INFECTION CONTROL POLICY REVISED 11

INFECTION CONTROL POLICY REVISED 11/99

INTRODUCTION

To ensure the use of proper procedures in the handling of patients consistent with the safe administration of anesthetic agents in order to prevent the introduction or the spread of infection.
The infection control procedures of the Department of Anesthesiology have been established to protect patients and personnel during all aspects of anesthesia. These procedures are annually reviewed and revised as necessary and approved by the Infection Control Committee prior to being put into practice. Employees are notified of all revisions and must be aware of all infection control procedures.
Sound principles of infection control shall be integrated into all procedures, processes, techniques, and methods utilized in direct and indirect patient care.

RESPONSIBILITIES

Infection control procedures are the responsibility of all anesthesia, medical, nursing, and health related personnel using the O.R. facilities. These policies will minimize the hazard of cross infection in the O.R. and they are enforced by the Director of Clinical Anesthesiology.

INFECTION CONTROL PRACTICES

All staff shall use Standard Universal Precautions for patient care and for contact with blood or body fluids to reduce exposure to bloodborne pathogens by using personal protective equipment as outlined in PM03-04, Appendix N, Standard Universal Precautions.
Occupational Health Services: Employees using O.R. facilities are subject to Occupational Health policies as described in PM03-06.

Residents who do not have a current statement as to their good health before beginning training, must also have pre-employment health screening.
Residents born after 1956 must show proof of immunity to measles, mumps, and rubella (MMR), or receive the vaccine. They will also receive a PPD and a Hepatitis B vaccine is available upon request. Residents born prior to 1957 will have a rubella titer documented.
Any employee with a contagious disease, i.e. elevated temperature, draining lesion, etc., should not have direct patient contact. If an employee is found to have an infectious disease, he/she is restricted from working with patients and must report to Occupational Health. Employees will be reassigned to areas where no patient contact is involved or be required to stay at home.
Employees who have been or suspect they have been exposed to an infectious disease should notify the anesthesia officer-of-the-day, and the Occupational Health Services.
For exposures, including needle sticks, the employee shall wash area immediately. Then notify unit supervisor and Occupational Health Services. After hours, contact nursing team coordinator via hospital operator.
Eating and drinking will be restricted to the lounge or clinical assignment room.
Post Exposure Protocol - If blood and/or body fluid exposure occurs, such as needle stick, direct skin contact, or splash to eyes, mouth or nose, wash/flush area as appropriate immediately. Report incident to Supervisor and Occupational Health. If Occupational Health is closed, notify Nursing Coordinator for evaluation by calling hospital operator. If post exposure prophylaxis is indicated for possible HIV exposure, it is optimal for treatment to begin within 1-2 hours after incident.

Education: Infection Control training is included in the Hospital's orientation for all new house staff. This includes training employees on their responsibilities and the importance of infection prevention and control. In addition, all Shands employees attend an annual infection control conference conducted by the Department of Infection Control personnel. All health related personnel will be required to read the Departmental and Hospital Infection Control policies and any revision to the policies throughout the year. Policies are posted throughout areas where infection control procedures must be observed by personnel.
Dress Code for Operating Room

To minimize the hazard of cross-infection in the O.R., the following policies are in effect for all medical, nursing, and health related personnel using O.R. facilities:
All persons who enter the O.R./O.B. suite must wear approved surgical scrub uniform.

All hair should be covered.
Mask should be changed when leaving and returning to the OR, or when moist or soiled.
Mask should be worn in all O.R./O.B. suites when sterile packs are open or a case is in progress.

Scrubs:

Scrub suits shall be worn in the Operating Room. Blue or gray/green will be the official color of the OR. They should be laundered daily by the hospital laundry. Blood stained or otherwise soiled scrub suits shall not be worn outside of the surgical suite and should be changed as soon as possible.
Short sleeve t-shirt may be worn under scrub tops. T-shirt sleeves must remain under scrub sleeves.
At no time are street clothes alone worn within the restricted areas of the surgical suite.
When OR personnel only deliver a patient to an area, they do not need to cover or change their scrubs when they return to the Operating Room. However, scrubs need to be changed upon return to the Operating Room if they will remain with the patient for a while to provide care or if they see other patients in the area.

Gowns: Impervious/fluid resistant gowns shall be worn in the Operating Room based on the professionals assessment of need or exposure prevention. Gowns will not be worn outside of the Operating Room.
Shoe and Shoe Covers

All personnel shall wear shoe covers when there is potential for shoes to become contaminated and/or soaked with blood, body fluids, or other potentially infectious material.
Surgical team members working at the sterile field shall wear shoe covers during surgical procedures. Shoe covers are optional for other operating room personnel and members of the surgical team.
Soiled shoe covers should be removed after case. Soiled shoe covers will not be worn outside the operating suite. Shoes should be made of leather or leather type material. Sandals and cloth shoes are not acceptable in the interest of safety. Clogs are worn at your own risk and are not recommended for O.R. use. Shoes shall be kept clean when worn in the O.R.

PATIENTS

Equipment: To minimize the risk of infection, the following procedures regarding use of equipment must be followed:

Intravenous catheters and arterial lines

Skin Prep Guidelines (Prepared by the Infection Control Department Shands at UF) - To be used for IV site preparation and maintenance, central cannula insertion and maintenance and surgical site prep.

Due to the unavailability of Hibistat®, a variety of skin prep practices are being used throughout the hospital. The Infection Control Department has noticed what appears to be an increase of coagulase negative Staph bacteremias. While the quarterly bacteremia rates for units should support this observation, the Infection Control Department would like to be proactive in reducing the potential for this increase. The following guidelines may also be found in the Infection Control Manual PM03-04 Appendix F and PM03-10.

Hospital approved skin preps listed in order of most to least preferred.

1. Chlorhexidine products (2% and/or 4%) Cida Stat, Endure 420, and Hibiclens.

These hospital approved handwashing soaps are found in patient care areas. To use, soak sterile gauze with soap containing chlorhexidine and then scrub site. Rinse area using alcohol soaked sterile gauze (removes soap residue with a minimum of sudsing). Another rinsing option is a sterile water or sterile saline soaked sterile gauze. Rinsing of the soap will not reduce the antiseptic activity of the chlorhexidine but will reduce the risk of skin irritation.

2. Povidone iodine (iodophor) may be used but must be allowed to completely dry prior to beginning procedure. Povidone iodine should not be washed off with alcohol because it’s germicidal action depends partially on the sustained release of free iodine. In order to speed the drying of povidone iodine, the manufacturer has added alcohol to some products. This combination of povidone iodine and alcohol can be found in two products available in the hospital. DuraPrep™ is available for large prep applications (O.R., Cath lab, Interventional Radiology). Smaller swabs are available for IV site preps and dressing changes.

3. Alcohol may be used if patient is allergic to the above products and only as a last option. (Studies have shown that alcohol is not as effective as a skin prep in preventing infections when compared to chlorhexidine or iodophors.)

Suctioning Equipment

Disposable sterile catheters and gloves are used whenever an endotracheal tube is suctioned out, and suctioning is carried out as atraumatically as possible.

Ventilators:

Ventilators and associated equipment are managed by Respiratory Care, except those permanently mounted on the anesthesia machines, which are managed by Anesthesia. These are wiped with a quaternary ammonium compound daily and when visibly soiled.
If contamination with body fluids occurs, a 1:5 chlorine bleach and water solution will be used.
If the ventilator is used on a patient requiring strict or respiratory isolation, the bellows will be removed by Clinical Engineering and sent to Central Sterile Supply for decontamination.

Epidural/Intrathecal Catheters/Other Analgesic Catheters: Catheters placed epidurally or intrathecally, for the purpose of regional analgesia are considered a minor surgical procedure and the following precautions shall be taken:

Wearing of sterile gloves
Wearing face mask
Skin preparation which consists of scrubbing the site with a germicidal solution with sterile swabs x 3.
Application of an occlusive dressing, which shall remain in place throughout therapy, unless the integrity of the dressing is compromised, at which time a new dressing will be applied using sterile technique.
Maintenance of a closed infusion system throughout the period of therapy, except for the changing of infusion bags. Tubing will be changed only in the event that the infusion tubing becomes contaminated or the catheter itself is changed.
Catheter disconnects will be dealt with by the anesthesiology staff on an individual basis. The following procedure should be followed:

Change infusion tubing
Using sterile technique, clean the catheter using povidone iodine, at least 12" from the exposed tip of the catheter. Allow to dry for two minutes, wipe off with sterile gauze. Cut the catheter with sterile scissors at about 10" from the exposed tip of the catheter. Reconnect the catheter to a new epidural connector and infusion tubing.
Catheter insertion sites shall be observed at least every shift by nursing personnel and daily by the anesthesiology pain team for evidence of infection. Suspected or confirmed infections related to catheter analgesia therapy will be reported to the staff anesthesiologist, with documentation and follow up in accordance with infection control policies.

All infusion pumps, patient control buttons and tote bags will be cleaned between patients by CDC in accordance with accepted hospital cleaning policies for non disposable items for patient care.
Catheters, tubings, adapters, dressings, tape and any other disposables used for catheter analgesia therapy shall be considered hazardous waste and will be handled and disposed of in accordance with established infection control policies. (See PM03-04, Appendix L)
All education of medical, nursing and ancillary personnel will include discussion and practical application of infection control policies and procedures related to catheter technique analgesia.

Administration of Anesthesia: During administration of anesthesia, the following procedures must be followed to minimize infection.

A protective screen must be placed between the patient's face and the operative site after skin preparation is finished.
Regional anesthesia must be considered a minor surgical procedure and the following precautions taken:

Wearing of sterile gloves.
Standard preparation of the patient's skin which consists of scrubbing the site with an antiseptic solution with sterile swabs twice.

INFECTED PATIENTS

Pre-surgical Evaluation: All surgical patients receive a pre-anesthesia visit before surgery. If the patient is found to have any possible contagious disease, the anesthetist will indicate this in the patient's chart. Special infection control procedures will be followed so that patients requiring respiratory or strict isolation will be isolated from non-infected patients and personnel. The procedures to be followed are found in the Hospital Infection Control Policy Manual, PM03-02.
Transportation of Infected Patients: Patients known to have a contagious disease will be brought to the O.R. just before surgery. All personnel involved are to be advised ahead of time of the transporting of such patients so that appropriate infection control measures can be taken.
Care During Surgery

On patients with known pulmonary infection, such as tuberculosis, and other diseases on Respiratory and/ or Strict Isolation, disposable equipment is used and then discarded. The choices of disposable equipment include Bacterial/Viral filters, breathing circuits and special C02 absorbers. After use, this equipment is disposed of in a closed red plastic bag marked "Contaminated - Do Not Open - Discard." Non-disposable equipment will be disinfected with a glutaraldehyde solution and when feasible will be gas sterilized.
On cases when contamination is discovered during a surgical procedure, all nondisposable equipment used on the patient is packaged in a special plastic bag (from Central Sterile Supply), sealed with a plastic tie, labeled, and sent to Central Sterile Supply marked "Contaminated - To Be Sterilized." When this equipment is returned to Anesthesia, it is rinsed, dried and repackaged for sterilization. If it is contaminated with blood or body fluids it is to be cleaned with a 1:5 solution of chlorine bleach and water then rinsed, dried and repackaged for sterilization. Anesthesia machines are washed with a quaternary ammonium compound and the soda lime is changed.

Post Anesthesia Recovery: The following procedures must be observed regarding post-anesthesia recovery:

Patients with types of infection that do not require Strict, Respiratory or Compromised Host Precautions (see V.D.3) can be recovered in the general area of the recovery room. Appropriate handwashing techniques and other precautions should be taken. (See Hospital Policy PM 03 and 03-04.)
When a surgical patient is known to have a communicable infection which requires Strict, Respiratory, or Compromised Host Precautions (see VI.C) the O.R. should call the Recovery Room with as much notice as possible to request Recovery Room services.

The Recovery Room will accept the patient, provided:

There is adequate space to isolate the infected patient from other post-op patients.
Recovery Room has adequate staff to assure a 1:1 nurse-patient ratio to ensure the patient's isolation and for protection of other patients.
If the patient is immunosuppressed, the anesthesiologist will decide whether or not the patient may safely be recovered in the Recovery Room or if he/she must be recovered in his/her assigned room by the anesthesiologist or when staffing permits, by the Recovery Room staff.

If the above conditions cannot be met, it then becomes the responsibility of the Anesthesiologist to provide care for the patient. When this occurs, Anesthesia personnel will remain with the patient in the O.R., in the Recovery Room, or in the patient's room until the patient is recovered enough to receive ordinary floor care or until the Recovery Room has the personnel and space to assume responsibility for the care of the patient.

EQUIPMENT AND MATERIALS

Flow of Dirty Equipment Through the Anesthesia Workroom: Dirty or contaminated equipment should be brought through the front door (the door closest to the double doors separating hallway 22C5.1 from hallway 22C6.4). This will allow for appropriate cleaning without contaminating any stored supplies. Use of the rear door to bring in used equipment should be avoided. After appropriate cleaning and/or sterilization the equipment may be recycled back to the storage areas of the workroom.
Cleaning and Sterilizing Anesthesia Equipment: Disposable equipment is used whenever possible and discarded after one-time use. Reusable connectors, corrugated hoses, breathing bags and masks are processed by pasteurization in Central Sterile Supply.
Anesthesia Carts: The top, front, and sides of the cart are wiped with a quaternary ammonium compound daily and when visibly soiled. Blood and secretions are cleaned immediately with a 1:5 chlorine bleach and water solution. The entire cart is cleaned, all equipment removed, the drawers are wiped with a quaternary ammonium compound.
Endotracheal Tubes: All endotracheal tubes are of the disposable type and are disposed of after one time use.
Reusable Items: Reusable items, such as face masks, breathing bags, corrugated tubing, and Y-pieces, are processed by pasteurization in Central Sterile Supply.
Laryngoscope Blades: Laryngoscope blades are rinsed in cool water, washed with a detergent, rinsed, washed in Steris system.
Airways: Disposable airways are used and discarded after one use.
Suctioning Equipment: Catheters are disposable and are discarded after one-time use.
Anesthesia Machines: External portions of gas machines are thoroughly cleaned daily with a germicide. The soda lime is also changed when necessary, based on color indicator or contamination from Respiratory or Strict Isolation cases and routinely after 14 days.
Blood Pressure Cuffs: Soiled blood pressure cuffs are wiped when visibly soiled immediately with a germicide solution (Virex) or with 70% isopropyl alcohol.
Transducers: Disposable transducers are used and discarded after each use.
Procedure for Cleaning TEE Probes: NOTE: When carrying the TEE Probes, always use a tip protector. The protectors will be stored in the cabinet immediately to the left of where the probes are. They will usually be on the bottom shelf. If you cannot find one, page a tech.

When dirty or used TEE probes are brought back to the workroom, it should be carefully placed into the cabinet labeled "Place Dirty TEE Probes Here".
When ready to clean, the top protector should be removed and the TEE probe shaft gently placed in the sink while the handle is hung from the hook above the sink, and the connector is placed on a dry surface two or three feet away from the sink.
A 4x4 with, Virex applied, should be used to wipe the handle portion of the probe and the cable leading to the connector.
A 4x4 with metrizyme generously applied should be used to wipe off the shaft from the end of the control handle to the tip, always being careful not to damage any portion. Particular care should be given to removing any foreign matter from the probe.
Being careful not to allow water to get on the control handle, rinse the shaft and tip with warm water.
Place the tip and shaft in one of the Metricide baths in the cabinet. Set the timer for 20 minutes.
When time is up, again hang the handle from the hook above the sink and thoroughly rinse the shaft and tip, again keeping water away from the control handle.
Hang the probe from the probe holder in the cabinet, making sure the shaft and tip are behind the bath container, allowing them to air dry.

Event Related Sterility - See Hospital Infection Control Policy PM03-10, Appendix A.
Storage and Stock Checking:

Manufactured disposable items and items with an expiration date shall be stored in a specified location. All items, including disposable items with a manufacturer expiration date, will be checked on a quarterly basis (with user sign off) to insure that they are current. All packages which will expire before the next scheduled check will be identified in a manner to assure use prior to expiration date.
Shelf Life: Shelf life is event-related, not time related. An event can compromise or destroy the bacterial barrier effectiveness of the packaged material (e.g., package is torn or wet). Items should be routinely inspected for evidence of moisture, soilage and/or tears that may have occurred during transit or storage by the user prior to use. Packages will be considered contaminated if they are damaged, wet or stained.

HOUSEKEEPING: Environmental Services is responsible for emptying Anesthesia laundry hampers and trash, mopping the floors and vacuuming the carpets in the office area. The workroom and lounge area is cleaned at least once a day.

SUBJECT: Usage and Disposal of Filled Syringes: PURPOSE: To provide a policy designating proper usage, labeling and disposal of syringes fill with drugs; and infection control to be followed by all Anesthesiology attendings, residents and anesthesia technicians in all anesthetizing locations. POLICY****

Medication drawn into syringes will be obtained only from sources labeled with the name, concentration, and expiration date. All syringes into which drugs are drawn (filled syringes) will be labeled with the name of the drug it contains and the concentration of the drug, if diluted. These syringes should only be filled by a licensed anesthesiologist or under the direction of a licensed anesthesiologist. All such syringes will be kept on the person of the anesthesiologist, the top of the anesthesia machine or cart or in the drug drawer of the cart. Used syringes will be marked (such as with an indelible marker or a label) and disposed of at the end of the case for which they were prepared, and all syringes will be disposed of at the end of the day. For the purpose of determining which syringes have been used, only unused filled syringe will be placed in the anesthesia cart's drug drawer. All other filled syringes will be considered to have been used, including any on or in the anesthesia cart at the beginning of the day. Disposal of syringes will be made by the anesthesiologist and by the anesthesia technician servicing the anesthesia cart. Carts will be serviced by an anesthesia technician between each case and at the end of the day.
Syringes filled by Pharmacy Services will be clearly labeled with the name, concentration, and expiration date of the drug they contain. These syringes will be treated in the same manner as syringes filled by anesthesiologists.
Multi-dose sources will be disposed of by the expiration date printed on the source label, and after the case in which they have been contaminated (by being used to reload syringes that been used to deliver drugs to any fluid path connected directly to a patient). Contaminated sources will not be placed in the drug drawer of the anesthesia cart. All contaminated drug sources will be disposed of at the end of the case, and all opened drug sources will be disposed of at the end of the day in the manner described for used syringes.

Note ** All needles will be used once only and not recapped by hand. (See also PM03-O1, Appendix B and PM03-04, Appendix M).