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Infection Prevention Update

Infection Prevention Update

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Infection Prevention Update

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  1. Infection Prevention Update Marie Kassai, RN, MPH, CIC, FAPIC Surgery Center Coalition October 4, 2018

  2. Miscellaneous Issues • If One Room has no generator • Battery is okay but you must follow the directions for testing the battery and for ensuring proper functioning • If you have a generator, must follow the State rules This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-NC-ND

  3. Infection Prevention Issues • Infection Prevention Plan – being asked for by State and by Accrediting agencies • Be clear in your Infection Prevention Plan what resources you are using for your policies: • If you are STATE licensed • CDC • ST79 2017 - AAMI DOCUMENT – Sterilization Bible • If you are CMS certified, you must also follow CMS Rules – Infection Prevention Document for Compliance - AORN • Hand Hygiene – CDC – Know what source for your Hand Hygiene Posters and Guidelines – CDC or WHO

  4. More Infection Prevention • Hand Hygiene – Sorry to bring this up again • Have specific policy – outline your requirement for nails and other issues like jewelry • AORN has a great Policy • Must use soap and water or alcohol gel after the removal of GLOVES – EVERY TIME • Must comply with One Needle/One syringe and One vial – If not sure or if MD asks and you are not sure – ASK • Linen must be covered • Scrubs for Operating Rooms must be “facility-laundered) • Sharps Containers – must be secured except in OR proper because of need to have container close to Point of Use • Masks – regardless of where used – remove • Items in drawers must being containers

  5. Facts Related to Sterilization – NJDOH and AAMI • Major Repair All Mechanical equipment - Anything that is outside the scope of Preventive Maintenance and alters the performance of the equipment • If the situation meets this definition then 3 biologicals and Bowie Dick must be done prior to use. Note: differs with machine • IFU – Should be available for all machinery and for all items used • If you use – One Source – the staff must know how to access the information

  6. Expiration Dates • If you don’t understand, call the company • Check all new supplies for expiration dates • Make sure you understand what they mean • Peel Packs – may mean that the pouch must be sterilized by the date and then it is event related • If you do not understand the date or the way it is written – call the manufacturerTip Protectors – • Date is the date by which the protector must be used • If expiration is on outside of box and not on individual items (bandaids) must leave them in package • Other Issues – • Christmas Tree Connectors are single-use • Electrodes have a shelf life – once opened

  7. Miscellaneous Issues • Two-Step TST – Remember MDs are employees • Done on hire • Is A TST has been done within the year only one has to be done • If positive – chest x-ray and then annual medical screening. • OR Surgical Attire – Follow AORN – has not changed its policy but is working on it • Cloth caps are considered part of uniform and if worn must be sent to Laundry • GI Center Attire • If procedures done in an licensed OR - must follow surgical attire • If not an OR , your policy will dictate – Follow SGNA, AORN or other guidance from an Endoscopy Resource such as CDC • CAVI-WIPE and other Wipes – read the IFU – on label • Most two step – Clean the surface, then disinfect with a second wipe, keep wet for the time indicated – may be one to 5 minutes depending on wipe

  8. Miscellaneous Issues • Temperature and Humidity Monitoring – Check AORN or AAMI Check all areas • Examples • Refrigerators • Sterile Storage • Decontam Area • Central – workroom • Monitor Devices – • High and low numbers needed • Have expiration dates • Check and record numbers when the facility is closed

  9. Eye Wash Stations This Photo by Unknown Author is licensed under CC BY-SA • Required by AAMI • Certain Accrediting agencies require Metered Device • Should not be on Decom Sink • Signage important • If metered – mixes cold and hot water – temperature 60 – 100 degrees • Test weekly and record Best is the metered eye wash – ANSII requirement • Eye Wash Bottles only acceptable as an alternative – not a replacement This Photo by Unknown Author is licensed under CC BY-SA

  10. Questions This Photo by Unknown Author is licensed under CC BY-NC