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
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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
ST 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 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
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This Photo by Unknown Author is licensed under CC BY-SA

10. Questions
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