www outpatientsurgery.net Surgery Infection Control 2012 ... · your equipment carries more than just patients our specialized programs: fulfill your infection prevention / performance

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OutpatientSurgery

May 2012RMagazine

2012 Manager’s Guide to

Infection ControlInfection Control

9 challenging quizzes aboutrisk-reducing musts, including:

Hand Hygiene p. 12

Surface Disinfection p. 16

Site Prepping p. 38

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2

FEATURES3 Why Does Patient Warming Matter?

The importance of staving off hypothermia goes well beyondpatient comfort.Daniel Sessler, MD

8 How Well Do You Know Your Low-Temperature Sterilization Options?Moist heat in the form of saturated steam under pressure is the most dependable way to destroy all forms of microbial life.Phenelle Segal, RN, CIC

16 Know Your Wipes, Mops & SpraysSee if you clean up on this 10-question surface disinfection quiz.Ann Marie Pettis, RN, BSN, CIC

22 Brushing up on Surgical GlovesA quiz about barrier protection’s front line of defense.Outpatient Surgery Magazine Staff

26 How Do You Dispose of Fluid Waste?The choices boil down to employee safety, cost and your clinical needs.Mary Wilson, RN, BSN, CNOR

30 Stay on Top of High-Level DisinfectionIs your endoscope reprocessing compliant with standards?Carol Imes, RN, MPA, CNOR

34 The Down and Dirty on DecontaminationSee if you’re using the right equipment and procedures whengetting instruments ready for sterilizing.Steven Johnson

38 Prep the Site RightAvoid SSIs with this review of pre-incision basics.Rhonda Knight, RN-IP, BSN, and Melanie Lewis, RN, BSN

Improve Your Hand Hygiene Compliance

Use this review of scrubbing, rubbingand washing to avoid harming

patients with touches meant to heal.Eileen A. Taylor, RN, BSN

May 2012 | www.outpatientsurgery.net

12

Infection ControlManager’s Guide to

Class is in session. This year’s Manager’s Guide to Infection Control is packed withthought-provoking quizzes aimed at testing your knowledge of key strategies in the fight against SSIs. Use the guide to gauge how much you know about infection control’sbest practices, and how much is left to learn. Are you following proper protocols whengloving, prepping and cleaning? Read on to find out. Sharpen your pencils, put away your notes and keep your eyes on your own work. Good luck!

Cover design by Ethan Anderson

To Our Readers

MAY 2012 | OUTPAT IENT SURGERY MAGAZ INE | 2

http://www.bbraunusa.com

L et’s find out what

you know about

the causes of

intraoperative

hypothermia, why

maintaining normothermia

is vitally important to your

infection control efforts

and the best ways to keep

patients warm and safe

from pre-op to PACU.


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P A T I E N T W A R M I N G

The importance of staving off hypothermiagoes well beyond patient comfort.

Why DoesPatient Warming

HOT TOPIC Keep patients normothermic throughoutsurgery to limit a host of post-op complication risks.

Matter?

Daniel Sessler, MDCleveland, Ohio

Q1. Intraoperativehypothermia cancause which of the following:a. increased bloodpressure

b. increased risk of wound infection

c. decreased drugmetabolism

d. all of the above

d. all of the above

http://www.equipsystems.com

Even mild hypothermia inhibits blood

coagulation, which has been shown to

significantly increase blood loss during many

types of surgery. Hypothermia increases

blood pressure, heart rate and plasma

catecholamine concentrations, which in turn triples the risk of heart

attacks. Drug metabolism is also reduced in hypothermic patients, meaning

the effects of anesthetics linger longer, thus prolonging post-op recovery

times. Finally, hypothermia

increases wound infection risks

by impairing immune function,

triggering thermoregulatory

vasoconstriction and decreasing

oxygen delivery to the surgical

site. In fact, mild hypothermia

triples wound infection risks in

patients who undergo colon

surgery.



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SNUG AS A BUG Activewarming is a welcomeperk for nervous patientsabout to enter chilly ORs.Q2. Maintaining

intraoperativenormothermia is______________.a. optionalb. required by community and professional societystandards

c. only marginallysupported by research

d. difficult and expensive

b. required by community and professional societystandards

Q3. Normal body temperature isusually:a. within the interthreshold rangeb. above the sweating thresholdc. below the vasoconstriction thresholdd. between the vasoconstriction and shivering thresholds

a. within the interthreshold range

http://www.rangerfluidwarming.com

The Surgical Care Improvement Project and the Physician Quality

Reporting Initiative require that you employ active warming to maintain

normothermia in all patients — regardless of age — who are undergoing

surgery lasting 60 minutes or longer under general or neuraxial anesthesia.

According to the guidelines, a body temperature equal to or greater than



QQ4. Typical surgical concentrations ofvolatile general anesthetics increasethe normal interthreshold range fromapproximately 0.2°C to __°C?a. no change b. 1°C c. 2°C d. 4°C

d. 4°C

5. Which of the following is the most reliable core-temperature monitoring site:a. rectum b. axilla c. esophagus d. forehead skin

c. esophagus

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36°C must be recorded within the 30 minutes immediately before or the 15

minutes immediately after anesthesia end time. Hypothermia can still occur

in patients during cases lasting less than 60 minutes. While these patients

aren’t considered high risk, they can and will feel cold, so warming as a

comfort measure is still recommended during shorter procedures.

A patient’s normal body temperature sits within the interthreshold range,

defined as core temperatures that do not trigger autonomic thermoregulatory

responses. Autonomic responses are about 80% determined by core

temperature; in contrast, about half of behavioral responses are driven by

skin temperature. Skin temperature therefore contributes more to thermal

comfort than to vasoconstriction, sweating and shivering.

Shivering, which occurs when temperatures dip below the shivering

threshold, is the body’s most intense defense against a drop in temperature.

But it’s hard for the body to maintain shivering for long periods, and it’s an

inefficient and metabolically costly response. Sweating, on the other hand,

occurs when temperatures push past the upper limit of the interthreshold

range. Sweating is effective and can dissipate 10 times the metabolic rate,

even when ambient temperature exceeds core temperature.

General anesthetics inhibit the body’s normal autonomic responses to

thermal perturbations through a slight increase in the sweating threshold

accompanied by marked and synchronous reductions in the vasoconstriction

and shivering thresholds. The consequence is that the interthreshold range —

normally a few tenths of a degree Celsius — increases to about 4°C. Patients

given volatile anesthesia are therefore poikilothermic over a wide range of

core temperatures. Patients given neuraxial anesthesia are also at risk.

Neuraxial anesthesia increases the interthreshold range, impairs peripheral

thermoregulatory defenses and blunts behavioral responses (patients feel

warm even when hypothermic).

Measuring the body’s core temperature to assess the onset of intraoperative

hypothermia is best done at the tympanic membrane, pulmonary artery, distal

esophagus or nasopharynx. Among these, the distal esophagus is the easiest

to use and most resistant to artifact. Near-core sites include the mouth, axilla

and bladder.

The secondary sites, however, carry accuracy limitations. Oral

temperatures, for example, can be inaccurate in patients who regularly

breathe through their mouth or who recently drank cold or hot liquids.

Temperatures measured on the skin’s surface are approximately 2°C

lower than core, and the temperature difference between skin and core

varies both among patients and within a given patient over time.

While the level of temperature accuracy needed to be clinically acceptable

is up for debate, the difference between the thermometer and site used to

measure core temperature and the actual core temperature should not

exceed 0.5°C — the smallest temperature differential associated with

complications caused by hypothermia.

Intraoperative

hypothermia can occur

when anesthesia impedes

the body’s normal ability

to regulate its core

temperature while it’s

exposed to a cold

environment, as is often

the case in ORs kept

chilly for the comfort of

the surgeons and staff. Hypothermia onset is characterized by a rapid

decrease in core temperature followed by a slower more gradual decline.



Q6. Initial hypothermia following induction of anesthesia results primarily from:a. ventilation with cold, dry respiratory gasesb. redistribution of heat within the bodyc. undressing patients in a cold environmentd. anesthetic-induced reduction in metabolic rate

b. redistribution of heat within the body

The rapid initial drop in temperature of 1°C to 1.5°C

in the first hour of general anesthesia occurs when the

anesthetics cause vasodilation, letting the body’s core

heat flow to the extremities. The more gradual,

straight-line loss of heat during longer procedures

occurs because the body’s core temperature plateaus

and remains constant after 3 to 4 hours of anesthesia.

Subsequent heat loss is therefore caused by the body’s

inability to metabolically produce heat that exceeds

gradual heat loss.

While warmed fluids administered during surgery do

not raise a patient’s body temperature, the practice is very effective in preventing the significant heat

loss that occurs when room temperature IV fluids or refrigerated blood are administered. A patient’s

core body temperature drops by 0.25°C for every 1 unit of refrigerated blood or 1 liter of IV solution

given. To avoid these incremental temperature drops that can add up to significant and potentially

dangerous lows, use fluid warmers when you expect to deliver large amounts of fluid during a case.

Fluid warming, though, is always a second-line approach and should be added to effective surface

warming methods during surgery when high volumes of fluid are being given (cases involving the

administration of 1 to 2 liters of fluid per hour, for example).

The ambient temperature in the OR impacts how quickly a patient’s body heat is lost through

convection from the skin and evaporation at surgical sites. Increasing the ambient temperature in your

ORs, however, isn’t a practical way to warm patients since you’d have to keep thermostats set at 73°F

or higher to maintain normothermia. Warmed cotton blankets reduce heat loss by approximately 30%,

which is a clinically important amount, but rarely enough to avoid hypothermia in surgical patients.

Mattresses that circulate warmed water underneath patients are nearly ineffective because little heat

escapes from a patient’s back that’s pressed firmly against the operating surface. These devices are

more effective when positioned over patients. Newer circulating water garments take advantage of this

approach and can eliminate metabolic heat loss, thus increasing mean body temperature by about 1°C



Q7. Which of the following is true about fluidwarming?a. fluid warming prevents fluid-induced cooling,but does not warm patients

b. each liter of IV fluid at ambient temperaturedecreases mean-body temperature by 0.5°C

c. fluid warming should be used in most patientsd. fluid warming is a reasonable alternative toactive surface warming

a. prevents fluid-induced cooling, but does notwarm patients

QUICK TIPS

2 Keys to Proper Patient Warming1.Measure core body temperature in patients undergeneral or neuraxial anesthesia for longer than 30minutes.

2. Unless hypothermia is specifically indicated forclinical reasons, make a concerted effort tomaintain patients’ intraoperative core bodytemperatures above 36°C.

— Daniel Sessler, MD

Q8. Which of the following is mosteffective in preserving intraoperativenormothermia:a. ventilation with warm, humidified gasesb. circulating water mattressc. increasing ambient OR temperature by 4°Cd. upper-body forced-air warming

d. upper-body forced-air warming

per hour. Forced-air

warming systems also

eliminate metabolic heat

loss, and therefore also

increase mean body

temperature by roughly

1°C per hour.

I recommend applying

effective surface warmers

to all patients, because

even during short cases,

the devices will increase

mean-body temperature

and improve patient

comfort. OSM

Dr. Sessler ([email protected])is the Michael Cudahyprofesssor and chair of theDepartment of OutcomesResearch at the ClevelandClinic in Ohio.


S T E A M & L O W - T E M P E R A T U R E S T E R I L I Z A T I O N

Steam is the most preferred, least

expensive and most reliable method

of sterilizing your non-heat-sensitive

instruments and equipment for surgery. Let’s

see how familiar you and your staff are

about steam and other low-temperature

sterilization options.

Moist heat in the formof saturated steamunder pressure is the most dependableway to destroy allforms of microbial life.Phenelle Segal, RN, CIC | Blue

Bell, Pa.

How Well Do You Know Your Low-Temperature

Sterilization Options?

How Well Do You Know Your Low-Temperature

Sterilization Options?

EVENT-RELATED STERILITYYou don’t have to reprocess sterile packs and individually wrapped items each month.

http://www.ivnow.com/video

http://www.cygnusmedical.com

Peracetic acid’s 23-minute cycle makes it a good just-in-time sterilization

method for heat-sensitive devices that will be used immediately. A

hydrogen peroxide gas plasma cycle takes 28 to 55 minutes, depending on

the sterilizer. Vaporized hydrogen peroxide sterilizes devices in pouches or

wrapped trays at 122°F during a 55-minute cycle. The cycle time for

ethylene oxide can be 12 hours or more in order for each load to properly

aerate. While each ozone load is low-cost because there’s no sterilant to

purchase — only water, oxygen and electricity — the 4.5-hour run time is a

drawback.

You are no longer required to reprocess unopened packs or individually

packed instruments unless the external integrity has been compromised.

This is known as “event-related sterility.” The instruments will remain



Q1. Put these low-temperature sterilization options in order by cycletime from shortest to longest.a. hydrogen peroxide gas plasma, vaporized hydrogen peroxide, ozone,ethylene oxide, peracetic acid

b. ethylene oxide, hydrogen peroxide gas plasma, vaporized hydrogenperoxide, peracetic acid, ozone

c. peracetic acid, hydrogen peroxide gas plasma, vaporized hydrogenperoxide, ethylene oxide, ozone

d. ozone, vaporized hydrogen peroxide, ethylene oxide, hydrogen peroxidegas plasma, peracetic acid

e. vaporized hydrogen peroxide, peracetic acid, hydrogen peroxide, gasplasma, ozone, ethylene oxide

c. peracetic acid, hydrogen peroxide gas plasma, vaporized hydrogenperoxide, ethylene oxide, ozone

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http://www.aspjj.com

sterile for an

indefinite period

unless the outer

package has been

compromised. You

need to be diligent

when recognizing

or identifying

affected packages

or packs.

Reprocessing

should take place

as soon as possible

or the packages should be removed from the storage area to prevent

inadvertent use.

Limited data are available, and studies have shown varying results. It

appears that while a 10- to 14-day

hang period appears safe, the lack of

data does not provide the industry

with the comfort in knowing that

waiting for that period of time will be

in the best interests of patients. AORN

and APIC suggest a 5- to 7-day storage

period between reprocessing and use.

It is crucial that you have a common

understanding of what is meant by

“flash” sterilization, since there have

been technological changes that

require a more nuanced understanding of this term. Flash sterilization has

traditionally referred to a very short sterilization cycle for a very small and

unwrapped load. One of the major concerns with this process has been that,

because loads were unwrapped, the sterility of the devices could not be

maintained after they were removed from the sterilizer. However, as

sterilizers have improved their abilities to allow for steam penetration, it has

become possible to effectively sterilize wrapped or contained (in specialized

metal containers, pouches or cassettes) loads in short cycles.

Sterilization of unwrapped or uncontained loads should not be routine

practice, but should be used only for an urgent and unpredicted need for a

specific device (such as when an instrument is drop-ped). Don’t use open

containers for short-cycle sterilization. Flashing is acceptable as long as loads

are wrapped or contained and facilities follow manufacturers’ guidelines for

all devices involved. If you’re routinely short-cycle sterilizing, use closed

containers designed for such a process and deliver devices to the sterile field

in covered form.

All sterilizers must be cleared by the FDA to run short cycles and validated

by their manufacturers to perform effectively in those cycles for defined

MAY 2012 | OUTPAT IENT SURGERY MAGAZ INE | 1 0


Q4. What are the ideal conditions for flash or immediate-use sterilization?a. any approved sterilizer can be usedb. process can occur in place of purchasing additional instrument setsc. routine sterilization of unwrapped or uncontained loads continues to beinappropriate and should be cited as a violation

d. none of the above

c. routine sterilization of unwrapped or uncontained loads continues to beinappropriate and should be cited as a violation

Q

Q

2. Which practice should you follow whenreprocessing sterile packs and individuallywrapped items?a. reprocess all sterile packs and items every monthb. reprocess sterile packs and items every 6 monthsc. reprocess the most commonly used sterile packs andinstruments monthly

d. reprocess unopened packs or individual items only ifthe external integrity has been compromised

d. reprocess unopened packs or individual itemsonly if the external integrity has been compromised

3. In light of conflictinginformation relating to thehang time of endoscopes,what’s the longest-allowedtime period betweenreprocessing and use on apatient?a. 5 to 7 days b. 10 to 14 daysc. up to 3 weeks d. unlimited time

a. 5 to 7 days

validation loads.

Laryngoscope blades are

considered semi-critical

items and therefore at a

minimum must undergo a

thorough pre-cleaning and

visual inspection followed by

high-level disinfection with

an approved product. The

blade must be dried before

being used on another

patient. If the manufacturer’s

instructions allow for

sterilization of the blade, it

can be sterilized as long as

the specific instructions are

followed. The handle can be thoroughly

wiped down with a hospital approved

germicidal product.

The monitoring of sterilizers is critical

to maintaining an infection-free

environment as the process can fail if

sterilizers malfunction or the operator

doesn’t adhere to best practices. It’s

imperative that you correctly monitor the different types of sterilizers

according to government requirements and manufacturers’ instructions. OSM

Ms. Segal ([email protected]) is president of Infection ControlConsulting Services (www.iccs-home.com) in Blue Bell, Pa.


ANESTHESIA ALERT Semi-criticalitems such as laryngoscopes at aminimum require high-leveldisinfection.

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Q5. What is an acceptable process for cleaning and disinfectinglaryngoscopes?a. wipe down the handle and blade with agermicidal wipe

b. wipe down the handle with a germicide and high-level disinfectant or, if approvedby the manufacturer, sterilize the blade

c. sterilize the handle and blade in anapproved sterilizer

d. none of the above

b. wipe down the handle with a germicide and high-level disinfectant or, if approved by the manufacturer, sterilize the blade

Q6. Which of the following steps is appropriate for monitoring thesterilization process?a. a chemical indicator is placed in each loadb. each load is monitored with mechanical indicators (time, temperatureand pressure, for example)

c. a biologic indicator is performed at least weekly and with allimplantable loads

d. all of the above

d. all of the above

http://www.buffalofilter.com

Gloves are not a substitute for hand

hygiene, as they do not completely

protect against contamination from

bacterial flora or infections caused by

hepatitis B, likely because of

undetectable defects or inadvertent

touching of the gloves’ outer surfaces

while taking them off. According to the

CDC’s “Guideline for Hand Hygiene in

Health-Care Settings,” you should wash

your hands with antimicrobial or non-antimicrobial soap and water or disinfect

them with an alcohol-based hand rub immediately after removing gloves.

It’s just as important to clean your hands after touching environmental

surfaces near patients, including patient gowns, bed linens and rails and

countertops. These surfaces can become contaminated with transient flora,

which according to the CDC can colonize the skin’s superficial layers, but

can be removed with routine handwashing.

Of the answer groups above, says the

CDC, male physicians are least likely to

follow proper hand hygiene protocols. In

fact, a study published in the December

2011 issue of the American Journal of

Infection Control showed that German

medical students failed to grasp hand

hygiene’s basic tenets. The study did

note, however, that nursing students

showed a much better understanding of

proper hand hygiene practices.


H A N D H Y G I E N E

Of all the tasks your staff completes

on a daily basis, caring for their

hands before surgery and between

patient encounters is the one they do most

often. But are you sure they’re doing it

correctly? Let’s see how much your staff

really knows about infection control’s most

basic practice.

Use this review of scrubbing,rubbing and washing to

avoid harming patients withtouches meant to heal.

Eileen A. Taylor, RN, BSN | Lebanon, N.H.

Improve Your Hand Hygiene Compliance

CLEAN START A large part of infectioncontrol success begins at the scrub sink. Q

Q

1. When is hand hygieneindicated?a. after removing glovesb. after touching OR countertopsc. before contacting a patientd. b & c, but not ae. a, b & c

e. a, b & c

2. Who has been shown to have the poorest rates of hand hygiene compliance?a. female physiciansb. male physiciansc. male nursesd. female nurses

b. male physicians

So while physicians might be the

toughest customers to observe

when it comes to hand hygiene

compliance, be aware of common

barriers to compliance and ensure

every member of your surgical team

is up to speed on acceptable

practices. Never assume they

understand hand hygiene’s core

practices, no matter how basic they

might seem. To wit: A study

appearing in the August 2011 issue

of the American Journal of Infection

Control showed nurses, infection

preventionists and hospital

environmental services managers

who were asked to assess the risk of infection in 16 real-life simulations

mistakenly believed touching environmental

surfaces carried less risk than touching

patients’ skin, even though evidence has

shown that touching 1 contaminated surface

can spread bacteria to up to the next 7

surfaces touched.

Hand antisepsis prior to surgery can be

accomplished with antimicrobial soap or an

alcohol-based rub. Prior to applying a rub,

the CDC instructs you to first use a nail

cleaner to remove debris from underneath

your fingernails while holding them under running water. Then wash your

hands and forearms with a non-antimicrobial soap if they’re visibly soiled or if

you’re preparing your hands before the first cases of the day.

Let your hands and forearms dry completely before applying an alcohol-

based surgical rub. (According to the World Health Organization’s

“Guidelines on Hand Hygiene in Health Care,” handrub formulation may be

impaired if hands are not completely dried before application.) Finally, let

the rub product dry completely — which only takes a matter of minutes —

before donning surgical gloves. Applying rub products without washing

your hands between subsequent cases of the day is acceptable.

According to the

WHO, hand antisepsis

must reduce the release

of skin bacteria from

the hands of your

surgeons and nurses for

the duration of surgery.

It must eliminate

transient flora and

reduce resident flora, and inhibit the growth of bacteria under gloves.

The immediate (just after application) and persistent (up to 6 hours)

activities of surgical scrub and rub products are vitally important. The

CDC says hand antisepsis using alcohol-based rub products containing

60% to 95% alcohol alone or 50% to 95% alcohol when combined with

limited amounts of a quaternary ammonium compound,

hexachlorophene or chlorhexidine gluconate lower bacterial counts on

the skin immediately after scrubbing and rubbing more effectively than

other agents do.



Q3. During surgical rubbingwith an alcohol-basedwaterless product, it ispreferable to apply theagent to:a. dry handsb. wet handsc. it doesn’t matter

a. dry hands

Q4. The primary aim of preparing your hands for surgery is to _______________.a. eliminate resident flora and reduce transient florab. eliminate transient flora and reduce resident florac. eliminate physical dirt and bodily fluidsd. eliminate proteinaceous material

b. eliminate transient flora and reduce resident flora

UNDERLYING ISSUE Should you treat your handsimmediately after removing gloves?

While the WHO’s hand-hygiene guidelines concede that scrubbing

and rubbing are both suitable practices, the organization gives the

nod to rubbing as the preferred method. “The antibacterial efficacy

of products containing high concentrations of alcohol by far

surpasses that of any medicated soap presently available,” the

guidelines note. Alcohol-based rubs also outpace medicated soap

scrubbing with respect to time and cost savings, potential damage to

caregivers’ hands and recontamination risks after hands have been

rinsed in water, according to the WHO.

If your staff or surgeons prefer the routine of a traditional scrub,

says the CDC, persistent antimicrobial activity of detergent-based

formulations is greatest for those

containing 2% or 4% chlorhexidine

gluconate, followed by hexachlorophene,

triclosan and iodophors. While 10-minute

scrubs have long been considered the

norm, the CDC notes 5-minute scrubs

reduce bacterial counts on hands as

effectively, and scrubbing for as little as

2 to 3 minutes reduces counts to

“acceptable” levels. The CDC also notes

that applying an alcohol-based product

after scrubbing with 4% chlorhexidine

gluconate or povidone-iodine for 1 or

2 minutes has been shown to be as

effective as a 5-minute scrub.

While you clearly must take into

account the effectiveness of a particular agent against the pathogens that contribute to healthcare-

1 4 | MAY 2012 | OUTPAT IENT SURGERY MAGAZ INE


Q5. Hand hygiene guidelines toutthe efficacy of scrubbing withantimicrobial soap prior tosurgery and recommend itspractice over rubbing withalcohol-based products.a. true b. false

b. false

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COMFORT MEASURE Alcohol-based rubscontaining emollients can knock down one of theprimary barriers to hand hygiene compliance.

http://www.surgicept.com

acquired infections when selecting the

product that’s best for your facility,

don’t ignore the very important issue

of staff acceptance.

Hand dermatitis, which can cause

severe dryness, itching and burning

sensation, is one of the primary barriers

to hand hygiene compliance. Reducing your staff’s exposure to soaps and

detergents — the products often to blame for the unwanted side effect — is

one way to avoid skin issues, but it’s an impractical solution. Instead, says the

CDC, provide your staff with moisturizing skin-care products or, better yet,

make the switch to alcohol-based rubs containing emollients that help to

soothe skin upon application.

The CDC says hand hygiene compliance issues can be traced to not only

healthcare workers, but also to the facilities in which they work. That means

the best way to improve your staff’s hand hygiene performance is to attack

the issue from facility-wide and frontline perspectives. Also know and

address the common barriers to hand hygiene compliance, identified by the

CDC as skin irritation caused by hand hygiene agents, inaccessible or

inconveniently located hand hygiene supplies, interference with patient

relationships, forgetfulness, lack of knowledge of the guidelines and

insufficient time. Having personal-sized alcohol-based hand rub dispensers

available for staff to carry in their pockets or attach to their scrubs to use at

the bedside when going from a “dirty” activity to a “clean” one increases the

probability that hand hygiene will take place during patient care, making the

right thing to do easier.

To address staff concerns over a perceived lack of time to perform hand

hygiene, place dispensers of alcohol-based hand rubs in convenient locations

throughout your facility. Alcohol-based rubs are quicker to apply, act faster

and are less irritating to your staff’s hands than a traditional soap and water

wash. Listen to staff in order to identify products they’ll use. The CDC advises

you to collect feedback regarding the feel, fragrance and skin tolerance of the

agents, but points out that “cost should not be the primary factor influencing

product selection.”

The CDC says staff education is the cornerstone of any successful hand

hygiene program. Create and enforce written guidelines and develop a culture

of adherence where individuals from all staffing levels model appropriate

behavior.

For example, all new clinical staff members at my hospital are required

to attend patient safety orientation on their first day of employment. At the

infection prevention session, we review our hand hygiene policy, discuss

how we conduct routine compliance observations throughout the hospital

and certify all attendees in hand hygiene. To be certified, they must

demonstrate proper handwashing (soap and water) technique and answer

several hand hygiene-related questions. Employees who earn certification

receive small stickers to wear on their ID badges. The stickers are a source

of pride, create on-the-floor role models and spark a healthy dose of peer

pressure that promotes the program throughout the hospital. OSM

Ms. Taylor ([email protected]) is an infection preventionpractitioner at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.



Q6. Approximately whatpercentage of nurses sufferfrom hand dermatitis?a. 5% b. 15% c. 25% d. 35%

c. 25%

See if you clean up on this 10-question surface disinfection quiz.

Ann Marie Pettis, RN, BSN, CIC | Rochester, N.Y.

Know Your

While surface disinfection may

seem like a commonsense

practice — how hard can it be

to use a wipe on a tray or table? — there’s

more to it than meets the eye. Test your

staff’s knowledge of the basic rules and

rationales surrounding proper cleaning

protocols with this evidence-based quiz.

C. difficile is an anaerobic, gram-positive


S U R F A C E D I S I N F E C T I O N

��

SPRAY AND SCRUB Nurses shouldunderstand the basic rules for cleaningall surfaces, from floor to ceiling.

http://www.healthcare.gojo.com/surgical-scrub-trial

bacterium that can persist for

extended periods on a variety

of surfaces in the environment

because it is spore-forming.

According to the Association

for Professionals in Infection

Control and Epidemi-ology’s

“Guide to the Elimination of

Clostridium difficile in

Healthcare Settings,” the term

“hypersporulation” has been

used “to denote the propensity

of the bacterium to move from

the vegetative form to the

spore form with increased

rapidity. The term has also been used to note that contact with some

germicides stress the bacterium, so it more readily transitions to the spore

form.”1In other

words, using the

wrong disinfectant

can actually make

C. diffmore

difficult to

eradicate.

The guide further

states, “Although

many EPA-

registered



Q1. A patient has explosive diarrhea in the OR. Youdiscover from the patient’s record that an assayfor Clostridium difficile is pending. Whatchemical disinfectant would you use to cleanthe room after the case?a. quaternary ammonium compoundb. hospital-grade, EPA-approved disinfectantc. 1:10 bleach-based product d. 70% isopropyl alcohol

c. 1:10 bleach-based product

FLOOR PLAN Do youknow which type of mop isbest to use in the OR?

��

http://www.pdipdi.com/af3

germicides kill vegetative C. difficile, only chlorine-based disinfectants and high-concentration,

vaporized hydrogen peroxide kill spores.” With vaporized hydrogen peroxide still emerging as an option

for outpatient facilities, this leaves the CDC-recommended regime: “meticulous cleaning followed by

disinfection using hypochlorite-based germicides,” that is, bleach-containing disinfectants.2

Because floors receive minimal hand contact, they should be cleaned “on a regular basis, when soiling or

spills occur, and when “a patient is discharged” from the area.2

Extraordinary cleaning and decontamination are not warranted,

as “studies have demonstrated that disinfection of floors offers no

advantage over regular detergent/water cleaning” and minimally

affects incidence of healthcare-associated infections.2

Further, floors should be tackled last during any cleaning

because “newly cleaned floors rapidly become recontaminated

from airborne microorganisms and those transferred from shoes,

equipment wheels and body substances,” according to the CDC.2

So if you clean the OR table after the floor, you risk spreading

any microorganisms from the table back to the floor — possibly negating the work you just did. Wet-

mopping or -vacuuming using an EPA-registered detergent/disinfectant is recommended after a

procedure that has resulted in a blood or body fluid spill, or “when a multi-drug-resistant organism is

likely to be in the environment.”2

S. aureus is the leading cause of surgical site infections

in the United States.3Antimicrobial prophylaxis is the

main strategy to prevent methicillin-resistant S. aureus,

but it’s important to note that surface disinfection also

plays a role. Evidence is accumulating that contaminated

surfaces contribute to transmission of all the answer

options as well as Acinetobacter baumannii and

Pseudomonas aeruginosa, and that improved

environmental decontamination helps



Q3. What is the leading cause of surgicalsite infections?a. methicillin-resistant Staphylococcus

aureusb. C. difficilec. vancomycin-resistant Enterococcusd. norovirus

a. methicillin-resistant S. aureus

Q2. When cleaning the OR betweencases or at the end of the day,it’s important to start bycleaning the floor, because it’sthe dirtiest and mostcontaminated surface in the room.a. true b. false

b. false

http://www.imagefirst.com

http://www.palmerohealth.com

to prevent and control outbreaks.4 MRSA, in fact, can live for months

on surfaces.5

It’s important to note that norovirus is the leading cause of outbreaks of

infection in general in the United States. This winter, norovirus was

frequently in the headlines for causing many outbreaks, giving it timely

significance for surgical facilities.6 A recent survey found that medical/

surgical units represented 25.7% of 386 outbreak investigations reported

by 289 hospitals over 24 months.6Unfortunately (although perhaps not

surprisingly), norovirus is “relatively resistant to the most common surface

disinfectants.”7

Non-critical items in the OR — those that come into contact only with

intact skin — carry little risk of infecting patients, but regulatory agencies

expect you to follow the

disinfectant label instructions.

However, William Rutala, MS,

MPh, PhD, prominent infection

prevention and control expert

and co-author of the CDC’s

“Sterilization and Disinfection

Guidelines,” writes that the

Environmental Protection Agency

would clear the CDC’s

environmental disinfection

guidelines only if it included a

disclaimer about deviating from

EPA-approved contact times.8 As such, there’s a disconnect between label

instructions and the evidence.

Dr. Rutala notes that adhering to a label’s prescribed contact time can

require 5 to 6 reapplications during each cleaning. He also says that

multiple studies demonstrate efficacy with a contact time of 1 minute,

and that thorough application of disinfectant is just as important as

contact time.8

“There are no data that demonstrate improved infection prevention by a

10-minute contact time versus a 1-minute contact time,” he writes, “and we

are not aware of an enforcement action against healthcare facilities for

‘off-label’ use of a surface disinfectant.”8

A 1-minute contact time is sufficient — but be sure to stress to your staff

that they must be thorough when cleaning.

MAY 2012 | OU T PAT I E N T SU RG E RY MAG A Z I N E | 1 9


Q4. The disinfectant you use to wipedown the Mayo stand betweenprocedures lists a contact timeof 10 minutes, but the solutiondries much faster than that. Doregulatory agencies expect youto reapply the disinfectantproduct to meet therecommended contact time?

a. yes b. no

a. yes

stay connected

with every issue ofOutpatient Surgery Magazine

online atwww.outpatientsurgery.net

http://www.outpatientsurgery.net

The use of a disinfectant with a

microfiber mop has demonstrated

95% microbial elimination.9

However, “a microfiber mop alone”

is incredibly close behind at 94%.9

Either option is a significant

improvement over a cotton-loop

mop alone (68%), although adding

disinfectant to the cotton-loop mop

raises microbial removal to 95%.

Yes, this matches the efficacy of microfiber plus disinfectant, but there is

further rationale for choosing the microfiber route. First, microfibers are thin

yet densely constructed and positively charged, so they attract dust and can

be wet with disinfectants while remaining absorbent. Second, the main

advantage of using a microfiber system is that the pads are single-use, so you

don’t risk transferring microorganisms to other rooms.

If you do stick with traditional cotton-loop mops, it’s important that you

decontaminate them regularly “to prevent surface contamination during

cleaning with subsequent transfer of organisms from these surfaces to

patients or equipment by the hands

of healthcare workers.” 9

Disinfectant wipes are a

wonderful tool for surface

cleaning, but if you don’t use them

properly, you may actually be

doing harm. Researchers at the

University of Cardiff (Wales) found

that antimicrobial-impregnated

wipes actually have the potential

to spread microorganisms and

cross-contaminate surfaces.10 They

determined that microorganisms

can live on wipes long enough to

make it to the next surface and

that, in order to minimize this

possibility, you should use each

wipe — and each side of each

wipe — only once, then dispose.10

And don’t forget to keep the container top closed during storage, so wipes

don’t dry out.


Q5. Studies show one of the following combinations is most efficacious for sanitizing floors. Which is it?a. microfiber mop aloneb. cotton-loop mop alonec. cotton-loop mop with disinfectantd. microfiber mop with disinfectant

d. microfiber mop with disinfectant

Q6. Which of the followingstatements is correct about theuse of disinfectant wipes?a. use each wipe only onceb. use each side of the wipe only oncec. neither d. both a and b

d. both a and b

Q7. Quaternary ammonium compoundimpregnated wipes effectivelydecontaminate keyboards andother high-touch computerequipment.a. true b. false

a. true

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http://www.apic.org/asccourse

According to the CDC, while quaternary ammonium compounds are

considered to have poor mycobactericidal activity, they (along with 70%

isopropyl alcohol, phenolics and chlorine-containing wipes) remove or

inactivate more than 95% of contaminants (including MRSA, vancomycin-

resistant Entercoccus and P. aeruginosa) from computer keyboards. Any

chemical used must be allowed to air-dry, which usually takes less than a

minute. Application doesn’t cause functional or cosmetic change, even after

300 applications.9

The correct order

is prions (such as

Creutzfeldt-Jakob

Disease), bacterial

spores (such as

C. difficile) fungi

(such as Candida),

vegetative bacteria

(such as

Staphylococcus

and Pseudomonas).9 There are others on the resistance spectrum, but prions

are the most difficult to kill. The good news? You can rest easy: Surfaces and

the environment don’t play a role in prion transmission.11

The CDC has received reports of contaminated chlorhexidine, quaternary

ammonium compounds, phenolics and pine oil.9 But these reports have

occurred within healthcare facilities, not at the point of production. The CDC

therefore recommends 3 control measures to ensure your EPA-registered

germicides will function as they are meant to: Follow label instructions for

dilution precisely — including instructions to not dilute; ensure that

uncontaminated water is used for diluting, that containers used for mixing are

properly

disinfected and

that the area used

for preparation is

clean; and store

germicidal

solutions

according to label

instructions (for

example, at the proper temperature, or in a cool, dry place).9

UV light as a method of surface disinfection originated in the food service

industry, and the benefits of its application have become apparent to

healthcare professionals in recent years. UV light offers “reliable biocidal

activity against a wide range

of pathogens,” the ability to

decontaminate surfaces and

equipment, no need to

disable the HVAC system or

to seal the room, no

potential for residue and

low acquisition costs.12

One study found that 30 minutes was an adequate exposure time to

inactivate gram-positive and gram-negative bacterial spores and fungi to the

order of 4 logs when UV light was used from a distance of 8 feet.13 (In fact,

even indirect UV light results in meaningful bacteria reduction.14) According

to Dr. Rutala, UV light kills 99.9% of vegetative bacteria within 15 minutes and

99.84% of C. difficile spores within 50 minutes.12

The use of UV light on surfaces is best left to terminal cleaning, particularly



Q8. Choose the microorganism set that correctly liststhe organisms from most-resistant to disinfectantsto least-resistant to disinfectants.a. prions, bacterial spores, fungi, vegetative bacteriab. vegetative bacteria, fungi, bacterial spores, prionsc. bacterial spores, prions, fungi, vegetative bacteriad. prions, fungi, bacterial spores, vegetative bacteria

a. prions, bacterial spores, fungi, vegetative bacteria

Q9. Which of the following increases the risk of yourdisinfectants becoming contaminated?a. dilutingb. using containers that haven’t been properly disinfectedc. improper storaged. all of the above

d. all of the above

Q10. When adding ultraviolet (UV) light for surface disinfection, you can skip the step of cleaning the room first because UV sterilizes all surfaces.a. true b. false

b. false

given the quick turnover times

necessary in surgical facilities. But

don’t discount the importance of

terminal cleaning, nor the effect UV

light can have on this task. Dr.

Rutala has noted that the “mean

proportion of surfaces disinfected at

terminal cleaning is less than 50%”

and that the lack of full effectiveness

of products, combined with the ease

of inserting human error in the

process, mean that most “terminal

cleaning methods [are] ineffective

… in eliminating epidemiologically

important pathogens.” 14

I can attest from personal

experience that for the 3 years we’ve used UV light for surface disinfection,

we’ve seen what we believe is good evidence for its effectiveness as an

additional tool for preventing healthcare-acquired infections. However,

although it’s true that UV light will reliably kill all organisms after the

appropriate dosage is reached, the question remains regarding how

adequately it disinfects shadowed areas. Because of this, thorough surface

cleaning per your usual protocols must always be done first. OSM

Ms. Pettis ([email protected]) is the director of infectionprevention at the University of Rochester (N.Y.) Medical Center.


S U R F A C E D I S I N F E C T I O N G L O V E S

WIPE OUT Even non-critical surfaces must becleaned according to disinfectant label instructions.

On the Web: For references, go to www.outpatientsurgery.net/resources/forms.

Brushing Up on

Surgical Gloves

A quiz about barrier protection’s front line of defense.Outpatient Surgery Magazine Staff

BEST BARRIER PROTECTION? Latex is superior as a barrierprotection in terms of leakage and perforation rates. Nitrile andneoprene are the best barrier protection in the non-latex materials.

Surgeons are fanatical about their gloves’ fit,

feel and comfort, but what about their role

in infection prevention? Gloves are on the

front lines of barrier protection, shielding hands

from exposure to blood, mucous membranes and

non-intact skin. They decrease the likelihood that

staff will transmit their own endogenous body

flora to patients. Not just any glove will do,

however. You must pick the right glove for the

right task. As you’ll see in this 8-question quiz,

there’s significant variability among various

glove designs.

It’s essential to examine

available data on different

materials to determine the

type of glove that will be

the most proficient in

meeting the barrier

protection needs of each of

your staff members in order

to prevent infections. “Both

the quality of the

manufacturing process and type of material influence (a glove’s) barrier

effectiveness,” says the CDC. “While there is little difference in the barrier

properties of unused intact gloves, studies have shown repeatedly that vinyl

gloves have higher failure rates than latex or nitrile gloves when tested under

simulated and actual clinical conditions. For this reason, either latex or

nitrile gloves are preferable for clinical procedures that require manual

dexterity or will involve more than brief patient contact.”

The ACS recommends the universal adoption of the double-glove (or

underglove) technique in order to

reduce body-fluid exposure caused

by glove tears and sharps injuries.

In addition, the ACS acknowledges

that double-gloving protects

patients from surgical wound

contamination by decreasing the

likelihood of sweat spilling from

surgeons’ gloved hands.

All gloving materials are


G L O V E S

��

Q1. According to the CDC, which glovematerial is preferable for clinicalprocedures that require manualdexterity or involve more than briefpatient contact?a. vinyl b. polyisoprene c. latexd. nitrile e. both c & d

e. both c & d

Q2. The American College ofSurgeons states that double-gloving reduces the risk ofexposure to patients’ blood byas much as ____% when theouter glove is punctured. a. 17% b. 47% c. 69% d. 87%

d. 87%

http://www.ansellhealthcare.com

benchmarked to latex, which is found

to be superior barrier protection in

research studies about leakage and

perforation rates. Nitrile and neoprene

offer the best barrier protection in

non-latex gloving materials.

“Although non-latex surgical gloves

provide basic barrier protection, the

rate at which they break or tear while performing routine surgery makes

them inferior to latex surgical gloves. … The data clearly supports high-

quality surgical latex gloves as the glove material of choice and the use of

non-latex gloves for patients and healthcare workers who are allergic to

latex,” says Denise M. Korniewicz, PhD, RN, FAAN, dean of the University

of North Dakota College of Nursing.

The CDC states, “Wearing gloves does not replace the need for

handwashing, because gloves may have small, inapparent defects or may be

torn during use, and hands can become contaminated during the removal of

gloves.” Handwashing is always the first line of defense against infections.

“Moisturizing is beneficial for skin health and reducing microbial

dispersion from skin, regardless of

whether the product used contains an

antibacterial ingredient,” says Elaine

Larson in “Hygiene of the Skin: When Is

Clean Too Clean?” in the March-April

2001 issue of the journal Emerging

Infectious Disease.

Certain chemicals, however, can

diminish the protectiveness of your

gloves. Any petroleum dressing or mineral oil can seriously weaken their

integrity in a very short time. The National Institute for Occupational Safety

and Health’s 1997 alert, “Preventing Allergic Reactions to Natural Rubber

Latex in the Workplace,” offers this advice to reduce the chance of adverse

reactions when wearing latex gloves:

• Don’t use oil-based hand

creams or lotions (which can

cause glove deterioration) unless

they’ve been shown to reduce

latex-related problems and

maintain glove barrier

protection.

• Avoid hand creams containing

mineral oil, petroleum, lanolin

and other oils (palm oil, for

example). All these creams

contain hydrocarbons, which


G L O V E S

Q3. What is the “gold standard”glove material for protectionfrom infection? a. polyisoprene b. latex c. nitrile d. vinyl

b. latex

Q4. If you don’t have time towash your hands, make sureyou wear gloves, which canreplace handwashingrequirements. a. true b. false

b. false

Q

EXTRA PROTECTION Double-gloving reduces the risk ofexposure to patients’ blood by as much as 87% when theouter glove is punctured.

5. What do hand lotions and latex gloves have to do with infectioncontrol?a. the use of hand lotion can decrease microbial dispersionb. it’s important to use non-petroleum lotion when wearing latex gloves sothat the barrier protection isn’t compromised

c. there’s no correlation between hand lotion, latex gloves and barrierprotection

d. both a & b e. none of the above

d. both a & b

cause deterioration of the physical and barrier properties of natural rubber

latex. Instead, use moisturizers that are water-based or contain sodium lauryl

sulfate as the active ingredient. When applied before donning an occlusive

glove, this type of lotion doesn’t compromise latex properties, and the

positive effects include an increased hydration level and water-barrier

function of the skin.

It’s always important to inspect the integrity of your gloves prior to donning

them. Note any signs of tampering on glove packages and do not use sterile

gloves if the package has been opened or damaged in any way. When you

open the package and examine the gloves, look for any signs of stains,

watermarks, discoloration, white lines, rips, holes or tears at the stress points

or the folds. If you find any of these problems, discard the gloves and get

another pair.

Wearing gloves of 2 different colors significantly enhances the recognition

of a perforation in your top glove when double-gloving. “More glove

perforations are detected when using a colored underglove indicator system

when compared to 2 pairs of standard latex gloves,” says AORN.

Make sure that you remove

gloves promptly after use,

before touching non-

contaminated items and

environmental surfaces, and

before treating another patient.

It is important to turn both

gloves inside-out to prevent

infectious materials from

touching anything. Drop used

gloves directly into an

appropriate container. Never

flick, snap or toss your gloves upon removal and always wash your hands

after removing your gloves to limit cross-contamination risks. OSM

E-mail [email protected].


G L O V E S

Q6. What are the factors to consider when inspecting gloves beforedonning to ensure optimal protection? a. note any signs of glove stains, watermarks, discoloration or white linesb. look for rips, holes or tears at stress points such as the foldsc. glove shipping and storage integrity, looking for already opened or damagedpackages.

d. all of the above

d. all of the above

Q7. What’s a good way to increase thelikelihood of noticing a gloveperforation when double-gloving?a. only wear the most expensive gloveavailable

b. wear a non-latex glove on the bottomand a latex glove on top

c. wear 2 colors of glovesd. wear the same color of gloves

c. wear 2 colors of gloves

Q8. What is the appropriate way to remove and dispose of gloves? a. remove gloves promptly after useb. when you remove gloves, ensure that they are inside-outc. flick, snap and toss your gloves into the garbaged. a & be. all of the above

d. a & b

Each of the 3 basic methods for fluid waste

management — dumping, solidifying and

closed direct-to-drain disposal — has its own

benefits and risks to consider. Take this short quiz

to help determine which approach is the best fit for

your facility.

F L U I D W A S T E M A N A G E M E N T

The choices boil down to employee safety, cost and yourclinical needs. Mary Wilson, RN, BSN, CNOR | Morgantown, W.Va.

How Do You Dispose of Fluid Waste?

WASTE NOT Using solidifier with anantimicrobial agent allows solidified fluid tobe deposited in the regular waste streamrather than in infectious red bag waste.

West Virginia University Hospital

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http://www.dornoch.com

Dumping fluid waste down

the hopper is the simplest and

most inexpensive option.

However, it does carry the

highest risk of employee

exposure due to the splashing

and aerosolization of

infectious waste. Dumping is

more viable during

procedures that produce low

volumes of fluid waste. Keep

in mind that your state and

local laws might prohibit the

dumping of infectious

medical waste into the

sanitary sewer system.

Solidifying waste is the

most efficient option because

canisters don’t need to be

transported for treatment. A

solidifying agent is added to

canisters while they’re still in

the OR; canisters filled with

the gelled fluid are then

disposed of in red bags, eliminating the need for a hopper dedicated to fluid

waste disposal. The risk of splashing and aerosolization is decreased, but not

eliminated.

Adding the weight of solidified fluid to your red bags, however, significantly

drives up regulated waste disposal costs. In addition, disposable canisters

utilized for this process are not always sturdy enough to sustain rough

treatment during the transport and disposal process, and may break open.

The solidifying agent is supplied in single-use packets, requiring an adequate

inventory of multiple-sized packs on hand at all times (packets are sold in a

variety of sizes to match the

amount of solidifier to the

amount of fluid in

containers).

Closed direct-to-drain

systems are the easiest way

to deal with large volumes

of fluid while limiting

possibilities of staff

exposure to open canisters.

One option of direct-to-drain

disposal automatically

drains fluid from the sterile

field into a mobile suction

unit. Later, the mobile unit is

wheeled to drainage ports

for emptying. Another

option involves attaching

full canisters to a wall-

mounted docking station,

which automatically drains

the fluid. Both systems are

designed to easily handle



DOWN THE DRAIN Dumpingfluid in the hopper is a low-costand time-saving option ideal forprocedures that produce lowvolumes of waste.

Q1. The primary way to develop asuccessful fluid waste disposalprogram is to _______.a. find the least expensive optionb. use the most automated system availablec. base your decision on costs, benefits andpracticality

d. base your decision on staff and surgeonpreferences for each procedure

c. base your decision on costs, benefits andpracticality

http://www.bemishealthcare.com

the large volumes of fluid

waste generated during

procedures such as

arthroscopy.

You’d be hard pressed

to find an efficiency- and

safety-minded

administrator who

wouldn’t want a closed

fluid management system

in her ORs. They are,

however, the most

expensive option and perhaps even require facility renovations in order to

add docking stations for system draining and cleaning. Some systems use a

disposable canister, which must be included in the cost evaluation. Canisters

that are disinfected and reused will have to be replaced when they are

damaged. The lifespan of closed systems vary with use and handling.

Keep in mind that the

initial capital investment of

direct-to-drain systems can

be recouped thanks to

improved fluid capture

efficiencies, faster room

clean-up, avoidance of lost

manpower hours resulting

from exposures to infectious

material or injuries from

lugging filled canisters

around the OR and a potential reduction in red bag waste disposal costs if

you currently solidify waste. You might even be able to secure a unit without

a capital outlay by agreeing to pay for the needed disposables over several

years. Automated closed systems may also have additional features such as

increased fluid capacity, multiple suction lines, digital fluid measurement or

integrated smoke evacuators that add to the device’s overall value.

The risk of employee

exposure to infectious

materials is a major

concern when handling

fluid waste. Regardless

of the system you opt

for, it’s important that

you take steps to

minimize this risk as

much as possible. For

example, don’t overfill

canisters if you decide to dump fluid waste in the hopper. Doing so increases

the risk of leaks and breaks. If you use a solidifier, overfilling canisters might

not leave enough room to safety add the agent or for it to work properly.

Always wear proper personal protective equipment when handling fluid

waste, including gloves, a mask and eye protection to keep yourself safe from

splashes or spills. As an extra safety precaution, add a splash shield to the

sink or hopper used for dumping.

In order for any system to be as effective as possible, staff must have a clear

understanding of the specific processes that ensure maximum safety and

efficiency. Always follow manufacturers’ guidelines when using solidifiers and

closed systems. Solidifiers have instructions for the amount of fluid waste



HOOKED UP A closed systemautomatically drains fluid into asewer system, easily handleslarge volumes of waste andprotects staff from exposure toinfectious material.

Q2. Potential benefits of mobile direct-to-drain fluid management systemsinclude all of the following except______.a. smoke evacuation capabilitiesb. low costc. multiple suction linesd. efficient room turnovers

b. low cost

Q3. The most important safety factors to consider when choosing a fluid wastemanagement system are _______.a. local and state regulationsb. risk of employee exposures to infectious wastec. staff education requirementsd. all of the above

b. risk of employee exposures to infectious waste

that can be solidified with each packet; the liquids won’t adequately solidify if

an improper amount is used. Closed systems have a process that must be

followed when emptying and cleaning the device in order to make it safe and

ready for the next procedure.

Compliance with state and local regulations regarding the disposal of

infectious fluid waste is also an important component when deciding on which

method is most appropriate for your facility. Be aware that there may be

licensing regulations related to the volume of medical waste that can be

generated from your facility.

Product evaluations should

involve judging all aspects of

the method you’re considering,

including staff and patient

safety during use, the risk of

exposure to splashing and

aerosolization of infectious

waste, potential exposure to solidifying chemicals and the associated risks,

and possibilities of system errors or malfunctions. When evaluating efficiency,

look at time requirements for following correct disposal procedures as well

as ease of set-up, preparation and use. Also consider staff training needs and

supply ordering and stocking requirements, including the cost of disposable

canisters or filters needed for mobile direct-to-drain systems.

Review your existing fluid management product contracts to ensure you

don’t inadvertently violate purchasing volume requirements when changing to

a new product and its corresponding disposal supplies. Such contract

violations can be costly if they cause an increase in the price of items due to a

change in the contract’s tier pricing.

Not necessarily. The amount of time required to complete fluid waste

disposal varies significantly based on

which method is selected and the

type of cases you host. A solidifier is

quick and efficient for most basic

procedures, but is cumbersome for

cases involving large amounts of

fluid. On the other hand, the addition of a closed system during large-volume

cases allows for the collection of all fluid without changing and solidifying

multiple canisters, thereby potentially increasing surgical efficiencies and

eliminating a messy and time-consuming burden for your surgical team.

Involve your frontline staff in the clinical evaluation process to get a true

measure of the overall impact and comparison to your current fluid collection

process. Will the new way of doing things have a positive or negative effect

on the quality of the patient care you provide? What are the advantages and

disadvantages of utilizing the product and process? For example, all suction

creates noise in the OR, and there is evidence that high noise levels increase

the risk of errors, so be sure to assess how loud the suction is on the

automated closed-systems you’re considering, which can vary dramatically. In

addition, a closed system’s suction efficiency may differ from that of previous

suction systems your staff has used.

There are several considerations that significantly influence your staff’s

acceptance of fluid waste disposal practices. Focusing on OR efficiency and

room turnover times can have a huge impact on your staff’s satisfaction with

the option you choose, which greatly impacts its use and ultimate benefit to

your facility. OSM

Ms. Wilson ([email protected]) is clinical preceptor for the Ruby DaySurgery Center at West Virginia University Hospitals in Morgantown, W.Va.



Q4. Your analysis of new fluidmanagement options should includean assessment of disposable costs.a. true b. false

a. true

Q5. Direct-to-drain disposal systems are the most efficientfluid management option.a. true b. false

b. false

reducing infectious organisms) are the most critical steps in preventing the

transmission of bacterial and viral contaminants. Instruments cannot be

disinfected if they are not clean.

Meticulous manual cleaning and decontamination must precede high-level

disinfection, with special attention given to complex medical devices with

multiple pieces, crevices, joints, lumens, ports and channels — such as

endoscopes.

Once a scope is removed from the patient’s

body at the procedure’s conclusion, wipe

down the exterior surface with a wet cloth

soaked in detergent solution, and suction the

solution through the scope’s suction channel,

alternating with air. This cursory, point-of-use

pre-cleaning is intended to clear gross

contamination and serves as a once-over

before the rigors of the sterile processing

room. Some manufacturers of automatic endoscope reprocessors claim that

their products can eliminate the labor of by-hand brushing before the high-

level disinfection they deliver, but most reprocessing standards still mandate

pre-cleaning.

Biofilm, a complex community of microorganisms embedded in a matrix of

extracellular material, can form on any surface that comes in contact with

fluid, including all internal and external surfaces of endoscopes, reusable

accessory equipment and even automatic endoscope reprocessors

themselves. As bacteria in the biofilm are altered and much more resistant to

chemical inactivation, mechanical cleaning may be necessary in order to

effectively remove established biofilms.


E N D O S C O P E R E P R O C E S S I N G

High-Level DisinfectionSTAY ON TOP OF

Is your endoscope reprocessing compliant with standards?

Carol Imes, RN, MPA, CNOR | Mentor, Ohio

SCRUB TECH Immersing a scope indisinfectant solution doesn’t preclude

the need for manual cleaning.

Q2. The chemical action ofhigh-level disinfectionsolution alone willremove biofilm from allinstrument surfaces.a. true b. false

b. false

Test your knowledge of high-level disinfection’s protocols and

processes with the following questions, based on AORN’s

“Perioperative Standards and Recommended Practices” and the

Society of Gastroenterology Nurses and Associates’ “Guidelines for Use of

High-Level Disinfectants and

Sterilants for Reprocessing

Flexible Gastrointestinal

Endoscopes.”

Cleaning (removing visible

soil and foreign matter) and

decontamination (removing or

Q1. Wiping a scope down with tap waterafter use is sufficient preparation forhigh-level disinfection.a. true b. false

b. false

Flexible endoscopes should be leak

tested after every use. Conduct leak

testing twice. First, attach the leak

tester and pressurize the scope. Then,

completely submerge the scope (and

pressurized insertion tube) into a basin

of water. If it doesn’t hold the air — that

is, if bubbles are visible — the scope

has failed the test. In the event of a leak

testing failure, follow the

manufacturer’s directions before

sending it out for repair.

Followmanufacturers’ reprocessing

instructions to the letter. Best practice is

to use the checklists that manufacturers

provide to ensure all steps are completed.

Regular in-services and annual competencies will help you maintain proper

cleaning protocols. Since CMS tends to look very closely at high-level

disinfection and sterilization processes during site visits, it’s critical for every

center to review their policies and practices, and make sure they are up to date.

Dilution, degradation, residual

debris and oxygen exposure can all

cause the solution to fall below its

minimum effective concentration. If it

does, it must be discarded, even if it

hasn’t passed its designated

expiration date.

A reservoir of high-level



��

Q4. Your analysis of new fluidmanagement options shouldinclude an assessment ofdisposable costs.a. true b. false

a. true

HANG LOOSE The best way to prevent scopedamage and contamination is to store themvertically and separately.

Q3. Leak testing is a mandatorystep in flexible endoscopereprocessing.a. true b. false

a. true

http://www.olympusamerica.com

disinfection solution has a usable lifespan of about 2 weeks. High-volume

endo centers may see the concentration weaken sooner than that. After you

reprocess more than a few scopes in a reservoir of solution, the solution is

not essentially the same as you’d reprocessed the first in. Monitor your

solution’s potency by checking the product’s expiration date, and by dipping

a test strip specifically designed for the solution and its active ingredient’s

minimum effective

concentration into the solution

you’re using, before every use.

Observe the test strip’s color

change at the elapsed time

directed by the manufacturer.

If the test strip indicates the

solution has fallen below the

minimum effective

concentration, its potency

cannot be guaranteed.

All high-level disinfectants — whose active chemical agents must be

cleared by the FDA for high-level disinfection — have individually specified

conditions for effective use. For instance, glutaraldehyde, an older option,

takes 20 minutes of contact at room temperature. Ortho-phthalaldehyde

(OPA) on the other hand, takes 12 minutes at 20ºC (room temperature) or

5 minutes when warmed to 25ºC by an automatic reprocessor.

Since reprocessing volume can make a big difference in your case flow

efficiency, and since manual cleaning has no corners to cut, a solution’s

built-in cycle time is often a major factor in your decision on which one to

purchase and use. Other factors include cost per cycle, the cost and usable

life of the test strips, the solution’s smell (glutaraldehyde is known for its



��

Q5. Chemical high-level disinfection isachieved by _____.a. always soaking an item for 20 minutesb. soaking an item at room temperaturec. immersion for a specific contact time,temperature and concentration

d. a & b

c. Immersion for a specific contact time,temperature and concentration

http://www.micro-sci.com

harsh scent and potential respiratory

irritation) and the ease and safety of

its use (OPA is ready to use with no

mixing required, and also doesn’t

demand ventilation to mitigate

exposure hazards to employees).

When handling chemical

disinfectants, you must wear gloves

appropriate for the specific

disinfectant solution at hand. If using

glutaraldehyde, 100% nitrile or 100%

butyl rubber gloves must be worn.

Polyvinyl chloride gloves are not

acceptable, as they absorb glutaraldehyde. When handling all other solutions,

gloves composed of less than 100% nitrile or butyl rubber can be worn.

Chemical disinfectants can irritate or stain skin and mucous membranes,

cause allergic reactions and may pose health risks, so any employee working

with them must wear protective apparel to shield themselves against

exposure. In addition to gloves, this apparel includes impermeable gowns,

jumpsuits or aprons; surgical masks;

and goggles or face shields. Post a

solution’s instructions for use so staff

will know current safety

recommendations.

After removing a scope from the

disinfectant solution, it must be

thoroughly, vigorously and

aggressively rinsed with sterile

water, in accordance with the manufacturer’s instructions. Rinsing removes

toxic and irritating residues that can cause tissue damage or staining, and

the sterile water sidesteps potential recontamination from the contents of

tap water.

After the water rinse, flush the scope with 70% to 90% isopropyl alcohol

(unless contraindicated by the manufacturer’s directions) in order to clear all

the channels of residual water, which could breed contamination. Forced-air

drying before storage will also reduce the possibility of recontamination by

waterborne microorganisms.

Endoscopes must

never touch the ground

or each other to avoid

cross-contamination.

They should be hung

vertically in a closed

cabinet to prevent

coiling or kinking, to

allow any remaining

moisture to drain from the scope and to decrease the possibility of

microbial growth in the scope. Open all valves and accessories to facilitate

drying and eliminate an environment conducive to bacterial colonization.

And when they are next used, transport them to the procedure room in a

clean, covered tray. OSM

Ms. Imes ([email protected]) is the director of the Mentor SurgeryCenter in Mentor, Ohio.



Q6. When handling chemicaldisinfectants, central sterilepersonnel must wear all of thefollowing protective apparel except _____.a. latex gloves b. protective eyewear c. masksd. moisture-repellant skin protection e. shoe covers

a. latex gloves

Q7. After the disinfectant solution’scontact time requirements havebeen met, the scope is readyfor use after it is removed fromthe soak pan, rinsed and dried.a. true b. false

a. true

Q8. When flexible endoscopes are hungvertically in a closed cabinet, they cantouch each other, but should not touch thefloor.a. true b. false

b. false

Simple cleaning and removal of gross soil is not enough to render items safe

for handling by reprocessing staff during inspection and assembly, or to

effectively decontaminate items that must move from a soiled utility or

decontamination area to a clean assembly or work area.

After thoroughly pre-

cleaning devices to remove

soil and debris, a reduction in

bioburden is the critical next

step in the disinfection

process. It is not possible to

clean and disinfect without

completing each step

separately and properly. Pay

close attention to device and

instrument disinfection labels

to help reinforce this concept.

To achieve intended results, keep instrument and device surfaces wet for the

prescribed disinfection period noted on the product label.

This can be a challenge, but ensuring proper contact time is essential.

Consult a qualified infection

prevention specialist when

selecting the disinfection

solutions that are appropriate

for the instruments and

devices you use.

Follow manufacturers’

instructions to the letter

when cleaning and processing


D E C O N T A M I N A T I O N

DecontaminationThe Down and Dirty on

See if you’re using the right equipment and procedures when getting instruments ready for sterilizing. Steven Johnson | Tacoma, Wash.

MultiCare Health System

S urgical instruments that aren’t clean

can’t be sterilized, making effective

decontamination the first, and

perhaps most critical, step of the

sterilization process. Decontamination

requires the right equipment, appropriate

safety measures and a solid knowledge of

acceptable washing methods. Test your

acumen with the questions below, and see

how your protocols measure up.

Q1. Reprocessing staff cansafely handle devicesonce cleaning andremoval of gross soil isaccomplished.a. true b. false

b. false

Q2. Ophthalmology instruments shouldreceive careful attention duringcleaning due to _________.a. their high replacement valueb. their delicate naturec. the possibility of patients developingTASS

d. all of the above

c. the possibility of patients developing TASS

TO THE LETTER Clean and processophthalmic instruments according tomanufacturer’s instructions to protectpatients from TASS.

MultiCare Health System

all instruments used in eye

surgery in order to minimize

the possibility of patients

developing Toxic Anterior

Segment Syndrome (TASS)

post-operatively. Improperly

processing instruments, such

as using non-recommended

detergents, can cause TASS.

Be particularly wary of using

enzymatic detergents and

inadequate rinsing. Using de-

ionized or distilled water in the final rinse process is highly effective in

reducing TASS risks.

Decontamination requires the elements of mechanical action to produce

agitation of cleaning solution and water, the presence of detergents and

cleaning chemicals, and a method to achieve minimum low-level disinfection

to render items safe for staff handling, whether through thermal or

microbicidal processes. Perform periodic efficacy testing to help identify

mechanical or chemical deficiencies in the decontamination process. Proper

instrument cleaning is also essential to the sterilization process.

Flush cannulated or lumened instruments with a sterile, water-filled

syringe before placing them in an ultrasonic cleaner, which should be run

prior to manual or automated decontamination. Ultrasonic cleaners send

high-frequency sound waves through the tap water and solution that

instruments are submerged in, which creates vibrating bubbles and

ultimately a vacuum effect that pulls debris from hard-to-reach areas.

Brushing the inside walls of lumened devices — orthopedic drill bits and

suction devices, for

example — to help

dislodge and remove

debris is critical.

Brushes must be

passed completely

through the lumened

device in order for

debris to be

effectively removed.

Using pipe cleaners to check lumens for proper cleanliness during the

assembly and inspection process is good practice. (Just be sure to flush

out with compressed air any lingering pipe cleaner fibers.)

Pre-soaking soiled instruments in an

enzymatic cleaner in the OR during room

turnovers speeds the decontamination

process and improves its results. Once

instruments have been transported to the

decontamination area, and before they’re

put through an automated washing cycle,

pre-cleaning should include manual brushing and inspection of difficult-to-

clean items, along with disassembly if indicated. Don’t overload automated

washers. Properly set up and configure washer loads to ensure maximum

instrument surface exposure for cleaning. Equipment maintenance and

periodic efficacy testing is vital to ensure proper machine function and

overall effectiveness of the decontamination process.



Q3. Effective instrument decontamination should include ________.a. mechanical action producing agitation ofcleaning solution and water

b. the presence of detergent or cleaningsolutions during the wash cycle orprocess

c. a method of achieving disinfectiond. a & b e. all of the above

e. all of the above

Q4. Effective decontamination of cannulated andlumened items or devices should begin with______.a. manual passage of an adequately sized brush toclean inner surfaces

b. ultrasonic cleaning c. flushing of the lumensd. mechanical cleaning

c. flushing of the lumens

Q5. The decontaminationprocess begins in the OR.a. true b. false

a. true

A comprehensive

safety program should

include the proper use

of PPE (including

protective gown, shoe

covers, proper length

decontamination

gloves, mask, eye

protection and face

shield) while handling

soiled items. Disposal

of sharps (needles,

sutures and knife blades, for example) should occur at the point of use (in

the OR) by staff familiar with the case and the instruments used in order to

avoid potential injury to the reprocessing staff. Transport contaminated

instruments from the OR to the decontamination area in a closed container.

Keep them wet during transport using a soaked towel or a spray or gel

product designed for the task. Do not transport them in containers filled with

water and enzymatic cleaner so as to avoid spillage. Use baskets or strainers

to isolate or identify potential reusable sharp injury sources such as scissors

and towel clips. Never reach gloved hands

into sinks containing submerged reusable

sharps, as that careless practice

significantly increases injury risks.

Effective instrument decontamination is

vital in preventing costly and debilitating

surgical site infections. A facility that

becomes linked to frequent or multiple

discoveries of contaminated instruments or

equipment will quickly suffer from damaged or

adversely affected relationships with patients and

surgeons alike. You can imagine a surgeon’s

frustration if he’d have to inform a patient that a

wound had to be irrigated or treated with antibiotics

because a dirty instrument was discovered during

the procedure. In addition, removing instrument

trays and supplies when dirty or contaminated

instruments are discovered — and resetting the case

— can be very costly for facilities.



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PRE-WASHED Instruments must beinspected and pre-cleaned before goingthrough an automated washer.

Q6. Employee safety during the decontaminationprocess can be maintained by practices andpolicies that include the following, except:a. mandated use of proper PPEb. removal of disposable sharps during sorting ofinstrument trays in the decontamination area

c. transport of instruments from the OR in water andenzymatic soaking solution

d. b & c

d. b & c

Q7. Improper decontamination can affectmultiple aspects of a surgery’s center’sfunction by __________.a. increasing patient risk from surgical siteinfections due to improperly cleaned instruments and equipment

b. fostering poor surgeon relations and creatingtrust issues

c. increasing procedure costs when dirtyinstruments are discovered

d. all of the above

d. all of the above

http://www.optisurgical.com

While there currently is no

mandated regulatory requirement to

monitor the various steps of the

decontamination process,

professional organization standards

and recommended practices now

address this issue with the

development, testing and refinement

of various automated washer and disinfector monitoring products. Adopting a

system that includes monitoring outcomes — depending on products selected

— of the decontamination process is considered best practice. This can

include simple mechanical checking of washer arms and baskets, assessing

staff for proper loading procedures and monitoring gross soil removal

through the use of various commercially available products. Record and

maintain the results of any monitoring efforts, along with any action taken for

unsatisfactory results. Many facilities are just beginning to implement

procedures to monitor decontamination processes, so stay ahead of the curve

for this important practice.

Along with routine and preventative maintenance of decontamination

equipment, provide staff with

adequate product resources to

achieve optimal results and

outcomes. Keep up to date on the

latest in cleaning and enzymatic

solutions, detergents and

disinfection processes in order to

support your staff’s decontamination

efforts and ensure consistently safe

results. Try to avoid frequent product changes that may create confusion

among users. Strength dilutions that differ greatly can be a problematic issue

if you suddenly discover staffers are not properly mixing detergents or

disinfection solutions. Be sure that ample supplies of cleaning rags or towels

are available so your staff always uses clean rags and avoid cross-

contamination risks from using soiled material multiple times. Dispose of

cleaning brushes when they become excessively worn or damaged. Stock

brushes in all lumen diameters and lengths to ensure proper cleaning. OSM

Mr. Johnson ([email protected]) is central supply service director atMulticare Health System in Tacoma, Wash.



Q8. Monitoring the decontaminationprocess using chemical,mechanical and biologicalproducts is required.a. true b. false

b. false

Q9. Critical elements of a safe andeffective decontaminationprogram include monitoring andevaluating products used bystaff.a. true b. false

a. true

Apatient’s skin is his primary protection against infection, but a

surgical incision can literally open him up to the threat of microbial

contamination. That’s why compliance with the practices and

processes of surgical site preparation are critical to your infection control

efforts. How vigilant is your staff against SSIs? Take the following quiz and

find out.

According to SSI

prevention guidelines from

the Joint Commission and

the Surgical Care

Improvement Project,

patients are to receive most


S I T E P R E P P I N G

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Q1. Most prophylactic antibiotics mustbe administered to surgical patientsat least 2 hours before incision time.a. true b. false

b. false

Rhonda Knight, RN-IP, BSN, and Melanie Lewis, RN, BSN

Madison, Ala.

Avoid SSIs withthis review ofpre-incisionbasics.

PATHWAYS TOPREPPING Yourchoice of antisepticskin prep dependson the surgical site,the patient’stolerance for theproduct and itseffectiveness andpersistence.

Rochester General Hospital Prep the

Site Right

http://www.carefusion.com/chloraprep

antibiotics within 1 hour before incision in order to

ensure that an adequate concentration of the drugs

reach the tissue at the surgical site during and

immediately after the procedure.

The choice of antibiotic to be administered, however,

depends on the procedure that’s being performed as

well as patient allergies, and this choice in turn

influences the timing of some doses. While most

antibiotics are to be given within an hour of surgery,

vancomycin and fluoroquinolones require 2 hours and

observation for any adverse reactions.

Some surgical facilities have found that documentation

of the drugs’ administration time, routine reviews of

these logs and including antibiotic delivery as an item to

be confirmed during pre-surgical time outs have helped

to keep compliance up and SSIs down.

Standard precautions — the battery of infection

prevention measures that include hand hygiene compliance, the wearing of personal protective

equipment, needlestick and sharps safety efforts and safe injection practices, among others —

should always be carried out whenever the skin is breached or there is the possibility of

exposure to bodily fluids or

non-intact skin.

SCIP recommends leaving

hair in place when it is

possible to do so. But when it

presents the potential of

interfering with an incision

site or laparoscopic port site,



2. The full complement ofstandard site preparationprecautions are notnecessary when startingan IV for surgery.a. true b. false

b. false

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CLEAN CUT If hair removal is absolutelynecessary, perioperative guidelinesoverwhelmingly recommend the use ofclippers to do the job.

Q3. Which is the safest method for pre-op hair removal?a. razor with soap and waterb. clippers with which you’ve trained staff in the proper usec. depilatory cream on the surgical aread. instructing the patient to shave the area before arrival

b. clippers with which you’ve trained staff in the proper use

http://www.opmarks.com

http://www.viscot.com

professional organizations from AORN to the CDC advise the use of clippers.

While clippers offer a close, safe shave, they can cause micro-abrasions if

used improperly, so make sure to include training in their use when in-

servicing and orienting staff on skin prep practices.

The scraping action of razors prior to surgery increases the risk of wound

infections due to the micro-abrasions they leave behind for bacteria residing

on the skin to enter. While depilatory creams may seem risk-free, they may

end up causing skin irritation. Also, make sure to specifically instruct your

patients not to shave their sites themselves, but to allow you to do it, if it is

necessary.

“No studies have

adequately assessed the

comparative effects of

these preoperative skin

antiseptics on SSI risk in

well-controlled, operation-

specific studies,” write the authors of the CDC’s guideline on preventing SSIs.

You’ve got a range of choices in terms of antiseptic skin preps, each with a

broad spectrum of activity and unique limitations. Alcohol kills microbes

quickly but its effect doesn’t last long, plus it can’t be used on mucous

membranes and it’s a flammable substance. Iodine’s action is similarly fast

with some residual action, and it can be used on mucous membranes and

around the eye, but it can be inactivated through contact with blood.

Chlorhexidine gluconate (CHG) has a long-lasting antimicrobial effect, but it

can cause eye and ear damage, and must be used with caution around

mucous membranes, which it may irritate.

While CHG solutions have received high marks in recent studies comparing

their effects to those of povidone-iodine, some observers have questioned

whether the alcohol that the CHG

formulations included didn’t give it

an uneven advantage. In the final

analysis, your choice of skin prep

should be driven by the location of

the surgical site, the patient’s

tolerance for the agent, the product’s effectiveness and persistence and, once

those factors have been satisfied, cost and case efficiency.

Surgical guidelines have traditionally recommended that antiseptic agents

be applied in a circular motion, beginning at the incision site and spiraling

outward. But this traditional method was developed when painting povidone-

iodine with sponges or gauze was the predominant prep. Many newer

formulations cleanse more effectively when applied with linear or back-and-

forth strokes and friction to work the agents into the skin.

What has not changed in prepping recommendations, however, is the need

to start at the least contaminated area and move to the most contaminated

area. This will keep the staffer prepping the site from spreading microbes into

cleaner areas. Similarly important is to avoid touching prepped areas with

sponges or applicators that have already moved to more contaminated areas.

New supplies only should be used if more prepping is required.

Enough prep should be applied to

cover the surgical site and to prepare

for the possibility that the incision

will be extended, another incision will

be needed or the drape’s fenestration

shifts. Keep in mind, though, that all

of the prepping agent must dry

completely before the surgery begins.



Q5. Skin preps don’t always have tobe applied in a circular pattern.a. true b. false

a. true

Q4. Clinical studies have conclusively proventhat 1 type of antiseptic skin preppingagent is superior to others for all cases.a. true b. false

b. false

Q6. When prepping a patient, it’sadvisable to use as little of thesolution as is necessary toachieve optimal antisepsis.a. true b. false

a. true

The contact time is necessary for the

agent to take full effect, but the

evaporation of alcohol is necessary to

mitigate the agent’s flammability.

Too much prep can lead to dripping

and pooling beneath patients and

even between devices such as

pneumatic cuffs and their skin. Besides the undetected fire hazard this may

present, the prolonged exposure can also result in skin irritation or

chemical burns.

In theory, the practice of draping is intended to create an aseptic barrier

that maintains the sterile field and protects a patient’s surgical wound from

contamination by the bacteria residing elsewhere on their skin. But the

CDC, addressing the existing evidence-based literature on the subject,

admits that there is little conclusive proof to show that drapes reduce the

incidence of SSIs. “The wide variation in the products and study designs

make interpretation of the literature difficult,” the agency notes in its

guidelines.

While there is no guarantee

that drapes shield the surgical

site from the threat of SSIs,

when used properly they do

no harm, and are still

recommended by the CDC

and AORN.

In the event that any non-

sterile equipment comes into

contact with any part of the

sterile field, the draping process must

be restarted.

Drapes should be opened and

applied by a surgical staffer

wearing sterile gloves. They should

be handled and placed cautiously to

avoid inadvertently contaminating

the gloved hands or the drapes.

They should also be handled as

little as possible, so as not to stir

up the operating room’s air, lint or

bits of wood pulp from the drapes,

and the airborne bacteria for which

the particles can be vectors. Once

placed, the drapes should not be

moved in order to avoid compromising their sterility. OSM

Ms. Knight ([email protected]) and Ms. Lewis([email protected]) are perioperative nurses at the MadisonSurgery Center in Madison, Ala.



Q7. There is clinical proof thatsurgical drapes are effective in preventing SSIs.a. true b. false

b. false

Q8. Which of the followingsituations during drapingnecessitates that the processbe redone?a. when the drape looks wrinkledb. when non-sterile equipment isplaced in the field

c. when a surgical staffer touchesthe drape with sterile gloves

d. when the drape touches the skinprep product

b. when non-sterile equipment isplaced in the field

WASH AND DRY No matter which prep you use, makesure it is completely dry before surgery begins, foreffectiveness and safety.

Rochester General Hospital

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