Objectives. Hand Hygiene. A Review of Asepsis and Safe Medication Practices. Medical vs Surgical Asepsis. Asepsis

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1 Objectives A Review of Asepsis and Safe Medication Practices Mary L. Gish, DNP, RN, NEA-BC Nurse Consultant III Center for Health Care Quality Licensing and Certification 1. Be more familiar with the potential breeches in asepsis in an ASC. 2. Be able to discuss the 7 Principles of Surgical Asepsis 3. Describe safe medication practices in the ASC practice setting. Asepsis Asepsis is the state of being free from disease-causing contaminants (such as bacteria, viruses, fungi, and parasites) or, preventing contact with microorganisms. The term asepsis often refers to those practices used to promote or induce asepsis in an operative field in surgery or medicine to prevent infection. Medical vs Surgical Asepsis Medical asepsis or clean asepsis is the state of being free from disease causing microorganisms. Medical asepsis is concerned with eliminating the spread of microorganisms through facility practices. Surgical or Sterile Asepsis includes procedures to eliminate micro-organisms from an area and is practiced by the members of the surgical team in operating rooms and treatment areas. Essential Components of Medical Asepsis Handwashing Utilizing gloves, gowns and masks as indicated Cleaning equipment Handling linens properly Hand Hygiene Sanitizer or Hand Wash Before and after gloving (sterile or clean) Medication Administration Feeding residents (before and after) Any invasive procedure (catheterization, blood glucose) Contact with resident Are sinks and hand sanitizers readily available? Are gloves readily accessible? Hand wash only for dietary, GI symptoms 1

2 Aseptic Technique Chain of Infection Infectious Disease Cycle Aseptic technique refers to a procedure that is performed under sterile conditions. This includes medical and laboratory techniques, such as with cultures. Pathogen Host Reservoir The largest example of aseptic techniques is in hospital operating suites. Aseptic technique is the effort taken to keep patients as free from micro-organisms as possible New Host (Disease) Portal of Entry Mode of Transmission Portal of Exit Infection Process Mode of Transmission Agents Bacteria Aerobic Anaerobic Viruses HBV Influenza Fungi Responsible for some of the most common infections Protozoa 1. Fomite Inanimate objects Stethoscope, thermometer, scissors 2. Vector Living carrier Human hands Entrance of Microorganisms Skin is the first line of defense Depends on nature of the pathogen Influenza (Respiratory Droplet) MRSA (Contact) HIV/HBV (Blood and Body Fluids) Infection Process Host A micro-organism must accept the host Infection develops as the strength and numbers grow in host Immunizations have proved effective in providing additional protection against infectious disease 2

3 Medical Asepsis = Standard Precautions 1. Combines Universal Precautions and BSI 2. Applies to all patient encounters 3. Emphasizes hand hygiene 4. Use of gloves, gown masks and eye protection depending on the anticipated exposure 5. Safe injection practices 6. Equipment or items in the resident environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission 7. Education and training are the foundation Standard Precautions 1. Combines Universal Precautions and BSI 2. Applies to all residents 3. Emphasizes hand hygiene 4. Use of gloves, gown masks and eye protection depending on the anticipated exposure 5. Safe injection practices 6. Equipment or items in the resident environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission 7. Education and training are the foundation Transmission Based Precautions 3 Categories Contact Precautions - excessive wound drainage, fecal incontinence, or other Droplet Precautions influenza, group A Strep Airborne Precautions - TB Hand Hygiene Sanitizer or Hand Wash Before and after gloving (sterile or clean) Medication Administration Feeding residents (before and after) Any invasive procedure (catheterization, blood glucose) Contact with resident Are sinks and hand sanitizers readily available? Are gloves readily accessible? Hand wash only for dietary, GI symptoms Surgical Asepsis Requires the absence of all microorganisms, pathogens and spores from an object Surgical Asepsis Principles of Sterile technique A sterile object remains sterile until touched by another sterile object Only sterile objects may be placed on a sterile field A sterile object or field out of vision is contaminated A sterile object or filed becomes contaminated by prolonged exposure to air 3

4 Surgical Asepsis Principles of Sterile technique When a sterile surface comes in contact with a wet, contaminated surface, the sterile object of field becomes contaminated Fluids flow in the direction of gravity The edge of the sterile field or container is consider contaminated Surgical Asepsis Opening Sterile packages Labels indicate the date that sterilization expires Compromised packaging are no longer considered sterile Providers follow strict handwashing protocol Principle # 1: Scrubbed persons function within a sterile field Surgical team consists of sterile and non-sterile members Sterile=Scrubbed Non sterile remain in periphery All wear scrub attire Scrubbed persons wear sterile gown, mask, gloves, shields Sterile areas Gown front from chest to sterile field level Sleeves 2 above elbow to cuff Principle #2 Sterile drapes are used to crate a sterile field Establish an aseptic barrier minimizing the passage of microorganisms Places on patient, furniture, and equipment to be included in the sterile field Only incisional area is exposed Only scrubbed personnel handle drapes Held higher than the OR table, from incision out Not moved or rearranged Top surface is only area sterile Principle #3: All items used on a field must be sterile Sterile and non sterile never mix Sterility is determined by events not by time Items are inspected for package integrity and indicators Otherwise considered contaminated Principle #4: All items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity Non-sterile personnel (i.e. Circ Nurse) uses good judgment when dispensing items Tossing may compromise field by tearing, displacing The 5 minute rule does not apply 4

5 Principle #4 Principle #4 continued Open the top wrapper away first, then open the flaps to each side The last wrapper flap is pulled toward the nonsterile person opened the package Once opened contents are sterile up to 1 inch outer edge Margin of safety Double wrapped relies on institution policy Principle #5: A sterile field should be maintained and monitored constantly Must be monitored by all members of OR team Sterility cannot be guaranteed but team must be vigilant Breeches require immediate action to correct Prepared as close to the OR time as possible Time and exposure are risk factors Risks: personnel, airborne contaminants, insects and liquids Principle #6: Personnel should move around the field in a manner that maintains sterility Establish safe distance or margin of safety between sterile and nonsterile areas Non-sterile personnel remain in non sterile areas Always face the field Never walk between two sterile fields Never reach over or risk contact of touching sterile field Principle #6: Personnel should move around the field in a manner that maintains sterility Patient is the center with scrubbed personnel close without movement away Move from sterile to sterile only Scrub personnel keep distance and pass face to fact or back to back Scrubbed keep same position throughout procedure Arms and hands always in the field Principle #7: Policies and Procedures for maintenance of sterile field should written, reviewed annually and available in practice setting Included in initial orientation and ongoing education of staff Training of aseptic technique and practices by skilled members to new and inexperienced. Mentors and preceptors 5

6 New Work Being Done Safe Injection Practices Pharmacy Guidelines Never re-use needles Never share lancet holders Never share insulin pens Never use finger stick devices for more than one person Never use a blood glucose meter for more than one person without cleaning and disinfecting it in between uses Never use insulin pens for more than one person Never fail to change gloves and perform hand hygiene between finger stick procedures ASHP(2013). Drug Distribution and Control: Preparation and Handling Guidelines. ASHP Guidelines on Compounding Sterile Preparations, retrieved 10/24/2014 from doclibrary/bestpractices/prepgdlcsp.aspx Pharmacy Guidelines Medication Safety What is a multi-dose vial? A multi-dose vial is a vial of liquid parenteral medication (injection or infusion) that contains more than one dose of medication. Multiple dose vials my be used for more than on patients as long as they are not accessed in a patient care area. ASHP (2013). Drug Distribution and Control: Preparation and Handling Guidelines. ASHP Guidelines on Compounding Sterile Preparations, retrieved 10/24/2014 from Multi-dose vials are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. The preservative has no effect on viruses 6

7 Medication Safety Can multi-dose vials be used for more than one patient? How? Dedicated to a single More than one patient not kept or accessed in the immediate patient treatment area. Medication Safety What are examples of the immediate patient treatment area? Examples of the immediate patient treatment area include patient rooms or bays, hallways and operating rooms. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use. Medication Safety Medication Safety Video When should multi-dose vials be discarded? Whenever sterility is compromised or questionable. If a multi-dose has been opened or accessed (28 days or manufacturer s date, soonest) Unopened = manufacturer s expiration date. Tools Available for Use CMS Exhibit 351 Infection Prevention Checklist for Outpatient Settings: Minimum Expectation for Safe Care 7

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11 References ASHP(2013). Drug Distribution and Control: Preparation and Handling Guidelines. ASHP Guidelines on Compounding Sterile Preparations, retrieved 10/24/2014 from Leopold, J. (2014)Aseptic Technique: Principles and Practices. AORN Journal, Volume 94, Issue 2, som107_exhibit_351.pdf AORN Journal , DOI: ( /j.aorn ) Copyright 2011 AORN, Inc Nurse Consultant Infection Prevention and Control Mary Gish, DNP, RN, NEA-BC Nurse Consultant III, Infection Control Thank You 11