Classification Scheme The Spaulding scheme classifies disinfection and sterilization methods for medical equipment by the risk of infection involved View the details of the classification scheme in Table 7 13 Table 7 Spaulding Disinfection and Sterilization Classification Scheme Recommendation Device Classification Critical Contact sterile tissue or the Semi critical Contact mucous membranes or non intact skin Non critical Contact intact skin vascular system Process Device Example s Surgical instruments angiocatheters Sterilization Anesthesia and respiratory therapy equipment breathing circuits endotracheal tubes endoscopes laryngoscopes
3. fiberoptic scopes Magill forceps cystoscopes Laryngoscope blades High level disinfection Laryngoscope handles Intermediate or low level disinfection Patient Care Items Electronic devices stethoscopes blood pressure cuffs arm board nametags pulse oximeter sensors head straps monitor cables blood warmers medication Sterilize devices with sterilants that destroy all vegetative bacteria nonlipid viruses and bacterial spores Rinse with sterile water Medical devices can be sterilized using chemical or physical properties depending on degree of contact with the patient Chemical germicides should be used rationally and in accordance with manufacturer recommendations and facility policy Clean and disinfect devices with high level disinfectants to destroy all vegetative bacteria and nonlipid viruses Rinse with sterile water Dry all equipment surfaces to prevent humidity from encouraging microorganism growth Wrap laryngoscope blades individually If high level disinfection is used a closed plastic bag may be used for storage If steam sterilized a peel pack may be used for storage Partially remove the blade from the package attach to light source and test or keep the blade covered manipulation of the blade onto the light source handle can be tested without actually removing the blade from the bag or pack without touching the blade itself Following testing inser
4. seeseeeeeeeeeeeereeeeeee 11 Needleand Syringe U SO scsicecvacssictsxgcs cesses tease Feagetaonngatvines ost E E E E EE E 12 Gels Lubricants and Ointment cccccccccccesesescsesesesesesesesesesesesesesesesesesesesesesesesesesesesesenees 13 Equipment and Environmental Cleaning Disinfection and Sterilization 0 0 0 ccecceceeeees 13 The Spaulding Disinfection and Sterilization Classification Scheme essesseseseceseceteeeeeees 13 Single Use Devices and Reprocessed Disposable Equipment eccesceeseeseesseeesseeeeceeeeeeeees 15 The Anesthesia Machine and Breathing System cece eeseceseceseceseceseeeseeeseeeeeeeeneeeaeeeaeeeaaeenaees 15 Equipment Considerations for Special Patient Populations ce eee eseeseesceeseeeeseeeseceseceseeeseeees 17 Environmental Suriaces dcssssecersnsssntessaseesnsabssdeesnscesanssasbuesaodcesivanstuetageasdeciasolayss sosesaesesnneedacheasaes 17 Tinens and Disposable Drapes sicsicce dsveisccceeseiesdeyebgessceveebelovesseevievvseccsyebascattvbspsasneasntessevsadaseisesere 18 Biohazardous Waste Management cessesscesssecssecsseceseceseceseceeeeseeeeeeecaeeeaeeeaeecaaecsaecaesnaeenaeens 18 Invasive Procedure Techmique ccecesccscessessecesesseeeceaecaeeecesecaeeeneeseceaeeaessecsaeeaeeeeeaecaeeeneeseenaeeetes 18 Considerations for Ultrasound Guided Procedures 0 ccceesseceecceceeeeeececeeaceceeneecsaeeesaaeceeaeeesaes 19 Considera
5. especially surgical masks during procedure e Prepare patient skin with an appropriate agent gt e Dress the insertion site with a sterile transparent occlusive dressing o Use chlorhexidine impregnated dressings at insertion sites to reduce epidural skin entry point colonization e Check the insertion site and overall patient status at least daily for early identification of superficial infection e g erythema tenderness itching at the site deep infection e g fever back pain lower limb weakness headache and sensory motor status e Remove once no longer clinically indicated 19 91 90 93 Disconnected Catheters The use of an epidural catheter for a prolonged period of time increases the risk of becoming disconnected from the insertion site which heightens the risk of infection The choice to reconnect or remove the catheter is at the discretion of the anesthesia professional if not addressed in facility policy Factors to be considered include the potential of contamination and patient specific risk benefit ratios 1 When a disconnected catheter is discovered and static fluid has moved more than five inches from the disconnected end the catheter should be removed Considerations for Central Venous Catheter Maintenance and Procedures Central venous catheters CVCs also known as central lines are used to administer medications provide fluids for nutrition and conduct medical tests Manufactu
6. Infection Control and Prevention Plan for Outpatient Oncology Settings 2011 http www cdc gov HAI settings outpatient basic infection control prevention plan 2011 central venous catheters html Accessed September 4 2014 Central line procedures http www anesthesiology uci edu clinical_centralline shtml Accessed September 4 2014 Lopez Briz E Ruiz Garcia V Cabello JB Bort Marti S Carbonell Sanchis R Burls A Heparin versus 0 9 sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults Cochrane Database Syst Rev 2014 10 CD008462 National Guideline C Standardizing central venous catheter care hospital to home http www guideline gov content aspx id 38459 Accessed 1 27 2015 Moran JE Ash SR Committee ACP Locking solutions for hemodialysis catheters heparin and citrate a position paper by ASDIN Semin Dial Sep Oct 2008 21 5 490 492 Infusion Nurses Society Aspirating a blood return from a catheter http www ins1 org files public QA_Session_1_Webinar pdf Accessed January 7 2015 UCDavis Health System Central Line Blood Draw http www ucdme ucdavis edu cppn resources clinical_skills_refresher central_line_blood_dra w Central 20Line 20Blood 20Draw pdf Accessed January 23 2015 Centers for Disease Control and Prevention CDC Approach to BSI Prevention in Dialysis Facilities i e the Core Interventions for Dialysis Bloodstream Infection BSI Prevention 2014 http www
7. LP Albrecht UV Sedlacek L Gemein S Gebel J Vonberg RP Portable UV light as an alternative for decontamination Am J Infect Control Dec 2014 42 12 1334 1336 Andersen BM K H J D Cleaning and Decontamination of Reusable Medical Equipments Including the use of Hydrogen peroxide Gas Decontamination J Microbial Biochem 2012 4 2 57 62 U S Food and Drug Administration Reusing Disposable Medical Devices 2014 http www fda gov MedicalDevices DeviceRegulationandGuidance ReprocessingofSingle UseDevices ucm121465 htm Accessed December 8 2014 Shuman EK Chenoweth CE Reuse of medical devices implications for infection control Infect Dis Clin North Am Mar 2012 26 1 165 172 Feigal D Reuse of Single use Devices 2000 http www fda gov NewsEvents Testimony ucm115002 htm Accessed December 2 2014 U S Food and Drug Administration CPG Sec 300 500 Reprocessing of Single Use Devices 2005 http www fda gov iceci compliancemanuals compliancepolicyguidancemanual ucm073887 ht m Accessed December 11 2014 Baillie JK Sultan P Graveling E Forrest C Lafong C Contamination of anaesthetic machines with pathogenic organisms Anaesthesia Dec 2007 62 12 1257 1261 Rothwell M Pearson D Wright K Barlow D Bacterial contamination of PCA and epidural infusion devices Anaesthesia Jul 2009 64 7 751 753 Wilkes AR Heat and moisture exchangers and breathing system filters their use in anaesthesia and intensive care Part 1 hist
8. cdc gov dialysis prevention tools core interventions html Accessed January 26 2015 The Johns Hopkins Hospital InterdiscipInary Clinical Practice Manual Infection Control Vascular Access Device Policy Adult 2008 http www hopkinsmedicine org armstrong_institute _files clabsi_toolkit vad_appx HL_Implan ted_Central_Venous_Access_Port pdf Accessed January 24 2015 Centers for Disease Control and Prevention Prevention Strategies for Seasonal Influenza in Healthcare Settings 2011 http www cdc gov flu professionals infectioncontrol healthcaresettings htm Accessed November 25 2014 Centers for Disease Control and Prevention Recommended Vaccines for Healthcare Workers 2014 http www cdc gov vaccines adults rec vac hcw html Accessed December 23 2014 34 119 Claborn KR Meier E Miller MB Leffingwell TR A systematic review of treatment fatigue among HIV infected patients prescribed antiretroviral therapy Psychol Health Med Aug 11 2014 1 11 120 Centers for Disease Control and Prevention Tuberculin Skin Testing 2012 http www cdc gov tb publications factsheets testing skintesting htm Accessed December 22 2014 121 Centers for Disease Control and Prevention Latent Tuberculosis Infection A Guide for Primary Health Care Providers 2013 http www cdc gov tb publications LTBI diagnosis htm 1 Accessed December 22 2014 122 Bujedo BM Current evidence for spinal opioid selection in pos
9. further spread of infection Table 3 offers examples of PPE and information on how to properly wear remove and dispose of the gear Table 3 PPE examples and guidelines PPE Indications Guidelines Removal Protocol Disposable e Routine patient Remove and replace gloves promptly when Grasp outer edge of glove near Gloves care contaminated or damaged This is an important practice wrist Non e Shared patient to keep anesthetizing locations and patient care areas Peel away from hand turning inside Sterile provider use of a clean out difficult to clean Remove gloves and perform hand hygiene after caring Hold removed glove in opposite device e g for a patient and between patients gloved hand computer Do not use the same pair of gloves for more than one Slide ungloved finger under wrist of keyboards patient gloved hand so finger is inside Special considerations such as pore size and glove composition e g latex may apply based on patient provider or procedure gloved area Peel off the glove from inside creating a bag for both gloves Dispose of gloves in proper waste receptacle Disposable e Surgical Gloves procedures Sterile e Vaginal deliveries e Invasive radiological procedures e Performing vascular access and procedures e Preparing total parental nutrition and chemotherapeutic agents Remove and replace gloves promptly when contaminated or damaged This
10. g intravenous and epidural pumps blood glucose meters and other point of care devices stand alone monitors blood and fluid warmers forced air warmers between cases and at the end of each day in accordance with facility specific policies Follow manufacturer recommendations regarding use exposure time and disposal of disinfectants and sterilants Place items that may be used during the next case on clean surfaces Consult the CDC recommendations for standard precautions and transmission based precautions for additional guidance 17 Linens and Disposable Drapes Handle linens and other disposable drapes in a manner that limits the transfer of blood and microorganisms e Handle contaminated laundry as little as possible Place and transport the laundry in labeled or color coded bags or containers Do not sort or rinse contaminated laundry Avoid body contact with soiled items When standard precautions are applied to the handling of soiled laundry alternative labeling or color coding is sufficient if it permits all personnel to recognize the container s as meeting compliance e Store laundered items in a clean dry area to prevent contamination by dust or other particles Biohazardous Waste Management Biohazardous waste refers to any item that is contaminated with infectious or potentially infectious materials Sharps disposal is of particular concern due to the potential for injury when handling e g needles scalpel blade
11. has progressed to TB disease o Other tests such as a chest x ray and a sample of sputum determine the presence of active TB disease in accordance with symptoms such as fever weight loss and night sweats 7 e Review your facility policy for specific guidelines for identification reporting and management of an active TB case o Facility policies should be implemented in accordance with Occupational Safety and Health Administration OSHA and state health department standards o Refer to Equipment Considerations for Special Patient Populations for information regarding the use of filters and appropriate cleaning procedures for the anesthesia machine following a suspected case of active TB Reducing the Risk of Adverse Events Anesthesia professionals should take precautions to mitigate adverse events such as ventilator associated pneumonia and surgical site infections SSIs which can potentially be encountered within their practice Recommendations to mitigate these adverse events are listed below Ventilator Associated Pneumonia e Practice hand hygiene prior to and following care e Use noninvasive ventilation when possible e Extubate as early as possible e Prevent aspiration Maintain patients in semirecumbent position 30 40 if possible Avoid gastric overdistention Avoid unplanned extubation and reintubation Use cuffed endotracheal tube with in line subglottic suctioning Maintain cuff pressure of at least
12. is an important practice to keep anesthetizing locations and patient care areas clean Remove gloves and perform hand hygiene after caring for a patient and between patients Do not use the same pair of gloves for more than one patient Special considerations such as pore size and glove composition e g latex may apply based on patient provider or procedure Partially remove the first glove by peeling it back with fingers of the opposite hand all five fingers should still be covered with the glove Remove the other glove completely turning it inside out only touching the outside of the glove with the covered fingers of the partially gloved hand Remove the glove on the partially gloved hand completely using the inside out removed glove Skin is only contacted by the inner surface of the glove Dispose of gloves in proper waste PPE Indications Guidelines Removal Protocol Regional receptacle neuraxial techniques Double Airway After performing the planned intervention immediately First remove the outer glove by Gloves manipulation remove and safely dispose of the outer gloves following the protocols for sterile Increased risk of Remove and replace gloves promptly when glove removal complications contaminated or damaged This is an important practice Remove other PPE equipment from needle stick to keep anesthetizing locations and patient care areas Remove inner glove follow
13. multi dose vial once opened e Do not keep multi dose vials in the immediate patient treatment area e g patient rooms or bays operating rooms anesthesia carts o Ifa multi dose medication vial enters a patient treatment area it should be treated as a single use vial and discarded at the end of the individual case e Discard multi use medication vials if sterility is compromised or questionable Discard multi use medication vials within 28 days of opening o If the manufacturer labelled expiration date falls within 28 days of opening discard the vial prior to the manufacturer expiration date 40 52 38 52 Gels Lubricants and Ointments e Dedicate ointments gels and lubricants to a single patient when possible e Use sterile skin prep agents when indicated Equipment and Environmental Cleaning Disinfection and Sterilization The following information regarding equipment and environmental cleaning disinfection and sterilization is not intended to be comprehensive Review the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities 2008 federal state or local statutes and regulations equipment manufacturer recommendations and facility policy and procedures as the best sources for current evidence based practice guidelines The following are general considerations for equipment and environmental cleaning and should not substitute review and adherence to previous referenced resources
14. on one patient for a single procedure Numerous studies have linked outbreaks of infection to the use of improperly reprocessed single use devices e Reuse of single use devices may expose healthcare providers and facilities to additional liability e Refer to the FDA for guidance and information on reprocessed single use devices To mitigate incidence of outbreaks it is recommended that healthcare facilities e Establish a policy to verify the cleanliness and functionality of reprocessed disposable equipment prior to use e Disassemble clean dry reassemble repackage and disinfect or sterilize reprocessed disposable equipment prior to use as appropriate 54 65 The Anesthesia Machine and Breathing System Although there is no direct contact between anesthesia machine controls and the patient microorganisms can be transferred between the machine and patient by the healthcare provider Refer to federal state or local statutes and regulations and facility policies as well as specific manufacturer instructions for guidance concerning e Cleaning and disinfecting the anesthesia machine e Pasteurizing or autoclaving of valves e Disassembling and disinfecting adjustable pressure limiting valves Anesthesia Machine Surfaces and Carts e Clean then spray or wipe anesthesia machine surfaces and knobs with an appropriate germicide between cases and at the end of each day e Take protective measures to prevent ma
15. patients regardless of 1 29 128 suspected or confirmed diagnosis or presumed infection status Sterilization the use of chemical agents or physical method to destroy all microorganisms including large numbers of resistant bacterial spores Used for sterilizing critical devices Transmission Based Precautions a set of practices that apply to patients with a documented or suspected transmissible and or virulent infection Provisions beyond the standard precautions are needed to interrupt transmission in healthcare settings Degrees of transmission based precautions vary based upon risk of transmission and virulence of infection and include contact droplet and airborne precautions 117579128 Tuberculosis Infection Latent a condition in which living Mycobacterium tuberculosis is present in the body but the disease is not clinically active Infected persons usually have positive tuberculin skin test but they have no symptoms related to the infection and are not infectious Tuberculosis Infection Active a condition in which living Mycobacterium tuberculosis is present in the body and the disease is clinically active Infected persons usually have positive tuberculin skin tests and symptoms related to the infection and are contagious gt Vaccine an agent that produces immunity and protects the body from the disease Vaccines are typically administered through injections by mouth by aerosol or through skin a
16. protect the patient from the anesthesia machine and to place a high efficiency filter in the expiratory limb to protect the anesthesia machine from the patient e Filters may be interposed between the endotracheal tube and the Y piece e Use circuit filters and follow up with post anesthesia machine disinfection after caring for patients with known pulmonary infection or trauma Carbon Dioxide Absorbers e Follow the manufacturer instructions for disassembly cleaning and sterilization of carbon dioxide absorbers e Clean canisters when the absorbent is changed and carefully remove debris from the screens e Discard disposable plastic canisters e Bellows unidirectional valves and carbon dioxide absorbers should be cleaned and disinfected periodically Circuits Anesthesia circuits may be manufactured as either single patient use items or multiple patient use items provided that a new breathing system filter is placed between the Y piece and endotracheal tube after sterilization or high level disinfection Anesthesia professionals should pay close attention to anesthesia circuit product labeling e Ata minimum provide high level disinfection for multiple patient use breathing circuits o If available ultrasonic cleaning is effective e The outer surface of the circuit can become easily contaminated when the system is not changed between patients and therefore should be disinfected between each use e End
17. treating clinician s orders Stabilize port with one hand and remove needle with the other hand Maintain positive pressure technique on the syringe while deaccessing by flushing the catheter while withdrawing the needle from the septum Apply dressing Port Maintenance and Care For short term use in outpatient settings a light dressing may be used in place of an occlusive dressing during the infusion ensure the needle is secure in the portal septum as described above When not P use implanted ports should be flushed every four to eight weeks to maintain patency Considerations for Arterial Catheters and Pressure Monitoring Devices Catheters that need to be in place for gt five days should not be routinely changed if no evidence of infection is observed Maintain sterility of stopcocks cap when not in use apply 70 percent alcohol prior to access Maintain sterility of pressure monitoring devices Minimize the number of manipulations and entries into the pressure monitoring device When the pressure monitoring system is accessed through a diaphragm rather than a stopcock scrub the diaphragm with an appropriate antiseptic agent before accessing the system Vaccinations Post Exposure Prophylaxis and Screening Preventative measures such as vaccination prophylaxis and screening can help protect healthcare workers from contracting and spreading disease Below are recommendations for vaccination prophylaxis a
18. 20cm H20 e Avoid nasotracheal intubation e Avoid histamine H2 blocking agents and proton pump inhibitors if possible due to risk of acid suppressive therapy enhancing bacterial colonization of aerodigestive tract e Perform regular oral care with an antiseptic solution e Eliminate potential contamination risk to equipment 23 00000 Use sterile water rinse Remove condensate from ventilatory circuit Change circuit only when visibly soiled Use sterile sheathe enclosed suction catheters oOoO00 Surgical Site Infection e Perform enhanced SSI surveillance to determine the source extent and potential solutions to the problem e Use proper hair removal methods to ensure the preservation of skin integrity e g avoid the use of razors or depilatories e Monitor the blood glucose level during the immediate postoperative period e Maintain perioperative normothermia for patients undergoing colorectal surgery Perioperative Antibiotic Therapy e Administer antimicrobial prophylaxis within one hour before surgical incision o Select appropriate agent based upon the type of surgical procedure gt e Deliver intravenous antimicrobial prophylaxis within one hour prior to incision recognizing that two hours may be allowed for the administration of vancomycin and fluoroquinolones e Discontinue prophylaxis within 24 hours of surgery and 48 hours of cardiac procedures e Use antimicrobial prophylactic agents in accordance with publi
19. ANA Board of Directors in 1992 and revised in 1993 1997 November 2012 In February 2015 the AANA Board of Directors archived the guide and adopted the Infection Prevention and Control Guidelines for Anesthesia Care Copyright 2015 33
20. American Association of Nurse Anesthetists 222 South Prospect Avenue Park Ridge IL 60068 AANA www aana com Infection Prevention and Control Guidelines for Anesthesia Care Table of Contents Vana CUA CEN OMI sess sds 5s cds oon edad ee vasa d awh eas coaedn te og does TEN T NE E T A 2 Standard Precautions 0 0 0 0 eccescssseecessecceeseeseceseeseeseceaecseeeceesecsaeeaeeseceaecaeeecesecaeeeeeesecsaeeaeeeeeeaeeaeeeneeaes 3 Fearn Hy S110 sisi ins cog sonia as oo nas edies a giad denen uhetete dldapastedaal tbe a a aa 3 Personal Protective Equipment cc ecceceeccesececeeseesecseeseeseceaecaeeeceaecseeeceesecsaeeaesseceaecaeeeeeesecaeeeneeae 4 Transmission Based Precautions 0 csccscesscsseceseeseeecseeseeeceaecaeeeeceaecaeeeceesecsaeeaeesecaeeaeseeeeaecaeeeneeaes 8 Respiratory Fy Siene 2 5 2ccssccccssesescetcovantersusodsacssondoeeeessas cecsoaa sous esisdsouysesics osacuneesaadesopsdsasisssabebeostaiazesteatedies 9 Skin Preparation eiieeii i evan a ta adagietesecesvbawtcadeedua inves aia ie a a a 9 Aseptic Technique ae cs casas si dade ssa dacs adda cadens dec reae exh RE E aE eE E E E E EE 10 Airway Management Considerations Specific to Anesthesia Professionals ccscsseeeees 10 Safe Injection Practices cis ccseescvesccsdsceecckecsusdcekccendevt cdevdeas cdentedectevecesaceeseesstevshesdete SEE OE iE erea EEN Kenit 11 Drug Preparation and Administration USP Chapter lt 797 gt Compounding
21. B Siboni K Infections following epidural catheterization J Hosp Infect Aug 1995 30 4 253 260 Hebl JR The importance and implications of aseptic techniques during regional anesthesia Reg Anesth Pain Med Jul Aug 2006 31 4 311 323 Paton L Jefferson P Ball DR The disconnected epidural catheter a survey of current practice in Scotland Eur J Anaesthesiol Sep 2012 29 9 453 455 Langevin PB Gravenstein N Langevin SO Gulig PA Epidural catheter reconnection Safe and unsafe practice Anesthesiology Oct 1996 85 4 883 888 Centers for Disease Control and Prevention Frequently Asked Questions about Catheters 2010 http www cdc gov HAI bsi catheter_fags html al Accessed January 21 2015 Centers for Disease Control and Prevention HICPAC 2011 Guidelines for the Prevention of Intravascular Catheter Related Infections 2011 http www cdc gow hicpac BSI 03 bsi summary of recommendations 2011 html Accessed January 20 2015 Centers for Disease Control and Prevention Central Line Insertion Practices CLIP Adherence Monitoring 2015 http www cdc gov nhsn PDFs pscManual Spsc_CLIPcurrent pdf Accessed December 19 2014 O Grady NP Alexander M Burns LA et al Guidelines for the prevention of intravascular catheter related infections Am J Infect Control May 2011 39 4 Suppl 1 S1 34 National Helathcare Safety Network Central Line Insertion Practices CLIP Training Course 2008 Centers for Disease Control and Prevention Basic
22. PE Indications Guidelines Removal Protocol contact with hazard exposure the duration of exposure and the outer glove following sterile glove infectious availability of other PPE removal protocol prior to removing material Pretest selected eye protection for suitability and eye protection Splash or spray appropriate fit Lift head band or ear piece hazards Clean and disinfect nondisposable eyewear prior to use Refrain from touching the face e g laser glasses goggles N95 respirator face shield shields Dispose of eye protection in proper receptacle for reprocessing or disposal Surgical Invasive Wear to cover facial hair If donning double gloves dispose of Masks procedures e g The surgical mask should cover the mouth and nose outer glove following sterile glove arterial and central and be secured in a manner that prevents venting at the removal protocol prior to removing venous access sides of the mask surgical mask regional Remove and discard when wet or soiled and at the end Undo the ties or grasp the elastics at anesthesia of a case or procedure the top and bottom of the mask and Regional Perform hand hygiene immediately following mask remove without touching the front of neuraxial removal and disposal the mask technique Dispose of mask in proper waste Potential for receptacle contact with infectious material Hair Upon entry to Cover hair facial hair sideburns and the back of the If donning double gloves dispose
23. a Facilities should consider use of a hypochlorite solution for environmental cleaning as an additional contact precaution During heightened periods of virulent and highly contagious infectious outbreaks e g Ebola virus disease EVD Enterovirus healthcare providers are encouraged to refer to the following resources for supplemental information regarding transmission based precautions Local and or state health departments Centers for Disease Control and Prevention CDC http www cdc gov Society for Healthcare Epidemiology of America http www shea online org Association for Professionals in Infection Control and Epidemiology http www apic org AANA Practice Committee www aana com 8 Respiratory Hygiene Respiratory hygiene includes cough etiquette and the appropriate use of isolation precautions to prevent the spread of infection Perform the following measures for cough etiquette when afflicted with a respiratory disease e Cover mouth and nose with a tissue when coughing or sneezing e Dispose of tissue after use in the waste bin e Perform hand hygiene following contact with respiratory secretions e Do not perform patient care when infected or ill During periods of elevated respiratory infection incidence facilities may offer facemasks to patients and healthcare providers who are coughing and take additional transmission based precautions as necessary Skin Prepa
24. bsorption 28 References 1 11 12 13 14 15 16 17 Siegel JD Rhinehart E Jackson M Chiarello L 2007 Guideline for Isolation Precautions Preventing Transmission of Infectious Agents in Health Care Settings Am J Infect Control Dec 2007 35 10 Suppl 2 S65 164 Centers for Disease Control and Prevention Data and Statistics Healthcare associated Infections HAIs 2014 http www cdc gov HAI surveillance Accessed November 26 2014 Petty WC Closing the hand hygiene gap in the postanesthesia care unit a body worn alcohol based dispenser J Perianesth Nurs Apr 2013 28 2 87 93 quiz 94 87 Anderson DJ Kaye KS Classen D et al Strategies to prevent surgical site infections in acute care hospitals Infect Control Hosp Epidemiol Oct 2008 29 Suppl 1 S51 61 Centers for Disease and Control Prevention Antibiotic Resistance Threats in the United States 2013 2013 Centers for Medicare and Medicaid Services Hospital Infection Control Worksheet 2014 http www cms gov Medicare Provider Enrollment and Certification SurveyCertificationGenInfo Downloads Survey and Cert Letter 15 12 Attachment 1 pdf Accessed January 7 2015 Centers for Medicare and Medicare Services Section 482 42 Condition of participation Infection control 2009 http www gpo gov fdsys pkg CFR 2009 title42 vol5 xml CFR 2009 title42 vol5 sec482 42 xml Accessed January 7 2014 Boyce JM Pittet D Guideline for Hand Hygiene i
25. cautions cannot be achieved Healthcare workers should don gloves gowns and N95 mask upon entering an infectious patient s room Immune healthcare workers are the preferred providers for infectious patients with airborne diseases Precaution Description Protocol Examples Contact Prevents Use single patient rooms when possible Include but not limited transmission of Maintain gt three feet spatial separation between to infectious agents beds in rooms with more than one patient e Clostridium spread by contact Wear a gown and gloves for all contact with the difficile with the patient patient or the patient s environment e Norovirus or environment Wear PPE before entering the patient s room and e Scabies discard it before exiting the patient s room Droplet Prevents Use single patient rooms when possible Include but not limited transmission of Maintain gt three feet spatial separation between to infectious agents beds in rooms with more than one patient e Influenza spread by close Wear a gown gloves and mask for all contact e Pertussis contact with with the patient or the patient s environment e Mumps respiratory Wear PPE before entering the patient s room and e Rubella secretions discard it before exiting the patient s room Place a facemask on the patient during transport Airborne Prevents Place patients in an airborne infection isolation Include but not limited to e M tuberculosis e Measles e Varicell
26. d to remove gloves wash hands and don new gloves which would conflict with the standard of clinical care for airway instrumentation and maintenance e Immediately following maneuvers undertaken to establish a patent airway the patient should be ventilated manually the breath sounds auscultated and the expired breath examined for presence of expired carbon dioxide e It is recommended that anesthesia practitioners consider double gloving prior to airway manipulation 10 o Following tube or device insertion remove contaminated outer gloves and perform necessary actions to assure airway security and patency e When the situation is stable remove the inner gloves perform hand hygiene and don clean gloves to continue with patient care e Targeted environmental cleaning of the anesthetizing area after each case and ongoing research to design new methods are each important to control bacterial transmission in the anesthetizing area Safe Injection Practices Improper injection practices put patients and healthcare providers at risk of infection from bloodborne pathogens which can lead to the spread of HAIs Following safe injection practices can prevent the spread of disease These measures can also protect providers from disciplinary action and legal recourse 044 Drug Preparation and Administration USP Chapter lt 797 gt Sterile Compounding The U S Pharmacopeia Convention USP is a scientific nonprofit
27. due to delay e Chapter lt 797 gt categorizes CSPs into three risk levels low medium and high and sets preparation standards for each level o Risk levels are defined according to the probability of CSP contamination e Anesthesia medications may meet the immediate use provision if the delay from preparation of CSPs following the preparation standards of a low risk level drug would render additional risk to the patient o Medium and high risk CSPs cannot be prepared under the immediate use provision 478 o CSPs prepared in accordance with the immediate use exception may not be stored or prepared by batch compounding Daily anesthesia workflow makes the immediate use provision challenging to meet as providers are prohibited from batch medication preparation 11 o The following criteria for low risk CSPs must be met to qualify for the immediate use provision The CSP should have no more than three commercially manufactured packages of sterile nonhazardous products from the manufacturer s original container and no more than two entries into a sterile administration container device or sterile infusion solution The compounding procedure is continuous and does not exceed one hour Aseptic technique is followed and the prepared CSP is under continuous supervision until administered Administration begins no later than one hour following the start of the CSP preparation The CSP must be labeled with pat
28. er associated urinary tract infections CAUTIS ventilator associated pneumonia and other HAIs Unsafe injection practices and improper reuse of needles syringes and single use devices as well as the increase in multiple drug resistant organisms MDROs have also contributed to a rise in emerging infections In 2011 there were over 721 000 cases of infections attributed to improper infection control practices in healthcare facilities accounting for about 75 000 deaths These rates of morbidity and mortality have serious health implications for patients and cost healthcare facilities millions of dollars annually adding urgency to the adherence to universal infection control practices Healthcare providers have an ethical duty to protect patients and prevent unnecessary harm In life threatening emergencies requiring immediate action healthcare providers should weigh the relative risk to patient life and determine the most appropriate infection control practice under those circumstances Following emergency care review all actions taken and intervene as appropriate to assure that all appropriate infection control guidelines and standards are addressed as soon as possible Healthcare providers shall document any deviations from these standards e g emergency cases for which informed consent cannot be obtained surgical interventions or procedures that invalidate application of a monitoring standard and state the reason for the deviation o
29. ers of bacterial spores Used for disinfection of semi critical devices 345718 Immunocompromised patients patients whose immune systems are deficient because of congenital or acquired immunologic disorders Examples include but are not limited to human immunodeficiency virus HIV cancer and organ transplant recipients Immunity protection against a specific disease indicated by the presence of antibodies in the blood that protect against a specific antigen pathogen Immunization the process by which a person becomes immune or protected against a disease typically through vaccination This process is not always effective at preventing disease Infection transmission of microorganisms into a host after evading immune system defenses resulting in the organism s proliferation and invasion within the host Usually triggers an immune response e g fever nausea aches Intermediate Level Disinfection a disinfection method that inactivates bacteria most fungi and most viruses but not bacterial spores Typically used for disinfection of non critical devices 34571 Low Level Disinfection a process that will inactivate most bacteria fungi and viruses but cannot be relied on to inactivate resistant microorganisms Used for disinfection of some non critical devices and environmental surfaces 7 8 Multidrug Resistant Organisms MDROs bacteria that are resistant to multiple classes of antimicrobial agents
30. es the incidence of infection Table 1 describes when hand hygiene is indicated and Table 2 describes specific hand hygiene definitions and protocols Table 1 Indications for hand hygiene Before After e Patient contact e Donning protective equipment Contact with patient s skin and immediate surroundings e g bedside area e Performing invasive procedures e g catheter e Contamination insertion epidurals surgery e Contact with body fluids and wounds e Removing protective equipment e Using the restroom Table 2 Hand hygiene definitions and instructions Term Definition Protocol Antiseptic Washing hands with water and an e Wet hands with water apply antiseptic soap and Handwashing antiseptic agent e g soap hand rub hands together for at least 20 seconds rub Alcohol Rubbing non visibly soiled hands e Apply manufacturer recommended amount to Based with a product that contains alcohol palm Handrubbing to decontaminate hands e Rub hands together covering all surfaces and fingernails until dry e Refrain from contact until hands are completely dry Surgical Washing hands with an antiseptic e Remove jewelry e g rings bracelets Hand agent before a surgical procedure wristwatches prior to performing surgical hand Antisepsis hygiene e Follow manufacturer guidelines for scrub time e Clean under fingernails using a nail cleaner e Keep natural nail length to les
31. ian attire as possible source of nosocomial infections Am J Infect Control Sep 2011 39 7 555 559 Virginia Department of Public Health Standard Precautions and Transmission Based Precautions 2012 http www vdh virginia gov epidemiology surveillance hai StandardPrecautions htm Accessed November 14 2014 Respiratory Hygiene Cough Etiquette in Healthcare Settings 2012 http www cdc gov flu professionals infectioncontrol resphygiene htm Accessed September 8 2014 Respiratory Hygiene Cough Etiquette in Healthcare Settings Centers for Disease Control and Prevention 2004 Zinn J Jenkins J Swofford V Harrelson B McCarter S Intraoperative Patient Skin Prep Agents Is There a Difference AORN J 2010 92 6 662 674 Digison MB A review of anti septic agents for pre operative skin preparation Plast Surg Nurs Oct Dec 2007 27 4 185 189 quiz 190 181 Checketts MR Wash amp go but with what Skin antiseptic solutions for central neuraxial block Anaesthesia Aug 2012 67 8 819 822 Preventing Central Line Associated Bloodstream Infections Useful Tools 2013 http www jointcommission org assets 1 6 CLABSI_ Toolkit Tool_3 8 Aseptic versus _Clean_Technique pdf Accessed November 14 2014 Miller DM Eriksson LI Fleisher LA Wiener Kronish JP Young WL Airway Management in the Adult In Miller DM ed Miller s Anesthesia Vol 2 Philadelphia PA Churchill Livingstone Elsevier 2010 1573 1610 Pedersen T Nicholson A Hovhan
32. ient identification information the names and amounts of all ingredients the name or initials of the CSP preparer and the exact beyond use date and time unless the CSP is immediately and completely administered by the CSP preparer or unless immediate and complete administration of the CSP is overseen by another preparer Ifthe prepared CSP administration has not started within one hour following the start of preparation the CSP must be promptly properly and safely discarded 44 45 All personnel involved in compounding should understand how they may contribute to the risk of CSP contamination during preparation To decrease the risk of contamination many hospital pharmacies commonly prepare medications used in delivery e g phenylephrine or buy ready to use prefilled medications e g fentanyl sufentanil Anesthesia professionals should prepare CSPs using proper aseptic technique 44 45 Needle and Syringe Use e Avoid recapping of needles and discard used needles and syringes into a puncture resistant sharps n 39 40 49 container e Consult the AANA Safe Injection Guidelines for Needle and Syringe Use and the CDC recommendations for safe injection practice for more complete guidance Syringes Needles and Needleless Access Devices 43 49 Use syringes needles and needleless access devices only once Do not refill a syringe once used even for the same patient Efforts should be made to kee
33. ing the injuries e g clean protocols for sterile glove removal HIV Hepatitis C Remove gloves and perform hand hygiene after caring Perform hand hygiene contamination for a patient and between patients Do not use the same pair of gloves for more than one patient Resume urgent patient care activities e g patient ventilation with sterile inner gloved hands Special considerations such as pore size and glove composition e g latex may apply based on patient provider or procedure Gowns Risk of limb Wear a gown that provides appropriate coverage Unfasten ties in back of neck and non contamination Secure gown in the back of the neck and waist waist sterile Discard after each use Remove the gown touching only the inside of the gown Roll or fold gown inside out Dispose of gown in proper waste receptacle Gowns Insertion of Wear a gown that provides appropriate coverage If donning double gloves dispose of sterile pulmonary artery Secure gown in the back of the neck and waist outer glove following sterile glove catheters and Discard after each use removal protocol prior to removing central venous gown catheters Follow removal protocol for non Invasive sterile gowns procedures e g Dispose of gown in proper waste surgery receptacle Eye Potential for Select appropriate eye protection based on the type of If donning double gloves dispose of Protection P
34. ips BJ Fergusson S Armstrong P Anderson FM Wildsmith JA Surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway Br J Anaesth Oct 1992 69 4 407 408 Centers for Disease Control and Prevention Interim Recommendations for Facemask and Respirator Use to Reduce 2009 Influenza A H1N1 Virus Transmission 2009 http www cdc gov h1n1flu masks htm Accessed July 7 2012 Bourdon L RP First Look New recommended practices for surgical attire AORN Connections 2014 100 5 C9 C10 Braswell ML Spruce L Implementing AORN recommended practices for surgical attire AORN J Jan 2012 95 1 122 137 quiz 138 140 Sehulster L Chinn RY Guidelines for environmental infection control in health care facilities Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee HICPAC MMWR Recomm Rep Jun 6 2003 52 RR 10 1 42 Wilson JA Loveday HP Hoffman PN Pratt RJ Uniform an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare associated infections Report to the Department of Health England J Hosp Infect Aug 2007 66 4 301 307 Gerba CP Kennedy D Enteric virus survival during household laundering and impact of disinfection with sodium hypochlorite Appl Environ Microbiol Jul 2007 73 14 4425 4428 Wiener Well Y Galuty M Rudensky B Schlesinger Y Attias D Yinnon AM Nursing and physic
35. iseptic agent until dry to reduce and or eliminate the presence of microorganisms Not indicated for visibly soiled hands Antiseptic Handwashing the process of washing hands with water and soap or detergent containing an antiseptic agent for at least 20 seconds to reduce and or eliminate the presence of microorganisms Indicated for visibly soiled hands A dant a 9 128 Asepsis a condition free from microorganism contamination Contact Precaution measures taken to prevent the transmission of infectious agents spread through direct or indirect contact with the patient or the patient s immediate environment Considered to be the lowest level of transmission based precautions gt Contamination direct contact with microorganisms often resulting in increased risk of infection Creutzfeldt Jakob disease CJD a degenerative neurological disorder transmitted by abnormal isoforms of neural proteins called prions CJD is also known as transmissible spongiform encephalopathy ESE Critical Device an infection risk category of medical equipment that directly contacts sterile areas of the human body e g bloodstream tissue vascular system There is a substantial risk of acquiring an infection if the item is contaminated at the time of use 3457 Decontamination a process or treatment that removes inactivates or destroys pathogens to the point where they are no longer capable of transmitting infection D
36. isinfectant a chemical agent used on inanimate objects to destroy pathogenic microorganisms but not necessarily all microbial forms e g bacterial endospores Refer to disinfectant label to determine whether the agent is a limited general or hospital grade disinfectant Disinfection the destruction of pathogenic and other kinds of microorganisms by physical or chemical means Destroys most recognized pathogenic microorganisms but not necessarily all microbial forms such as bacterial spores Droplet Precaution measures taken to prevent the transmission of infectious agents spread through close respiratory or mucus membrane contact with patients Considered to be the intermediate level of transmission based precautions gt Droplets small moisture particles typically generated when a person coughs or sneezes or when water is converted to a fine mist These particles may include infectious pathogens which tend to quickly settle out from the air so that any risk of disease transmission is generally limited to persons in close proximity to the droplet source 9 8 8 Hand hygiene a general term for removing microorganisms from hands 26 Healthcare associated infection HAD an infection that develops in a patient as a result of receiving care in a healthcare facility High level disinfection an advanced disinfection method that disinfects bacteria fungi and viruses but not necessarily high numb
37. l source of epidural abscess Anesthesiology Dec 1996 85 6 1276 1282 Grewal S Hocking G Wildsmith JA Epidural abscesses Br J Anaesth Mar 2006 96 3 292 302 Birnbach DJ Meadows W Stein DJ Murray O Thys DM Sordillo EM Comparison of povidone iodine and DuraPrep an iodophor in isopropyl alcohol solution for skin disinfection prior to epidural catheter insertion in parturients Anesthesiology Jan 2003 98 1 164 169 Kinirons B Mimoz O Lafendi L Naas T Meunier J Nordmann P Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children a randomized controlled trial Anesthesiology Feb 2001 94 2 239 244 Shibata S Shibata I Tsuda A Nagatani A Sumikawa K Comparative effects of disinfectants on the epidural needle catheter contamination with indigenous skin bacterial flora Anesthesiology 2004 101 Shapiro JM Bond EL Garman JK Use of a chlorhexidine dressing to reduce microbial colonization of epidural catheters Anesthesiology Oct 1990 73 4 625 631 Mann TJ Orlikowski CE Gurrin LC Keil AD The effect of the biopatch a chlorhexidine impregnated dressing on bacterial colonization of epidural catheter exit sites Anaesth Intensive Care Dec 2001 29 6 600 603 33 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 Holt HM Andersen SS Andersen O Gahrn Hansen
38. lushing system e g single dose vials prefilled syringes o Ata minimum use a 10 mL syringe e Flush the catheter vigorously using a positive pressure technique by maintaining pressure at the end of the flush to prevent reflux 108 st 108 Positive Pressure Technique This technique may not apply to neutral displacement or positive displacement needleless connectors e Flush the catheter continue to hold the plunger of the syringe while closing the clamp on the catheter and then disconnect the syringe S Withdraw the syringe as the last 0 5 1 mL of fluid is flushed when using catheters without a clamp 20 Heparin Flushes e Flushing CVCs with heparin solutions is a recommended practice in many guidelines despite the lack of conclusive evidence of efficacy and safety compared with 0 9 percent normal saline flushing e Heparin flushes are appropriate for maintaining patency of CVCs for dialysis o Higher concentrations of heparin should be used for patients who have evidence of occlusion or thrombosis o The injected volume of the heparin flush should not exceed the internal volume of the catheter Assessing Placement and Patency Aspirate catheter for blood return to identify correct placement of the catheter within the vein indicated by blood return in syringe Clear line of hemoglobin to prevent clotting in catheter Flush immediately with saline after aspirating to assess for patency and detect
39. n Health Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC SHEA APIC IDSA Hand Hygiene Task Force Am J Infect Control Dec 2002 30 8 S 1 46 World Health Organization WHO guidelines on hand hygiene in health care 2009 Pittet D Allegranzi B Boyce J The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations Infect Control Hosp Epidemiol Jul 2009 30 7 61 1 622 Boyce JM Pittet D Guideline for Hand Hygiene in Health Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC SHEA APIC IDSA Hand Hygiene Task Force Society for Healthcare Epidemiology of America Association for Professionals in Infection Control Infectious Diseases Society of America MMWR Recomm Rep Oct 25 2002 51 RR 16 1 45 quiz CE41 44 Biddle C Shah J Quantification of anesthesia providers hand hygiene in a busy metropolitan operating room what would Semmelweis think Am J Infect Control Oct 2012 40 8 756 759 Rowlands J Yeager MP Beach M Patel HM Huysman BC Loftus RW Video observation to map hand contact and bacterial transmission in operating rooms Am J Infect Control Jul 2014 42 7 698 701 American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques Practice advisory for the prevention diagnosis and management of infectious complications as
40. n and spinal tissues mucus membranes or genitalia e Concentrations gt 0 5 percent not recommended for procedures such as epidurals and other neuraxial procedures due to neurotoxicity Povidone iodine e Suitable alternative when Chlorhexidine is contraindicated e Highly effective against a broad range of microorganisms and acts immediately e Safe to use on face head mucous membranes vaginal area and during other neuraxial procedures e Minimally persistent compared to Chlorhexidine e Limited residual activity e Decreased effectiveness in the presence of blood and organic material Parachoroxylenol e Less effective than chlorhexidine gluconate and povidone iodine at eliminating microorganisms e Moderately effective against a broad range of mircoorganisms 9 Agent Description and Recommendations Moderate persistent residual activity Nontoxic with no tissue contraindications Remains effective in the presence of blood and organic material and in the presence of saline solution Todine base with alcohol Highly effective against a broad range of microorganisms Acts immediately 32 33 Highly flammable Fire Risk Agents that are alcohol based or have flammable properties have the potential to increase the risk of surgical fires Aseptic Technique Aseptic technique requires multiple methods to prevent the transmission of micr
41. n the patient s record The American Association of Nurse Anesthetists AANA supports patient safety through the use of evidence based infection prevention and control practices The purpose of these guidelines is to describe infection prevention and control best practices to increase awareness and reduce the risk of patients Certified Registered Nurse Anesthetists CRNAs and other healthcare providers transmitting and acquiring an HAI These guidelines do not supersede federal state or local statutes or regulations or facility policy but constitute minimum practice recommendations and considerations The Centers for Medicare and Medicaid Services CMS has developed a comprehensive worksheet to determine facility compliance with the Infection Control Condition of Participation Standard Precautions Standard precautions are the basic level of infection control protocols that reduce the risk of disease transmission when providing patient care Basic standard precautions include but are not limited to Hand Hygiene Personal Protective Equipment Respiratory Hygiene Safe Injection Practices Equipment and Environmental Cleaning Disinfection and Sterilization Anesthesia and other healthcare providers should always refer to their facility s policy on infection control standard precautions Hand Hygiene Hand hygiene is the practice of removing microorganisms from hands gt 10 Performing proper hand hygiene significantly reduc
42. nd screening Seasonal Influenza Flu Vaccination The CDC recommends that all healthcare workers receive an annual influenza vaccine The nasal spray flu vaccine is not recommended for healthcare workers who may work with severely 22 immunocompromised patients If unable to obtain the influenza vaccine consult facility policy regarding patient care Hepatitis B Vaccination Healthcare providers who perform tasks that may involve exposure to blood or body fluids should receive a three dose series of hepatitis B vaccine at 0 1 and 5 month intervals Test for hepatitis B surface antibody anti HBs to document immunity 1 2 months after the third dose e A recombinant vaccine indicated for active immunization against disease caused by hepatitis A virus and infection caused by all known subtypes of hepatitis B virus has been approved by the FDA and is available for use Post Exposure Prophylaxis Immediately review and follow facility policy for recommendations regarding a high risk exposure event to hepatitis B hepatitis C human immunodeficiency virus or M tuberculosis Tuberculosis TB Screening e Healthcare providers who may be occupationally exposed should receive TB skin testing annually and post exposure o A positive TB skin test Mantoux tuberculin skin test or TB blood test only indicates that a person has been infected with TB bacteria It does not tell whether the person has latent TB infection LTBI or
43. nisyan K Moller AM Smith AF Lewis SR Pulse oximetry for perioperative monitoring Cochrane Database Syst Rev 2014 3 CD002013 30 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 One and Only Campaign Frequently Asked Questions FAQs Regarding Safe Practices for Medical Injections http www oneandonlycampaign org sites default files upload pdf Injection 20Safety 720FAQ s_7Tpages_FINAL pdf Accessed January 23 2015 Centers for Diseaes Control and Prevention Safe Injection Practices to Prevent Transmission of Infections to Patients 2011 http www cdc gov injectionsafety IPO7_standardPrecaution html Accessed November 20 2014 Centers for Disease Control and Prevention Protect Patients Against Preventable Harm from Improper Use of Single Dose Single Use Vials 2012 http www cdc gov injectionsafety CDCposition SingleUseVial html Accessed November 20 2014 Safe Injection Guidelines for Needle and Syringe Use Park Ridge IL American Association of Nurse Anesthetists 2014 Safe Injection Practices and the Criminalization of Reuse http www aana com myaana Advocacy stategovtaffairs Pages Safe Injection Practices and the Criminalization of Reuse aspx Accessed November 24 2014 Information for Providers Injection Safety 2011 http www cdc gov injectionsafety providers html Accessed November 14 2014 USP Cha
44. o clean Clean and perform steam sterilization of instruments for 30 to 60 minutes at 132 C Perform steam sterilization for 18 minutes at 134 C 138 C when using a prevacuum sterilizer o Immerse instruments in 1N sodium hydroxide solution for one hour at room temperature followed by steam sterilization for 30 minutes at 121 C as an alternative to the prevacuum sterilizer Disinfect noncritical items and environmental surfaces with bleach or 1N sodium hydroxide for 15 minutes at room temperature Consult the CDC recommendations for best infection control practices when working with patients with CJD Tuberculosis Place a high efficiency particulate air HEPA filter between the breathing system and the patient Sterilize or perform high level disinfection on equipment used on patients with cases of suspected or confirmed Tuberculosis Culturing anesthesia equipment is not required Environmental Surfaces Facilities should establish a routine disinfection policy for environmental surfaces and a program for monitoring compliance and performance improvement The policy should include the frequency and level i e high level low level of disinfection and a list of the facility approved EPA registered disinfectants or detergents Thoroughly clean environmental surfaces to reduce transmission of HAIs from surfaces to providers and patients Clean anesthetizing locations and equipment surfaces e
45. of Coverings semi restricted neck using a clean covering outer glove following sterile glove and restricted Launder reusable cloth caps daily and when visibly removal protocol prior to removing areas soiled surgical cap Regional Remove cap using gloves refraining neuraxial from contacting inner part of cap technique Dispose of cap in proper waste receptacle Shoe Risk of splash Slip coverings over shoes prior to donning gloves and If donning double gloves dispose of Coverings contamination other PPE outer glove following sterile glove Shoe coverings must be changed each time a worker exits the area removal protocol prior to removing shoe covers With already donned gloves remove PPE Indications Guidelines Removal Protocol shoe coverings Dispose of coverings in proper waste receptacle Spray shoes with disinfectant if necessary Scrubs Follow facility Wear a clean set of scrubs each day and change into Follow your facility policy regarding policy regarding clean scrubs if contaminated removal of scrubs upon exiting donning scrubs o Home laundering scrubs is acceptable if they restricted and semi restricted areas prior to entering have not been contaminated with blood or restricted and infectious material semi restricted o Launder in hot water with sodium hypochlorite areas and detergent Dry using high heat Cover Follow facility Cover apparel should be clean or single use Foll
46. oorganisms from the environment healthcare provider and patient Table 6 refers to recommendations for aseptic procedure Table 6 Guidelines for aseptic technique Precaution Guidelines Equipment May include some or all of the following items depending on the Maximal sterile procedure barriers e Sterile gloves e Sterile gowns e Surgical masks e Sterile drapes Preparation e Antiseptic skin preparation of patient prior to procedure o Consult manufacturer product instructions for directions and warnings regarding the proper use and application of specific skin antiseptics such as chlorhexidine alcohol or povidone iodine e Ensure that all instruments equipment and devices are sterile Environmental e Close doors during operative procedures Controls e Minimize unnecessary staff and traffic in out of operating room Contact e Precautions should be taken to mitigate contact with non sterile surfaces and objects Airway Management Considerations Specific to Anesthesia Professionals Airway management poses unique challenges to anesthesia practitioners in limiting or preventing environmental contamination In order to mitigate disease transmission while ensuring the standard of care for proper airway management the following practices are recommended e Maintenance of oxygenation takes priority over all issues e Ventilate the patient immediately upon airway manipulation o CDC guidelines indicate the nee
47. organization responsible for defining standards for medicines and other products using a system of standards and quality control along with a national drug formulary USP Chapter lt 797 gt is not law but is an accepted guideline for best practices for compounding sterile preparations CSPs USP General Chapter lt 797 gt Pharmaceutical Compounding Sterile Preparations describes conditions and practices for preparing CSPs These guidelines apply to all healthcare providers administering CSPs within an institution when that institution has adopted use of Chapter lt 797 gt Federal state and local statutes and regulations and accreditation standards may also require compliance with USP lt 797 gt guidelines Anesthesia professionals should ensure compliance with applicable statutes regulations accreditation requirements and facility policies in the preparation of CSPs The following summarizes USP Chapter lt 797 gt as it applies to anesthesia professionals e All CSPs must be compounded with aseptic manipulations entirely within an ISO Class 5 using a containment hood or compounding aseptic isolator or better air quality environment 8 o The only exception to this is the immediate use provision designed for the following situations Cardiopulmonary resuscitation Emergency room treatment Preparation of diagnostic agents Critical therapy where normal CSP preparation would cause more harm to the patient
48. ory principles and efficiency Anaesthesia Jan 2011 66 1 31 39 Spertini V Borsoi L Berger J Blacky A Dieb Elschahawi M Assadian O Bacterial contamination of anesthesia machines internal breathing circuit systems GMS Krankenhhyg Interdiszip 2011 6 1 Doc14 U S Food and Drug Administration List of Single Use Devices Known To Be Reprocessed or Considered for Reprocessing Attachment 1 2014 http www fda gov MedicalDevices DeviceRegulationandGuidance ReprocessingofSingle UseDevices ucm121218 htm Accessed January 8 2015 Medtronic Monitoring End Tidal Carbon Dioxide EtCO2 2003 http www physio control com uploadedfiles products defibrillators product_data operator_checklists Ip12_etco2_c hecklist_3200569 001 pdf Neft MW Goodman JR Hlavnicka JP Veit BC To reuse your circuit the HME debate AANA J Oct 1999 67 5 433 439 Brimacombe J Stone T Keller C Supplementary cleaning does not remove protein deposits from re usable laryngeal mask devices Can J Anaesth Mar 2004 51 3 254 257 Clery G Brimacombe J Stone T Keller C Curtis S Routine cleaning and autoclaving does not remove protein deposits from reusable laryngeal mask devices Anesth Analg Oct 2003 97 4 1189 1191 table of contents Miller DM Youkhana I Karunaratne WU Pearce A Presence of protein deposits on cleaned re usable anaesthetic equipment Anaesthesia Nov 2001 56 1 1 1069 1072 Coetzee GJ Eliminating protein from reusable laryngeal mask ai
49. ow your facility policy regarding Apparel policy regarding Lab coats are not recommended in the operating room removal of lab coats upon entering e g lab use of cover as they have the potential to become contaminated and exiting restricted and semi coats apparel restricted areas Launder cover apparel after each daily usage and when contaminated Transmission Based Precautions In addition to standard precautions transmission based precautions should always be followed once a patient develops symptoms of an infection to reduce opportunities for disease transmission The three categories of transmission based precautions include contact droplet and airborne precautions Because diagnostic tests are often required to confirm an infection and generally require a few days for conclusive results precautionary measures should be taken until the presence or absence of infection is confirmed Table 4 describes protocols and examples of transmission based precautions Table 4 Transmission based precautions 9 transmission of infectious agents suspended in the air room designed with monitored negative pressure 12 air exchanges per hour and air exhausted directly to the outside or recirculated through high efficiency particulate air filtration Facilities should establish a respiratory protection program Isolate N95 or higher level masked patients in a private room when airborne pre
50. p syringes prepared for single patient use under direct observation or locked securely with a patient identification label attached Infusion Sets Bags and Pumps Use infusion pump syringe and intravenous administration sets only once Do not use bags or bottles of intravenous solution as a common source of diluent for multiple patients Clean and process intravenous infusion and syringe pumps according to manufacturer recommendations between patients Medication Vials and Ampules Prevent coring and particulate contamination by applying in line final filtration using a 45u rater Use 70 percent alcohol to clean the access diaphragm of medication vial or to clean the outside of an ampule prior to insertion of a device or needle into the vial Use 70 percent alcohol to clean the diaphragm prior to access when removing the cap from a new vial 12 e Handle and discard medications according to facility policy and manufacturer guidelines Single dose Vials e Use single dose vials for medications when possible e Do not combine or save leftover medications from single dose vials ampules for later uge 3240 e Discard single dose medication vials ampules and intravenous infusion bags safely after use on a single patient 39 40 50 Multi dose Vials e Dedicate multi dose vials to a single patient when possible e Usea syringe or needle only once to withdraw medication from a multi dose vial o Label the date on the
51. pter lt 797 gt and Anesthesia Practice Park Ridge IL American Association of Nurse Anesthetists 2011 lt 797 gt Pharmaceutical Compounding Sterile Preparations USP lt 797 gt Guidebook to Pharmaceutical Compounding Sterile Preparations Rockville MD 2008 U S Pharmacopeial Convention USP NF General Chapters for Compounding 2015 http www usp org usp healthcare professionals compounding compounding general chapters Accessed January 27 2015 Kastango ES Compounding USP lt 797 gt inspection regulation and oversight of sterile compounding pharmacies JPEN J Parenter Enteral Nutr Mar 2012 36 2 Suppl 38S 39S Kastango ES Bradshaw BD USP chapter 797 establishing a practice standard for compounding sterile preparations in pharmacy Am J Health Syst Pharm Sep 15 2004 61 18 1928 1938 Injection Safety 2014 http www cdc gov injectionsafety Accessed November 14 2014 Dolan SA Felizardo G Barnes S et al APIC position paper safe injection infusion and medication vial practices in health care Am J Infect Control Apr 2010 38 3 167 172 Singhal SK Particulate contamination in intravenous drugs coring from syringe plunger J Anaesthesiol Clin Pharmacol Oct 2010 26 4 564 565 Centers for Disease Control and Prevention Questions about Multi dose vials 2010 http www cdc gov injectionsafety providers provider_faqs_multivials html Accessed January 23 2015 The Joint Commission Multi do
52. ration Preparing the patient s skin prior to performing clinical procedures significantly reduces the risk of infection Individuals should always follow manufacturer recommendations and their facility policy for the proper use of skin prep agents An ideal skin prep agent should decrease microorganism count inhibit rebound and regrowth of microorganisms activate quickly and be effective against a variety of microorganisms Each prep agent has a specific mechanism of action along with specific advantages and disadvantages that should be weighed in all clinical situations The patient s allergies skin condition and other contraindications as well as the site of the procedure should be considered prior to applying the agent Table 5 provides examples of skin prep agents as well as advantages and disadvantages to use Table 5 Skin prep agent examples descriptions and recommendations Agent Description and Recommendations Chlorhexidine e Preferred skin prep agent due to immediate action residual activity and gluconate persistent effectiveness against a wide range of microorganisms e Strong tendency to bind to tissue contributing to extended anti microbial 33 action e Highly effective in the presence of blood and organic material e Addition of alcohol to the disinfectant provides more rapid and effective germicidal activity e Limited sporicidal activity e Not recommended for use on eyes ears brai
53. rer recommendations and facility policies should be followed for specific care and maintenance of CVCs Table 8 describes the different types of CVCs 103 Table 8 Examples and descriptions of Central Venous Catheters CVCs Catheter Description Tunneled catheter e g Hickman e Surgically inserted for extended use months to Groshong years e Catheter and attachments emerge from underneath the skin Non tunneled catheter e g Quinton e Percutanesously inserted for shorter use 1 2 weeks e Catheter attachments protrude directly Peripherally Inserted Central Catheter e Inserted into a peripheral vein in the arm 19 PICC Implanted Port e Inserted entirely under the skin e Medications administered through blunt needle e g Huber needle placed through the skin to the catheter Central Venous Catheter Insertion In order to reduce the incidence of infections such as central line associated bloodstream infections the following is recommended for the proper insertion of a central line e Consider the risks and benefits of placing a central line at various sites e g subclavian peripheral jugular femoral before insertion e Perform hand hygiene and don sterile gloves sterile gown surgical cap and surgical mask and cover the patient s entire body with a large sterile drape prior to insertion e Prepare patient skin using appropriate agent e Use antibiotic impregnated ca
54. resistance Specimen Collection Access the catheter as outlined above maintaining aseptic technique Draw the first 3 5 mL of blood dispose in an appropriate biohazardous waste receptacle or return to the patient in accordance with the procedure or as indicated by the patient Before specimen is collected flush catheter in accordance with facility policy and per the treating clinician s orders Discard 1 5 2 times the volume of the internal catheter lumen before drawing the specimen Collect the specimen 4 Flush the catheter as directed by the procedure and facility policy and per treating clinician s orders 4 o Clamp the catheter as flushing is completed and promptly dispose of used syringe s Changing the Injection Cap e g needleless connector When there are signs of contamination e g blood precipitate damage e g leaks septum destruction change immediately Unless otherwise indicated by manufacturer recommendation change injection port cap weekly Scrub the injection cap and catheter hub with appropriate agent e g chlorhexidine isopropyl alcohol clamp the catheter if necessary as cap is removed Attach a new cap to catheter hub using aseptic technique Site Dressing Supplies for site cleansing and dressing are single use items o Refer to manufacturer recommendations to ensure compatibility with catheter material Wear clean gloves S Prepare patient skin with appropria
55. rforming invasive procedures will help prevent adverse events such as surgical site infections central line associated bloodstream infections and catheter associated urinary tract infections Healthcare providers should perform hand hygiene before assembling equipment as well as before and after performing the procedure All invasive procedures should be performed using aseptic technique and in accordance with facility policy 18 Considerations for Ultrasound Guided Procedures Ultrasound guidance for procedures such as vascular access and catheter placement has been shown to reduce infection rates and improve patient satisfaction e Site selection should consider factors such as vessel size depth course surrounding structures and adjacent pathology prior to access e Prepare patient skin with appropriate agent o Use of single use containers sachets as multi use bottles can result in bacterial contamination e Use a sterile sheath sterile probe covers and sterile ultrasound gel to mitigate the risk of contamination e Disinfect ultrasound probes between each procedure and patient o Direct application of non manufacturer approved cleaning solutions to the transducer may result in damage Considerations for Epidural Catheters and Continuous Peripheral Nerve Block Catheters e Adhere to strict aseptic technique and use single use sterile gel to prevent contamination during catheter placement e Don maximal sterile barriers
56. rways A study comparing routinely cleaned masks with three alternative cleaning methods Anaesthesia Apr 2003 58 4 346 353 Greenwood J Green N Power G Protein contamination of the Laryngeal Mask Airway and its relationship to re use Anaesth Intensive Care Jun 2006 34 3 343 346 32 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 Centers for Disease Control and Prevention Infection Control Practices Creutzfeldt Jakob Disease 2010 http www cdc gov ncidod dvrd cjd gqa_cjd_infection_control htm Accessed September 4 2014 Rutala WA Weber DJ Creutzfeldt Jakob disease recommendations for disinfection and sterilization Clin Infect Dis May 1 2001 32 9 1348 1356 Weber DJ Rutala WA Managing the risk of nosocomial transmission of prion diseases Curr Opin Infect Dis Aug 2002 15 4 421 425 Rutala W A Weber D J Society for Healthcare Epidemiology of America Guideline for disinfection and sterilization of prion contaminated medical instruments Infect Control Hosp Epidemiol Feb 2010 31 2 107 117 Sehulster L Chinn RY Guidelines for Environmental Control in Health Care Facilities Centers for Disease Control and Prevention 2003 Weber DJ Anderson D Rutala WA The role of the surface environment in healthcare associated infections Curr Opin Infect Dis Aug 2013 26 4 338 344 Centers for Disea
57. s drill bits glass items e Dispose of all regulated waste in specified biohazard waste receptacles following federal state and local statutes and regulations e If abiohazardous waste container becomes contaminated place the container inside of another biohazardous waste container e Consult relevant EPA documents for specific guidance Single Use Items Discard disposable single use devices in a biohazardous bag container e g breathing circuits airway devices orogastric tubes immediately after use Reprocessed Items e Place items that will be reprocessed in a plastic bag or container immediately after use e Close containers prior to removing from the anesthetizing location Sharps aes include any device that may puncture skin e g needles syringes scalpels lancets blades glass e Use safety devices when possible e Do not bend or recap contaminated needles If a needle must be bent use the one handed technique e Discard sharps immediately in a closeable sharps container Drug Disposal Follow facility policy and applicable federal state and local statutes and regulations regarding the appropriate method for disposal of partially remaining drugs in vials ampules syringes and IV bags Invasive Procedure Technique Invasive procedures such as catheter insertion often expose patients and healthcare providers to heightened risk of exposure and infection 1 Ensuring that the proper measures are taken prior to pe
58. s than 1 4 inch e Do not wear artificial nails or nail extenders Performing adequate hand hygiene while providing anesthesia care can be challenging due to the nature and intensity of care anesthesia professionals provide Observational studies of anesthesia professionals in the operating room indicate that there are a high number of missed hand hygiene opportunities during patient care Given the demands of anesthesia care and proportion of missed hand hygiene opportunities aggressive strategies are needed to improve hand hygiene among anesthesia professionals The considered use of single and double exam gloves that may be removed after contamination the availability of alcohol based sanitizer in the anesthetizing area targeted environmental cleaning of the anesthetizing area after each case and ongoing research to design new methods are each important to control bacterial transmission in the anesthetizing area 3 Personal Protective Equipment Personal protective equipment PPE is specialized clothing or equipment worn for protection against contamination PPE protects the patient and the healthcare provider from transmitting and contracting infection Always perform hand hygiene prior to applying PPE after removing all PPE except for respirators and prior to exiting the operating or patient room While donning PPE providers should refrain from touching surfaces and their face when possible to prevent the
59. se Control and Prevention Laundry Washing Infected Material 2011 http www cdc gov HAI prevent laundry html Accessed December 22 2014 Occupational Safety amp Health Administration Bloodborne Pathogens 1910 1030 United States Department of Labor 2011 Environmental Protection Agency Wastes Hazardous Waste http www epa gov epawaste hazard index htm Accessed November 24 2014 American Institute of Ultrasound in Medicine AIUM Practice Guideline for the Performance of Selected Ultrasound Guided Procedures 2014 http www aium org resources guidelines usGuidedProcedures pdf Accessed December 14 2014 Birnbach DJ Stein DJ Murray O Thys DM Sordillo EM Povidone iodine and skin disinfection before initiation of epidural anesthesia Anesthesiology Mar 1998 88 3 668 672 Mirza WA Imam SH Kharal MS et al Cleaning methods for ultrasound probes J Coll Physicians Surg Pak May 2008 18 5 286 289 Dawson S Epidural catheter infections J Hosp Infect Jan 2001 47 1 3 8 American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial t Practice advisory for the prevention diagnosis and management of infectious complications associated with neuraxial techniques a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques Anesthesiology Mar 2010 112 3 530 545 Sato S Sakuragi T Dan K Human skin flora as a potentia
60. se Vials 2010 http www jointcommission org mobile standards_information jcfaqdetails aspx StandardsFA Id 143 amp StandardsFAQChapterld 76 Accessed January 30 2015 Rutala WA Weber DJ Healthcare Infection Control Practices Advisory Committee Guideline for disinfection and sterilization in healthcare facilities Atlanta GA Centers for Disease Control and Prevention 2008 Centers for Disease Control and Prevention Guide to infection prevention for outpatient settings Minimum expectations of safe care 2011 http www cdc gov HAI pdfs guidelines Outpatient Care Guide withChecklist pdf Dorsch J Dorsch S Cleaning and Sterilization In Brown B ed Understanding Anesthesia Equipment 5th ed Philadelphia PA Lippincott Williams and Wilkins 2008 955 1000 Juwarkar CS Cleaning and Sterilization of Anaesthetic Equipment Indian J Anaesth 2013 57 5 541 550 Call TR Auerbach FJ Riddell SW et al Nosocomial contamination of laryngoscope handles challenging current guidelines Anesth Analg Aug 2009 109 2 479 483 31 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 The Joint Commission Laryngoscopes Blades and Handles How to clean disinfect and store these devices 2012 http www jointcommission org mobile standards_information jcfaqdetails aspx StandardsFAQ Id 508 amp StandardsFAQChapterld 69 Accessed December 2 2014 Petersson
61. shed guidelines 4 7 24 Conclusion This document presents current evidence based infection prevention practices safety considerations and guidelines for healthcare providers facilities and patients The science and practice of infection prevention and management continues to evolve Healthcare teams must maintain their familiarity with infection prevention and control practices as they are updated in federal state and local statutes and regulations as well as nationally recognized infection prevention and control practices and guidelines Examples of organizations that promulgate such recognized guidelines include the CDC APIC and SHEA As the breadth and depth of infection control and prevention science continues to grow CRNAs have the opportunity to contribute to this burgeoning field through research education and practice improvement Excellence in infection prevention will lead to improved patient outcomes and spur excellence throughout clinical practice 25 Infection Prevention and Control Glossary Airborne Precautions measures taken to prevent the transmission of infectious agents suspended in the air which can remain infectious over long distances Considered to be the highest level of transmission based precautions gt 08 Antiseptic an agent that is used on skin or tissue for inhibiting the growth of and destroying microorganisms Antiseptic Handrubbing the process of rubbing hands with an alcohol based ant
62. sociated with neuraxial techniques a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques Anesthesiology Mar 2010 112 3 530 545 Karlet M Gold M Grace Ford M Manju M Griffis C Infection Control It s Everyone s Business http www aana com meetings meeting materials assemblyschoolfaculty Documents Griffis_Infection 20Control 20Lecture pdf Accessed December 23 2014 Twomey C Does Double Gloving Double the Protection A Look at the Issues 2000 http www infectioncontroltoday com articles 2000 05 infection control today does double gloving doubl aspx Accessed December 2 2014 National Institute for Occupational Safety and Health How to Prevent Needlestick and Sharps Injuries NIOSH Fast Facts 2012 http www cdc gov niosh docs 2012 123 pdfs 2012 123 pdf Accessed December 2 2014 29 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 Roxburgh M Gall P Lee K A cover up Potential risks of wearing theatre clothing outside theatre J Perioper Pract Jan 2006 16 1 30 33 35 41 Koscielniak Nielsen ZJ Dahl JB Ultrasound guided peripheral nerve blockade of the upper extremity Curr Opin Anaesthesiol Apr 2012 25 2 253 259 Attire 2014 http www aorn org Secondary aspx id 20970 amp terms cover 20apparel Accessed December 19 2014 Phil
63. t the blade back into the package and return to a clean storage location This protocol applies to disposable blades as well At a minimum wipe the handle with an intermediate level disinfectant after use This protocol applies to disposable handles as well Clean all equipment between patients and when visibly soiled in accordance with manufacturer recommendations and facility policy o Low and intermediate level disinfection differs by disinfectant type concentration and exposure to pathogen Stethoscopes may be washed with water and perice Device Example s Process Recommendation Classification administration pumps wiped with alcohol carts beds and monitors Use protective covering for non critical surfaces that are difficult to clean e g keyboard covers Hydrogen peroxide gas decontamination is an effective sterilization method for reusable items that are difficult to clean Environmental Surfaces Low level Clean all equipment between patients and Bed rails food utensils disinfection when visibly soiled in accordance with bedside furniture unless manufacturer recommendations and facility computer keyboards otherwise policy floors mobile devices noted Use protective covering for non critical surfaces that are difficult to clean e g keyboard covers Single Use Devices and Reprocessed Disposable Equipment e A single use device is a medical device that is only to be used
64. te agent o Ifreplacing dressing remove existing dressing inspect the site visually and document prior to skin prep Except for dialysis patients do not apply topical antibiotic ointment or cream to catheter site 115108 Cover site with either sterile gauze or sterile transparent semipermeable dressing Replace or change dressing when indicated 0 21 Considerations for Implanted Ports In addition to the following recommendations always discuss with the patient the best approach or technique for accessing and deaccessing the patient s port Port Access Procedure Don clean gloves Examine the port site for complications to look for any swelling erythema drainage or leakage or assess for presence of pain discomfort or tenderness Palpate the outline of the port to identify insertion diaphragm o Mark location on patient skin for blunt needle insertion Remove gloves perform hand hygiene and don new sterile gloves S Cleanse port site with appropriate agent prior to entry Stabilize port with one hand and insert blunt non coring needle e g Huber needle until port backing is felt S Aspirate blood to ensure patency by return Stabilize needle port with tape securement device or stabilization device o Apply gauze and tape for short term use e g outpatient treatment Port Deaccess Procedure 108 116 Don clean gloves Flush device in accordance with facility policy and per the
65. terials stored on the anesthesia machine from becoming inadvertently contaminated by airborne debris e g blood Remove equipment from drawers clean and disinfect drawers regularly Place a clean covering on the top of the anesthesia cart at the beginning of each case Wipe small surfaces with 70 percent isopropyl alcohol to reduce bacterial contamination Clean carbon dioxide and soda lime absorbers when the absorber is changed and remove debris from the screens 15 Anesthesia Breathing System Review the user manual to determine manufacturer cleaning recommendations for the breathing system Filters Breathing system filters are single use items that are assessed according to their bacterial filtration efficiency BFE and viral filtration efficiency VFE The efficacy of filtration for bacterial contaminants is higher than for viral particles Filters may prove problematic during spontaneous respiration due to increased resistance to air flow Aside from patients with an active Myobacterium tuberculosis infection no recommendation is made for the routine use of breathing system filters due to inconclusive data demonstrating their efficacy in reducing the risk of patient infection However when a patient with a respiratory infection must be given inhalational anesthesia a filter should be used e Practitioners may choose to place a high efficiency filter on the inspiratory limb of the breathing circuit to
66. theter if the catheter is to remain in place for longer than five days 106107 e Replace catheter when adherence to aseptic technique cannot be ensured e g catheters inserted during a medical emergency Otherwise do not routinely replace CVCs e Remove any intravascular catheter once it is no longer indicated e For complete guidance refer to the CDC Guidelines for the Prevention of Intravascular Catheter Related Infections Central Venous Catheter Access When accessing central venous catheters closed access systems are preferred in addition to the following recommendations e Scrub the injection cap e g needleless connector with an appropriate antiseptic agent and allow to dry according to manufacturer recommendation 0S o Povidone iodine is the recommended agent for children lt two months old e Access the injection port with the syringe or intravenous tubing o If necessary open the clamp Flushing Technique Refer to the manufacturer instructions for the catheter and the needleless connector for the appropriate technique to use unless otherwise specified perform the following e The type of flush e g saline heparin dilute heparin concentration volume and frequency of flushing should be determined in accordance with manufacturer indications for use and facility policy and per the treating clinician s orders Individualized patient needs should also be considered e Use a single use f
67. tidal carbon dioxide tubing should be changed between patients e Following anesthesia care of a patient with pulmonary infection or trauma disinfection of the internal and respiratory system anesthesia machine components is mandatory Heat and Moisture Exchangers e Heat and moisture exchangers alone are not effective in decreasing the transmission of microorganisms to the anesthesia breathing system Supraglottic Airway Devices e If possible use disposable single use device laryngeal mask airways LMAs due to the extreme difficulty in completely eradicating protein deposits from reusable LMAs 7 16 e Reusable LMAs should be rinsed and soaked in enzymatic detergent prior to autoclaving to remove occult blood o Numerous studies have demonstrated that protein deposits are extremely difficult to eradicate completely from reusable LMAs e Consult manufacturer directions for cleaning and sterilizing supraglottic airway devices Equipment Considerations for Special Patient Populations Creutzfeldt Jakob Disease Multiple use devices used on patients with Creutzfeldt Jakob Disease CJD may transmit the disease To properly disinfect equipment consult the following recommendations Use disposable equipment when possible for patients with CJD incinerate equipment after use 7 Destroy laryngoscopes and supraglottic devices used on patients with CJD Safely discard devices that are difficult or impossible t
68. tions for Epidural Catheters and Continuous Peripheral Nerve Block Catheters 19 Considerations for Central Venous Catheter Maintenance and Procedures cccceeseeeeeereeeees 19 Considerations for Implanted Ports oo eee eeceessecseceeceseceseceseceeeesseesseessaeeeneeeaeesaaecaaecaeenaeenaeens 22 Considerations for Arterial Catheters and Pressure Monitoring Devices s ce eeeeeseeeseeeteeeeees 22 Vaccinations Post Exposure Prophylaxis and Screening 0 cccceecceseeseeeeceeeceeeceseceeeeeeecneeeeees 22 Reducing the Risk of Adverse Events cccccccccssecssecsseceseceseceseceseceseeeeeeseceseaeeeaeecaeecaaecaaeceaeenaeeeaeees 23 TC HUN CO a 3 E E A sees cao cane oven exe T EEN E TE eee 25 Infection Prevention and Control Glossary ccccccccsscceseceseceseceseceeeeeeeseceeeaeeeaeeeaeecsaecaeceaeenaeeeaeen 26 Referentes esne npes a den vox EEE EE A E EEE EE EE TE EO EREE E 29 Introduction Effective infection control and prevention protocols reduce the transmission of communicable diseases in all healthcare settings A major cause of healthcare associated infections HAIs is the lack of consistent compliance by healthcare workers with basic prevention techniques such as hand hygiene Failure to follow the principles of aseptic technique as well as ineffective equipment decontamination and surgical site preparation have contributed to increased rates of surgical site infections SSIs cathet
69. toperative pain Korean J Pain Jul 2014 27 3 200 209 123 Coffin SE Klompas M Classen D et al Strategies to prevent ventilator associated pneumonia in acute care hospitals Infect Control Hosp Epidemiol Oct 2008 29 Suppl 1 S31 40 124 Bratzler DW Dellinger EP Olsen KM et al Clinical practice guidelines for antimicrobial prophylaxis in surgery Surg Infect Larchmt Feb 2013 14 1 73 156 125 National Guideline C Clinical practice guidelines for antimicrobial prophylaxis in surgery http www guideline gov content aspx id 39533 Accessed 1 27 2015 126 Bratzler DW Dellinger EP Olsen KM et al Clinical practice guidelines for antimicrobial prophylaxis in surgery Am J Health Syst Pharm Feb 1 2013 70 3 195 283 127 American Society of Health System Pharmacists ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery Am J Health Syst Pharm Sep 15 1999 56 18 1839 1888 128 Prevention CfDCa Infection Control Glossary 2013 http www cdc gov OralHealth infectioncontrol glossary htm Accessed November 20 2014 129 Rutala WA Weber DJ Sterilization high level disinfection and environmental cleaning Infect Dis Clin North Am Mar 2011 25 1 45 76 130 Weber DJ Raasch R Rutala WA Nosocomial infections in the ICU the growing importance of antibiotic resistant pathogens Chest Mar 1999 115 3 Suppl 34S 41S The Infection Control Guide for Certified Registered Nurse Anesthetists was adopted by the A

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