1. Module F
Medical Asepsis, Hand Hygiene, and Patient Care Practices In Home Care and Hospice
Welcome to Module E, Medical Asepsis, Hand Hygiene and Patient Care Practices in Home Health and Hospice.

2. Objectives Describe the principles and practice of asepsis
Understand hand hygiene
Understand the role of the environment in disease transmission
There are three main objectives for the this module.
Describe the principles and practices of asepsis
Understand hand hygiene
Understand the role of the environment in disease transmission

3. Defining Asepsis Medical Asepsis Surgical Asepsis Definition
Clean Technique
Sterile Technique
Emphasis
Freedom from most pathogenic organisms
Freedom from all pathogenic organisms
Purpose
Reduce transmission of pathogenic organisms from one patient-to -another
Prevent introduction of any organism into an open wound or sterile body cavity
Asepsis is the condition of being free from disease producing microorganisms. Aseptic technique refers to all those procedures that reduce or eliminate pathogens and their actions or minimize their areas of existence. There are two types of asepsis, Medical and Surgical.
Medical asepsis, also referred to as clean technique, is used during most routine patient care activities and non-surgical procedures. With medical asepsis, emphasis is placed on removing most of the pathogenic organisms to reduce transmission from one patient to another.
Conversely, surgical asepsis, also called sterile technique, is used only during surgical procedures. Unlike medical asepsis, the goal of surgical asepsis is to ideally remove all pathogenic organisms and prevent the introduction of any organism into a normal sterile body site.

4. Medical Asepsis
Measures aimed at controlling the number of microorganisms and/or preventing or reducing the transmission of microbes from one person-to-another: Clean Technique
Know what is dirty
Know what is clean
Know what is sterile
Keep the first three conditions separate
Remedy contamination immediately
Medical asepsis is based on several measures with the goal of controlling the number of microorganisms, not making things sterile. To achieve medical asepsis we must understand what is dirty, what is clean, what is sterile, how to keep these things separate, and how to remedy any contamination that might occur. When approaching each patient care activity, consider the following principles as a framework to guide your practice.

5. principles of Medical Asepsis
When the body is penetrated, natural barriers such as skin and mucous membranes are bypassed, making the patient susceptible to microbes that might enter.
Perform hand hygiene and put on gloves
When invading sterile areas of the body, maintain the sterility of the body system
When placing an item into a sterile area of the body, make sure the item is sterile
When performing invasive procedures, like placing an IV or giving an injection, one of the bodies’ first lines of defense against invading microorganisms is bypassed: the skin. When we bypass the skin, we increase the susceptibility of the patient to invading microorganisms. For example, when placing an IV into the patient’s bloodstream (which is a sterile system) we perform hand hygiene and put on gloves to prevent our normal body flora from contaminating the insertion site. Next we decontaminate the patient’s skin using an antiseptic. This reduces the level of microbial burden at the insertion site so microbes are not carried through the skin during the insertion. Finally, we use a sterile IV catheter and sterile solutions so we do not introduce any additional microbes into the bloodstream.

6. principles of Medical Asepsis
Even though skin is an effective barrier against microbial invasion, a patient can become colonized with other microbes if precautions are not taken.
Perform hand hygiene between patient contacts
When handling items that only touch patient’s intact skin, or do not ordinarily touch the patient, make sure item is clean and disinfected (between patients).
The second principle of asepsis is focused on preventing the transfer of microorganisms from one patient to another via healthcare provider hands and shared equipment. All of us are colonized with many different types of bacteria, some helpful and some potentially pathogenic. When we fail to take the opportunity to perform hand hygiene between patients or clean and disinfect shared patient equipment like blood pressure cuffs between patients, we are creating opportunities for cross contamination that can introduce new, harmful microbes to patients.

7. principles of Medical Asepsis
All body fluids from any patient should be considered contaminated
Body fluids can be the source of infection for the patient and you
Utilize appropriate personal protective equipment (PPE)
When performing patient care, work from cleanest to dirtiest patient area.
The third principle of asepsis is recognizing that any body fluid is potentially contaminated. This means that if it is wet and not yours you should use the appropriate personal protective equipment (PPE) and perform hand hygiene after handling potentially contaminated fluids, and when performing patient care activities. Remove gloves and perform hand hygiene between dirty and clean patient care activities. For example, follow a wound dressing change with glove removal and hand hygiene before performing an injection on the same patient. By doing so, you can feel confident that you have not introduced any more microbes at the injection site.

8. principles of Medical Asepsis
The healthcare team and the environment can be a source of contamination for the patient
Health care providers (HCP) should be free from disease
Single use items can be a source of contamination
Patients environment should be as clean as possible
The final principle of asepsis is that healthcare providers and the environment can also be a source of contamination. Healthcare providers can reduce their opportunities of transmitting disease by staying up to date on vaccinations, maintaining good personal hygiene, and performing hand hygiene appropriately.
Additionally, single use items can be a source of contamination if they are reused on another patient. For example, many sterile solutions used for irrigation do not have bacteriostatic or bacteriocidal compounds that prevent growth of microbes once they have been opened. Because of this, any excess fluid left in the bottle should be discarded - not stored for later use. It is important that you read the labels and follow manufacturers’ instructions for use.
The environment is also a potential source of contamination for the patient. If surfaces and shared patient equipment are not cleaned appropriately, they can be a source of cross-transmission. The role of the environment is discussed later in this section.

9. Surgical Asepsis
Practices designed to render and maintain objects and areas maximally free from microorganisms: Sterile Technique
Know what is sterile
Know what is not sterile
Keep sterile and not sterile items apart
Remedy contamination immediately
Measures that keep and maintain objects and areas maximally free of microorganisms so that normally sterile body sites are not contaminated are the basis of surgical asepsis. Understanding which equipment and areas are sterile, and which are not, and keeping these two separate so as not to introduce contamination is critical to achieving surgical asepsis.

10. Principles of Surgical Asepsis
The patient should not be the source of contamination
Healthcare personnel should not be the source of contamination
Recognize potential environmental contamination
Surgical Asepsis, also called “sterile technique,” is used mainly in the operatory or for sterile procedures. These are practices designed to render and maintain objects and areas maximally free of microorganism. Practices that can maximally reduce skin microorganism are accomplished by using soap initially to remove soil, using antimicrobial agents that provide a residual suppression for periods of time, preparing the patient’s skin with an antiseptic agent, maintaining a sterile field, using sterile gloves, gowns, drapes, and in OR suites controlling from outside contamination of the clean environment by increased high efficiency air filtration (HEPA) and positive pressure rooms.
Procedures that should follow surgical aseptic techniques are those procedures associated with a high risk of infection due to interruption of normal defense defenses or contamination of mucous membranes or non-intact skin. Examples include the insertion of central lines, or urinary catheters, preparation and administration of medications and fluids administered via vascular catheters (e.g.. parenteral nutrition solutions), and surgical wound care.
If procedures are performed at the bedside, control activities to reduce airborne transmission, separate clean and dirty activities (avoid having cleaning, dusting, sweeping, or vacuuming during the procedure), use traffic control by excluding family, pets, and anyone not assisting with the procedure. This is especially important for the high risk patient population that includes the burn patients, oncology, organ transplant, and neonates to maximally reduce organism exposure during invasive procedures.

11. Remedy Contamination
Every case is considered dirty and the same infection control precautions are taken for all patients
When contamination occurs, address it immediately
Breaks in technique are pointed out and action is taken to eliminate them.
Once there has been a breach in sterility, it is important that the contamination is recognized quickly and steps are taken to remedy the situation promptly.

12. Two of the primary practices of aseptic technique are appropriate hand hygiene and disinfection of surfaces and shared equipment. This diagram demonstrates how both hands and the environment play a role in the transmission of disease between two patients. The left side of the diagram shows transmission by the hands of the healthcare provider and the right side shows transmission by environmental surfaces and shared equipment.
Rutala WA and Weber DJ (2010) Lautenbacch et al.(eds.) in Practical Healthcare Epidemiology

13. Hand Hygiene The substance of asepsis
Hand hygiene is a general term that applies to routine hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis.
iStockphoto

14. What is Hand Hygiene Handwashing Antiseptic Handwash
Alcohol-based Hand Rub
Surgical Antisepsis
Hand hygiene substantially reduces potential pathogens on the hands and is considered a primary measure for reducing the risk of transmitting organisms to patients and health care personnel. Hospital-based studies have shown that noncompliance with performing hand hygiene is associated with health care-associated infections, the spread of multi-drug resistant organisms, and has been a major contributor to outbreaks. Studies have shown that the prevalence of health care-associated infections decreases as hand hygiene measures improve.

15. Why is hand hygiene so important?
Hands are the most common mode of pathogen transmission
Reduces the spread of antimicrobial resistance
Prevents healthcare-associated infections
All of us have bacteria on our hands, even after performing hand hygiene. These bacteria are normal resident bacteria that generally reside in deeper layers of skin and are not likely to be removed during routine hand hygiene and are less likely to be associated with healthcare-acquired infections. When we provide patient care or have contact with the immediate patient environment, we pick up transient, potentially pathogenic microorganisms on our hands. In the study cited above, the researchers found that healthcare providers contaminate their hands with an additional 100 to 1000 bacteria during clean activities like taking vital signs. By performing appropriate hand hygiene, we remove these transient microorganisms so they cannot be transmitted to other patients.

16. Hand-borne Microorganisms
Healthcare providers contaminate their hands with colony-forming units (CFU)of bacteria during “clean” activities (lifting patients, taking vital signs).
In the study sited above, the researchers found that healthcare providers contaminate their hands with an additional CFU of bacteria during clean activities like taking vital signs. By performing appropriate hand hygiene, we remove these transient microorganisms so they cannot be transmitted to other patients.
Pittet D et al. The Lancet Infect Dis 2006

17. Transmission of pathogens on Hands Five elements
Germs are present on patients and surfaces near patients
By direct and indirect contact, patient germs contaminate healthcare provider hands
Germs survive and multiply on healthcare provider hands
Defective hand hygiene results in hands remaining contaminated
Healthcare providers touch/contaminate another patient or surface that will have contact with the patient.
Transmission of health care-associated pathogens from one patient to another via healthcare provider hands requires five sequential steps:
1. Organisms are present on the patient’s skin, or have been shed onto inanimate objects immediately surrounding the patient;
2. Organisms must be transferred to the hands of the healthcare provider;
3. Organisms must be capable of surviving for at least several minutes on the healthcare provider’s hands;
4. Hand washing or hand antisepsis by the healthcare provider must be inadequate or entirely omitted, or the agent used for hand hygiene
inappropriate; and
5. The contaminated hand or hands of the caregiver must come into direct contact with another patient or with an inanimate object that will come into direct contact with the patient.

18. Hand hygiene compliance is low
Author
Year
Sector
Compliance
Preston
1981
General Wards
ICU
16%
30%
Albert
41%
28%
Larson
1983
Hospital-wide
45%
Donowitz
1987
Neonatal ICU 30
Graham
1990 32
Dubbert 81
Pettinger
1991
Surgical ICU 51
1992
Neonatal Unit 29
Doebbeling 40
Zimakoff
1993
Meengs
1994
Emergency Room
Pittet
1999 48
<40%
Adherence of healthcare providers to recommended hand hygiene procedures has been reported with great variation, and in some cases is unacceptably poor. A meta-analysis of 34 studies of hand hygiene practices of healthcare providers found, across all studies, there was average hand hygiene compliance rate of 40%.
Pittet and Boyce. Lancet Infectious Diseases 2001

19. Reasons for noncompliance
Inaccessible hand hygiene supplies
Skin irritation
Too busy
Glove use
Didn’t think about it
Lacked knowledge
Some of the most frequent reasons given for the lack of hand hygiene were:
products were inaccessible,
the products caused skin irritation,
healthcare providers were too busy and it interfered with patient care,
they were wearing gloves and felt hands were not contaminated,
they just didn’t think about it, and
they lacked the knowledge of when and how to perform hand hygiene.

20. When to perform hand hygiene
The 5 Moments
Consensus recommendations
CDC Guidelines on Hand Hygiene in healthcare, 2002
Before touching a patient
Before and after touching the patient
Before clean / aseptic procedure
Before donning sterile gloves for central venous catheter insertion; also for insertion of other invasive devices that do not require a surgical procedure using sterile gloves
If moving from a contaminated body site to another body site during care of the same patient
After body fluid exposure risk
After contact with body fluids or excretions, mucous membrane, non-intact skin or wound dressing
After removing gloves
After touching a patient
After removing gloves
After touching patient surroundings
After contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient
This table demonstrates the correspondence between the WHO 5 Moments of Hand Hygiene and the CDC Guidelines on Hand Hygiene.

21. HOW TO HAND RUB
To effectively reduce the growth of germs on hands, hand rubbing must be performed by following all of the illustrated steps. This takes only 20–30 seconds!
The use of an alcohol based hand rub is preferential to hand washing when hands are not visibly soiled. You should not use alcohol based hand rubs after providing care to patients with diarrhea. Review the steps for hand rubbing shown here.
credit: WHO

22. HOW TO HAND WASH
To effectively reduce the growth of germs on hands, handwashing must last at least 15 seconds and should be performed by following all of the illustrated steps.
Hand washing with antiseptic soap and water should be used when hands are visibly soiled and after providing care patients with diarrhea. Review the steps for hand washing shown here.
credit: WHO

23. Hand rubbing vs Handwashing
15sec
30sec
1 min
2 min
3 min
4 min 6 5 4 3 2 1
Bacterial contamination (mean log 10 reduction)
Handwashing
Handrubbing
Hand rubbing is:
more effective
faster
better tolerated
Why is hand rubbing with an alcohol-based hand sanitizer preferred over hand hygiene with antiseptic soap and water? When compared side by side using seconds of use, hand rubbing was significantly more efficient in reducing hand bacterial contamination.
Pittet and Boyce. Lancet Infectious Diseases 2001

24. Summary of Hand hygiene
Hand hygiene must be performed exactly where you are delivering healthcare to patients (at the point-of-care).
During healthcare delivery, there are 5 moments (indications) when it is essential that you perform hand hygiene.
To clean your hands, you should prefer hand rubbing with an alcohol-based formulation, if available. Why? Because it makes hand hygiene possible right at the point-of-care, it is faster, more effective, and better tolerated.
In summary, hand hygiene should occur where care is delivered. Healthcare providers should know the indications for when to perform hand hygiene. Caregivers should preferentially choose to use an alcohol based hand rub over and hand washing, unless their hands are visibly soiled or they provided care to a patient with diarrhea. Healthcare providers should use the correct technique and duration.
You should wash your hands with soap and water when visibly soiled.
You must perform hand hygiene using the appropriate technique and time duration.

25. Rutala WA and Weber DJ (2010) Lautenbacch et al. (eds
Rutala WA and Weber DJ (2010) Lautenbacch et al.(eds.) in Practical Healthcare Epidemiology
In addition to hand hygiene, one of the most important concepts to understand is the role of the environment in disease transmission in healthcare settings. Patients colonized or infected with epidemiologically important pathogens shed these microorganisms into the environment and contaminate surfaces and shared patient equipment in their immediate surroundings. This pathway can be disrupted by adequately and thoroughly disinfecting the contaminated surfaces. Failure to do so poses a risk for transmission of infection.

26. Definitions Spaulding Classification of Surfaces:
Critical – Objects which enter normally sterile tissue or the vascular system and require sterilization
Semi-Critical – Objects that contact mucous membranes or non-intact skin and require high- level disinfection
Non-Critical – Objects that contact intact skin but not mucous membranes, and require low or intermediate-level disinfection
The Spaulding classification scheme is used to classify surfaces and objects in healthcare based on the intended use and type of disinfection they require. Critical objects are items that enter normally sterile tissue, like surgical instruments, and require sterilization; semi-critical objects are items, like endoscopes, which have contact with mucous membranes and non-intact skin and require high-level disinfection; and finally, we have non-critical objects, like exam tables and blood pressure cuffs, which are in contact with intact skin and require only low-level disinfection.

27. Disinfection Levels
High – inactivates vegetative bacteria, mycobacteria, fungi, and viruses but not necessarily high numbers of bacterial spores Intermediate – destroys vegetative bacteria, most fungi, and most viruses; inactivates Mycobacterium tuberculosis Low - destroys most vegetative bacteria, some fungi, and some viruses. Does not inactivate Mycobacterium tuberculosis
There are three levels of disinfection: High, Intermediate, and Low. High level disinfection kills all microorganisms except for small numbers of bacterial spores. Intermediate level disinfection kills all non-spore forming bacteria including Mycobacterium tuberculosis, as well as most fungi and viruses. Low level disinfection also kills most microorganisms, with the exception of spores and Mycobacterium tuberculosis.

28. Categories of Environmental Surfaces
Clinical Contact Surfaces
Nursing bag, counter tops, BP cuffs, thermometers
Frequent contact with healthcare providers’ hands
More likely contaminated
Housekeeping Surfaces
Floors, walls, windows, side rails, over-bed table
No direct contact with patients or devices
Risk of disease transmission
There are two categories of environmental surfaces. Clinical contact surfaces have a high potential for direct contamination from patient secretions, especially during procedures that generate spray or splatter. These surfaces also have frequent contact with the contaminated hands of healthcare providers and patients. These surfaces can become a reservoir for contamination of instruments, patient care devices, and healthcare provider bare or gloved hands.

29. Sterile/Clean Supplies
Sterile/clean supplies and equipment should be carried in nursing bag/plastic container
Bag and supplies are to be maintained as clean as possible
Perform hand hygiene before removing any patient care supplies or equipment
Carry only supplies needed for that patient, and remove only those articles that are needed for care.
Be careful not to reach into the nursing bag with potentially contaminated gloves
In Home and hospice care, sterile and clean supplies and equipment should be carried in a nursing bag or plastic container. While the nursing bag is the primary storage for all patient care equipment needed during the care episode, it is important that it be maintained in a manner that prevents contamination. Health care workers should perform hand hygiene before removing any patient care supplies or equipment, and should only carry the supplies needed for that patient and remove any articles that are not needed for care of that patient. It is also important that providers are careful to never reach into the nursing bag with potentially contaminated gloves.

30. Nursing Bags
Until recently, home care providers had many unanswered questions about the role nursing bags. Do bags act as reservoir for human pathogens? We know the bag is brought into the patient’s home and then accessed during the provision of care. We also know that it is carried from patient to patient and home to home via a car, which are all areas for potential contamination unless following well defined protocols. 30

31. Contamination of Nursing Bags
127 home health nurses provided bags and equipment for culture.
351 cultures of bags and equipment obtained over a 20 month period.
A study was undertaken to ascertain the level of contamination that was present on a home health workers bag home health nurses provided their bags and equipment for culture. This study was completed over a 20 month period from January 2005 – August 2006.
Slides used with permission: Madigan, EA and Kenneley, IL, Case Western Reserve, 2006.
Kenneley IB, Madigan B: Infection Prevention and Control in Home Health Care: The Nurse’s Bag. AJIC 2009; 37:

32. Study Findings
66.7% of the outside, 48.4% of the inside and 22.3% of patient care equipment from nurses’ bags contaminated with:
Gram-negative bacteria (E. coli and P. aeruginosa)
MRSA
VRE
33% contaminates on the outside of bag were contaminated with normal flora (Staphylococcus, Diphtheroids, Bacillus species)
Overall 66.7% of cultures collected from the outside of the 127 nursing bags, 48% of cultures collected from the inside of bags, and 22% of cultures collected from patient care equipment tested positive for pathogens. The pathogens included the gram-negative bacilli, and multi-drug resistant organisms including MRSA and VRE. As expected there were a number of normal flora \identified that made up 33% of the isolates found on the outside of bag.

33. Recommendations Use less porous surface materials for nurses bags
Use of solutions containing bleach worked best to decrease bacterial contamination
Outside of bags should be cleaned routinely (daily or weekly)
Non-porus bags can be wiped with EPA-registered disinfectant
Porous bags should be laundered
Evidence for exactly which care and handling practices worked best to decrease the contamination rates of the nurses’ bags suggest that (1) the use of less porous surface materials are optimal for nurses’ bags, (2) the use of institutional cleaners that contain sodium hypochlorite as the active ingredient worked best to decrease bacterial contamination rates, and (3) the outside of the nurses’ bags optimally should be cleaned at daily or at least weekly intervals. These interventions should be tailored based on not only the bag cleaning protocols, but also the type of bag surface material used, hand hygiene practices, the frequency of use and the type of patients seen.

34. Nursing bag management recommendations
Should not be placed in a location where it may become contaminated such as on the floor.
Always place on a visibly clean dry surface away from children and pets. May use newspaper for surface cover.
If the home is heavily infested with insects or rodents, leave the bag in car or hang on a doorknob.
If contaminated with blood or body fluids, decontaminate using an EPA-registered disinfectant detergent.
Nursing bags should not be placed in a location where it may become contaminated such as on the floor. Always place the bag on a visibly clean dry surface away from children and pets. This can be achieved by placing newspaper or chux pad to create a clean dry surface cover, on which the bag can be placed. If the home environment is known to be heavily infested with insects or rodents, it is best to leave the bag in car or hang it on a doorknob. If the bag becomes contaminated with blood or body fluids, then decontaminate by using an EPA-registered disinfectant detergent and launder it.

35. Nursing Bag
Unused supplies may be saved and used for another patient unless:
item removed from the bag and the patient required Contact Precautions
item was visibly soiled
item was opened or the integrity of the package had been compromised
manufacturer expiration date had been exceeded
Unused supplies may be saved and used for another patient unless:
item removed from the bag and the patient required Contact Precautions
item was visibly soiled
item was opened or the integrity of the package had been compromised
manufacturer expiration date had been exceeded

36. Home Care Personnel Vehicle
Separation of clean and dirty in vehicle
Patient care and personal items stored separately
Clean supplies should not be stored on floor (carpeting is heavily soiled)
Store contaminated items and equipment needing cleaning (i.e., sharps containers) in trunk. Avoid spilling.
Home care personnel must use their personal vehicle for transportation of clean and contaminated patient are articles. Therefore it is prudent to employ basic infection control principles of separation and appropriate storage of clean and dirty items within the vehicle. As such, patient care items and personal items belonging to the employer should be stored in separate areas of the vehicle. All clean patient care supplies, including the nursing bag, should be stored in an area of the vehicle that is clean and not likely to be become wet or soiled. Supplies should not be stored on floor of the vehicle because the floor is heavily soiled. Items considered contaminated (such as sharps containers, equipment needing cleaning prior to reuse) should be transported in a designated “dirty” area of the vehicle such as the trunk. These items should be stored and transported so that spilling or contamination of other items is avoided.

37. Recommendations for Asepsis in Procedures

38. Wound Care Wound care is performed using clean technique
Clean gloves used to remove old dressings
Gloves removed, hand hygiene performed
New gloves donned for application of new dressing
“No-touch technique” can be used changing surface dressings
Use only sterile irrigation solutions
Solutions are one-time use and remaining amount must be discarded
Soiled dressing should be contained within plastic bag and discarded in patient’s trash
If disposal is not possible in home, transport soiled dressings for final disposal.
Medical asepsis or clean technique is used for most wound care rather than sterile technique. Sterile technique is required if ordered by the MD or for fresh surgical wounds. Wound protocols will vary depending on the type of wound. For decubititus care, because these are already colonized with the patient’s own flora, clean technique is generally used. Medical aseptic technique is used for wound care including the use of clean gloves. Clean exam gloves should be used to remove old dressings. Hands are then washed and new clean exam gloves are donned for the application of the new dressing. Alternatively, “no touch technique” may be used which is using the same gloves for entire dressing during wound care. If wounds require irrigation, only sterile irrigation solutions should be used. It should be noted that these solutions are considered single-use as they have no preservative to prevent contamination after opening, so there is no safe storage time following use. All remaining solution should be discarded after care has been rendered. All dirty dressings should be placed in a plastic bag and disposed of in patient’s trash. If this is not possible, transport soiled dressings to facility for final disposal.

39. Infusion Therapy
Follow the 2011 Guidelines for Prevention of Intravascular Catheter-related Infections
See Summary of Recommendations
These guidelines have been developed for healthcare personnel who insert intravascular catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home healthcare settings. They are intended to provide evidence-based recommendations for preventing intravascular catheter-related infections. Major areas of emphasis include 1) educating and training healthcare personnel who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a >0.5% chlorhexidine skin preparation with alcohol for antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters and chlorhexidine impregnated sponge dressings if the rate of infection is not decreasing despite adherence to other strategies These guidelines also emphasize performance improvement by implementing bundled strategies, and documenting and reporting rates of compliance with all components of the bundle as benchmarks for quality assurance and performance improvement.

40. Phelbotomy All venous access done using safety-engineered device
Sterile technique must be followed
No recapping needles
Disposed of needles immediately in sharps container at point of use
All venous access will be done using sterile technique and only using safety-engineered devices, with no recapping and the sharp disposed of immediately at the point of use.

41. Blood and Blood Products transport
Temperature
Blood and Pack Red Blood Cells
1-10°C
Platelets
1-10°C (if stored cold), or 20-24°C (if stored at room temperature)
Liquid Plasma
Temperature must be monitored using temperature sensitive tags or thermometers
Protect product against direct exposure to ice packs or coolants
The FDA requires that when transporting blood or blood products for infusion. Take a moment to review these requirements.
FDA Regulation (21 CFR 600)

42. Specimen Collection and transport
Specimens should not be hand carried to the employee’s vehicle
Specimens should be placed in a plastic zip lock lab specimen bag bearing a biohazard label
Specimens should be placed in a secondary specimen bag for transportation
Secondary specimen bag may be transported in the clean section of the vehicle
Specimens should not be hand carried to the employee’s vehicle. Specimens should be placed in a plastic ziplock lab specimen bag bearing a biohazard label and carefully closed. The health care provider should take care not to contaminate the outside of the specimen tubes or the bags. The specimens should then be placed in a secondary specimen bag, preferably a rigid container for transportation. This container should display a biohazard symbol. The secondary specimen bag may be transported in the clean section of the vehicle.

43. Urinary Catheter Insertion and management
Follow the 2009 CDC Guideline for the Prevention of Catheter-Associated Urinary Tract Infections
See Summary of Recommendations
This guideline updates and expands the original Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-associated Urinary Tract Infections (CAUTI) published in This revised guideline reviews the available evidence on CAUTI prevention for patients, including those requiring chronic indwelling catheters and individuals who can be managed with alternative methods of urinary drainage (such as intermittent catheterization). The revised guideline also includes specific recommendations for implementation, performance measurement, and surveillance. This document is intended for use by infection prevention staff, healthcare epidemiologists, healthcare administrators, nurses, other healthcare providers, and persons responsible for developing, implementing, and evaluating infection prevention and control programs for healthcare settings across the continuum of care.

44. Intermittent urinary Catheters
Clean technique is considered adequate for patient doing self I/O catheterization.
Reusable catheters by a single patient
wash in soap and water
boil for 15 minutes
jar of water and microwaving (high for 15 min)
thoroughly drain catheter and store in ziplock bag
Forr intermittent urinary catheterization done by the patient and patient family care givers, clean technique is considered adequate.
Patients may individually use reuse catheters by disinfecting using the following procedure:
First, wash in soap and water; then either boil on stove top for 15 minutes; or place in an open jar of water and microwave on high for 15 minutes, (instruct patient for extra care and safety precautions in handling boiling water and hot catheters); thoroughly drain catheter and store in a ziplock bag.

45. Maintenance of Leg Bags
Empty bag and rinse with tap water
Clean bag with soapy water and rinse
Soak 30 minutes in vinegar solution
Soak cap in alcohol
Empty bag, drain and air dry by hanging
Alternative:
Rinse bag with tap water
Instill bleach solution (1 tsp to 1 pint water) through tubing
Agitate briefly and let bag hang 30 minutes
Empty, drain and let air dry by hanging
Leg bags are favored when the patients are ambulatory. The patients or caregivers should be taught to empty the bag at frequent intervals. After use, the bag should be emptied and rinsed and hung to dry. The urinary leg bag cap may be soaked in alcohol for 30 minutes and then recapped after the bag has air dried.
Alternatively, some patients may want to instill vinegar or dilute bleach solutions and soak for 30 minutes to prevent or control odors.

46. Tracheostomy Care
Use clean technique unless tracheostomy is less than one month old
Suction catheters are changed at least daily.
Flush the catheter with saline after use.
Suction canisters and tubing should only be used for one patient and discarded when necessary.
Suction tubing should be rinsed with tap water after each use. Disinfect tubing once a week with a 1:10 bleach water solution.
Tracheostomy care in the home uses clean technique unless the tracheostomy is less than one month old, or the physician orders sterile care. The suction catheters should be changed at least daily and flushed with saline after each use. The suction canisters and tubing should be used for only one patient and discarded when necessary, for example if unable to completely clean visible contamination when decontaminating. The suction canisters should be emptied daily and washed with soap and water to prevent buildup in the canister. Suction tubing should be rinsed with tap water after each use. The tubing should be disinfected once a week with a 1:10 bleach water solution. The bleach solution is good for 30 days if kept in a closed opaque container.

47. Respiratory Therapy tracheal suction catheters
Hydrogen Peroxide Method
Clean with soap and water
Rinse with tap water
Flush with 3% hydrogen peroxide
Place in container of 3% hydrogen peroxide; soak for 20 minutes
Rinse and flush with sterile water before use
Store in new clean plastic bag
Boiling Method
Clean with soap and water
Boil in water for 10 minutes
Dried on clean towel or paper towels
Allow to cool before use
Store in a new clean plastic bag
It is up to the home care organization and the physician to allow reuse of tracheal suction catheters. If this is decided, the catheters must be cleaned and disinfected between uses. One of the two methods may be used for this purpose. The first method of disinfection involves soaking the catheter in a 3% hydrogen peroxide solutions, and the other involves boiling the catheter. It is important to note that hydrogen peroxide solution should be changed daily, or sooner of grossly contaminated.

48. Enteral Feeding Unopened enteral therapy stored at room temperature
For diluted or reconstituted formulas:
Follow label instructions for preparation storage and stability
Most are stable if covered and refrigerated for 24 hours
Check expiration dates
Enteral feeding may be a source of infection through contamination of the formula. Unopened enteral therapy fomula can be stored at room temperature in the home. When formulas are diluted or reconstituted, the label instructions for preparation, storage and stablility should be closely followed. Most of these formulas should be covered, refrigerated and used within 24 hours from the time the container was opened. Expiration dates should be checked before the container is opened and the formula is administered.

49. Enteral Feeding
Feeding bag and tubing should be rinsed after each feeding; tap water may be used
Do not top off an existing bag of formula with new formula
During feeding, check bag and tubing for foreign matter, mold and leakage.
If the enteral feeds are not part of a premixed closed system, then the feeding bag and tubing should be rinsed after each feeding and tap water may be used.
Newly prepared formula should not be added to and existing formula that has been hanging. Topping off with new formula is discouraged because the new formula may become contaminated with bacteria from the old formula if it has been hanging too long. During the feeding, the bag and tubing should be check intermittently for foreign matter, mold and leakage.

50. Cleaning Enteral Feeding Equipment and Supplies
Handle formula, equipment and supplies with clean technique.
Equipment used for formula preparation should be cleaned using
A dishwasher or
Hot, soapy water
Bags and tubing should not be used for more than 24 hours. After 24 hours:
Discard tubing or
Clean with soap and water, rinse, drain and air dry
Proper handling and cleaning of enteral formula equipment and supplies using clean technique are important for reducing the risk of formula contamination. Equipment used for preparation of formula should be washed in a dishwasher or using hot, soapy water. If a blender is used, all washable components should be washed as above, using a dishwasher or hot, soapy water. Enteral feeding bags should not be used for more than 24 hours, after which they should either be discarded or washed with soap and water, rinsed, drained and allowed to air dry.

51. References
CDC Guidelines for Hand Hygiene in Healthcare Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC Hand Hygiene Task Force. MMWR October 25, 2002, 51(RR-16).
CDC Guidelines for Environmental Infection Control in Health-care Facilities, HICPAC, MMWR June 6, , 52(RR-10).
Rhinehart, Emily. Infection Control in Home Care and Hospice. Washington, D.C.: APIC, 2005