BASIC ASEPSIS: - Gundersen Health System

BASIC ASEPSIS:
A CRITICAL ELEMENT IN BREAKING THE CHAIN OF INFECTION
Marilyn Michels, RN BSN CRRN CIC
Standard Precautions and basic asepsis - Implementation of "Standard Precautions" is the
primary strategy for successful prevention of healthcare associated infections of not only health
care workers but also our patients. It contains the fundamental practices of infection control for
the care of all individuals, regardless of their diagnosis or presumed infectious status. Effective
use of personal protective equipment (PPE) can protect the health care worker from the patient’s
infectious agents and vice versa. Since the development of Universal Precautions, there has been
an emphasis on protecting the health care worker but we have forgotten message that these same
practices can also protect the patient from infection if done correctly.
Surgical Conscience (Four Components):
Optimal patient care during invasive procedures requires the sound practice of asepsis coupled
with surgical conscience. Surgical conscience incorporates knowledge of aseptic principles,
perpetual attention to detail and experience. Open and honest communication is crucial for
acknowledgement of questionable breaks in technique or risks to patient safety. Surgical
conscience recognizes the intimate contact between the patient and the surgical team and
includes attention to personal hygiene health. Employees should feel comfortable to call-in if
they are ill. (Editorial in Annals of Surgery, 1950 pp315-18. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1616565/pdf/annsurg01395-0161.pdf)
• Caring
o Care enough to take care of yourself, know when to stay home.
o Care enough to educate yourself and peers on the institution’s policies and
procedures.
o Care enough about your patients to develop a strong surgical conscience.
• Conscience
o Ability to see and correct breaks in technique.
o Inner guide to do what is right, not what it is the easiest, fastest, or fear of retaliation.
• Discipline
o To follow policies and procedures that are in place.
o To teach and mentor staff.
o Always take the high road.
• Technique
o Assimilation of all these values with the knowledge of aseptic principles that develop
over time.
o Techniques evolve through time, trial, and error / quality improvement studies.
o Be open-minded.
o Seek out evidence-based practice to challenge or implement changes.
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Aseptic technique - Aseptic technique is the effort taken to keep patients as free from hospital
micro-organisms as possible (Crow 1989).
• Sterile technique or surgical asepsis - A technique that restricts any microorganisms in the
environment, on equipment and supplies from contaminating the wound or vascular system.
It is the required technique for the use of critical items that enter sterile tissue or the central
vascular system. At a minimum, sterile technique involves meticulous hand hygiene, use of a
sterile field, sterile gloves for application of a sterile dressing and sterile instruments. Sterile
technique may be expanded to include the use of clean attire, sterile surgeon gowns, surgical
masks, hair covering and a controlled environment
• Clean technique or medical asepsis - A technique that places emphasis on the prevention of
cross contamination or transfer of microorganisms to the involved body site, other body sites
of the patient, between patients or the environment. It requires the use of Standard
Precautions for the protection of the employee from the patient’s body fluids, secretions, and
excretions. It is appropriate for the use of semi-critical items that have contact with intact
mucous membranes. Clean technique includes meticulous hand hygiene, a clean environment
including a clean field, use of clean gloves, sterile instruments, and prevention of direct
contamination of materials and supplies.
Spaulding classification scheme
Body Contact Disinfection Requirements FDA Device Class
sterile body cavity sterilization critical
mucous membranes high level semi-critical
intact skin low level non-critical
• Critical items - A category assigned to items that present a high risk of infection if the item
is contaminated with any microorganisms, including bacterial spores. This category includes
surgical instruments, cardiac catheters and indwelling urinary catheters, implants, and
needles. Most of the items in this category should be purchased sterile or be sterilized.
• Semicritical items - A category assigned to items that come in contact with mucous
membranes or with skin that is not intact. These items must be free of all microorganisms,
with the exception of high numbers of bacterial spores. Intact mucous membranes are
generally resistant to infection by common bacterial spores but are susceptible to other
organisms, such as tubercle bacilli and viruses. Respiratory therapy and anesthesia
equipment, endoscopes, and diaphragm fitting rings are included in this category.
Semicritical items generally require high-level disinfection with the use of wet pasteurization
or chemical germicides (i.e. gluteraldehydes, chlorine). Terminal sterilization of instruments
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is done to remove all pathogenic organisms before use on the next patient although items
may be handled using clean technique during the procedure.
• Noncritical items- A category assigned to items that come in contact with intact skin but not
with mucous membranes. Intact skin acts as an effective barrier to most microorganisms.
Examples of noncritical items include blood pressure cuffs, exam tables, electronic
thermometers and furniture. Most items can be effectively cleaned with a hospital-grade
disinfectant.
Traffic patterns
• Good traffic control patterns protect personnel, patients, supplies, and equipment from
potential sources of cross-contamination. The practice setting should be designed to facilitate
movement of patients and personnel into, through, and out of defined areas within procedure
areas.
• Movement of personnel is kept to a minimum while invasive or noninvasive procedures are
in progress. Movement not only includes movement in an out of the procedure room but also
movement within the procedure area.
• The flow of clean and sterile supplies and equipment is separated from contaminated
supplies, equipment, and waste by:
o Space,
o Time, or
o Traffic patterns.
• The surgical suite has three distinct areas defined by the activities that are performed in each
area.
o Unrestricted area: serves as the central control point established to monitor the
entrance of patients, personnel, and materials. Street clothes may be worn in this area.
o Semi-restricted area: is the peripheral support area that has storage areas for clean
and sterile supplies, work areas and corridors leading to the restricted areas. Traffic is
limited to authorized personnel and patients. Personnel are required to wear clean
attire and cover all hair. No food or drink is allowed in this area.
o Restricted area: includes the procedure/operating rooms, the clean core, and the
scrub sink areas. Clean attire and hair covering is required. No food or drink is
allowed in this area. Masks are required where open sterile supplies or scrubbed
persons are located.
Hygiene
• Standard Precautions, a consistent method of taking precautions with body substances,
should be applied to all patients at all time, irrespective of the diagnosis, in order to prevent
the transmission of infectious agents.
• All healthcare workers, visitors, and patients should have good hygiene practices.
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o Hands with intact skin - Healthy skin is less apt to harbor potentially dangerous
organisms.
o Free from upper respiratory illnesses - Sneezing, coughing and talking may contribute
to the spread of organisms that may inhabit the upper respiratory tract.
o All health care workers should be immunized against influenza to not only prevent
the spread of influenza but also the spread of other common organisms from the
upper respiratory tract, such as Staph aureus.
• Respiratory Hygiene/Cough Etiquette: Targets patients and visitors with undiagnosed
transmissible respiratory infections, and apply to persons with signs of illness including
cough, congestion, rhinorrhea, or increased production of respiratory secretions when
entering a healthcare facility. Elements include:
o Education of healthcare facility staff, patients and visitors.
o Posted signs, in language(s) appropriate to the population served, with instructions to
patients and visitors.
o Source control measures (e.g., covering the mouth/nose with a tissue when coughing
and prompt disposal of used tissues, using surgical masks on the coughing person
when tolerated and appropriate).
o Hand hygiene after contact with respiratory secretions.
o Spatial separation, ideally >3 feet, of persons with respiratory infections in common
waiting areas when possible.
o Vaccination against respiratory illnesses as appropriate including influenza, pertussis,
and pneumonia.
• Hand hygiene
o Alcohol based gels
• Gel in and Gel out- Waterless, alcohol-based hand rubs are now the preferred
products for routine hand hygiene in healthcare settings, unless hands are
visibly soiled. The CDC recommends that healthcare workers be provided
with a readily available alcohol-based hand rub product at the entrance to each
patient care room, at the patient’s bedside, or at other convenient locations.
• Recommendations for increased use of waterless hand hygiene products do
not negate the need for hand washing sinks. The efficacy of alcohol-based
products or soap and water depends on the technique of the user.
o Artificial fingernails or nail extenders are prohibited for those having direct contact
with patients especially those at high risk (e.g. NICU. ICU, OR).
o Soap - Hands should be washed with soap and water when visibly soiled with dirt or
proteinaceous contaminates such as blood, other body fluids, secretions, and
excretions, as soon as possible. Hands should also be washed with soap and water
before eating and after using the restroom. Hands should be washed with soap and
water (with or without gloves) if exposed (suspected or proven) to Bacillus anthracis,
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Clostridum difficile, and some viral organisms such as Norovirus, Norwalk virus or
Rotovirus.
• Antimicrobial
• Surgical scrub agents
• Bar soap
o Lotions – should be provided. Personal hand lotions are discouraged in the patient
care area. Outbreaks have been traced back to contaminated lotion.
o 5 Moments for Hand Hygiene from the World Health Organization includes Human
Factors Engineering principals. It focuses on principals –not tasks and offers what we
should do and the rationale. (See Hand Hygiene presentation for more information.)
1. Before patient contact- prevents organisms of the healthcare environment
(including the worker) from contaminating the patient or their environment
Example – shaking hands
2. Before aseptic task- immediately before touching site to be protected will prevent
any organisms (patient’s or healthcare environment’s) from contacting the aseptic
area. Examples: medication administration, IV line care, food prep
3. After exposure to body fluids - protects self and environment from contamination.
Examples: oral care, emptying urinals.
4. After patient contact
5. After contact with patient surroundings
Items 4 & 5 above protects healthcare environment from patient contaminants.
Examples: adjusting blanket of patient in hallway, adjusting IV flow rate.
o Hand hygiene is the corner stone of infection prevention and control and is identified
as the first step of Standard Precautions.
o Ayliffe (1978) developed the Seven step hand washing technique
1. Palms
2. Backsides
3. Between fingers
4. Back of fingers
5. Thumbs
6. Fingertips
7. Wrists
Ayliffe SA et al (1978) A Test for Hygienic Hand Disinfection. Journal of Clinical Pathology. Vol 31, p
923.
o Alcohol-based rubs - follow the manufacturer’s recommendation for use;
• Dispense an appropriate amount of product (2.5 grams) into one hand
• Spread over both hands to wrists, interlace fingers and spread under
fingernails, and rub into skin until dry (approximately 15-30 seconds)
• Wash hands with soap and water after 8-10 applications of alcohol gel to
remove accumulated emollients.
o Soap (plain lotion soap) and water instructions are as follows:
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• Wet hands with water
• Apply soap products per manufacturer’s recommendations, usually 1-2 pumps
from the dispenser or 3-5 mL.
• Rub hands together vigorously, covering all skin surfaces and under rings
• Rinse thoroughly
• Dry hands with a disposable towel that is then used to turn off the water
faucet.
o Remember - Clean hands are the corner stone of standard and transmission-based
precautions.
Gloves
• Purpose
o Prevent exposure to healthcare worker
o Protect the patient from hand contamination by the health care worker
• Type
o Vinyl
• Not appropriate for tasks longer than 15-20 minutes in duration
• No fit
• Tear easily with stretching
o Latex
• Provides better protection than vinyl
• Better fit
• More elastic than vinyl
• Sensitivity may develop with repeated exposure
o Nitrile
• Able to tolerate wider temperature variances
• Better fit than vinyl
o Others
• One pair or double glove?
o Need a set to remove the old dressing
o A fresh pair of gloves is donned just prior to a procedure to prevent contamination of
the field and procedure area. Gloves are promptly removed after removing
contaminated items from the field, including the clean drape.
o Double glove when tearing or puncturing of glove can be anticipated during the task
(e.g. caring for trauma victim)
o Extra gloves should not be stored in pockets with other personal items.
• Clean or sterile
o Hands should be cleaned before reaching into glove box.
o Sterile gloves are:
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• Recommended when doing dressing change on a fresh surgical wound that is
not completely healed.
• Required if inserting a sterile catheter or needle in deep tissue or body fluids,
usually to obtain fluid or instill therapeutic agent.
• Worn if handling instruments/supplies used for invasive procedures of sterile
body cavities.
• Selected based on a number of factors, including size, the task has to be
performed, anticipated contact with chemicals, and chemotherapeutic agents,
and latex sensitivity.
Gowns
• Impervious gowns (isolation gown, lab coat or non-sterile surgeon gown) are:
o Worn when it is likely that personal clothing will be soiled with any patient's body
fluids.
o Laundered by the institution.
• The need for and type of gown selected is based on the nature of the patient interaction
including the anticipated degree of contact with infectious material and potential for blood
and body fluid penetration of the barrier. Gowns may be worn not only to protect the clothing
of the health care worker but may also provide clean/sterile attire.
• Impervious gowns used for personal protection should not be worn outside of the area where
the exposure was anticipated (e.g. blue lab coats should not be seen in the hallways).
• AAMI Level 1 gown is typically used for isolation gowns or standard precautions. There is a
consistent level of barrier protection throughout the gown – no reinforced areas.
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Masks
• Mask
are used for three primary purposess in healthcare settings:
• Placed on healthcare personnel to protectt them from contact with
infectious material from
patients (e.g., respiratory secretions and sprays of blood or body fluids, consistent with
Standard Precautions).
• Placed on healthcare personnel when engaged in procedures requiring sterilee technique to
protect patients from exposure to infectious agents carried in a health-care worker’s mouth or
nose.
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• Placed on coughing patients to limit potential dissemination of infectious respiratory
secretions from the patient to
others (see Respiratoryy Hygiene/Cough Etiquette, CDC’s
Guideline for Isolation Precautions).
• Procedural maskss are the least effective and are not appropriate in a surgical setting.
• Surgical masks are tie masks and provide
better protection than procedure masks (ear-loop
masks)
Respiratory Protection
• To protect the health care worker – should be worn consistently with bronchoscopy
procedures
• Primarily designed to protectt the health care worker from droplett nuclei but some designs
may also protect the patient from aerosols from the health care worker
Eye Protection
• Worn
to protect the eye and face from infectious materials.
• The degree of protection required depends upon the circumstances of exposure, other PPE
used,
and personal vision needs.
• Personal eyeglasses and contact lenses are not considered adequate for eye protection.
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All Personal Protective Equipment (PPE) should be promptly removed after completing the
procedure or when there is no longer a risk of exposure. PPE should
not be seen
in the hallway
or outside of the procedure area.
Dressing
changes for patients with chronicc wounds
Minor invasive procedures
• Must
do
o PPE – sterile gloves
o Skin prep
o Sterile drape
• Remove hair only
if necessary – seldom necessary. Do not use a razor but clip. Consider
implementation with IV starts, electrode placement on patients anticipated to
require heart
surgery, etc.
• Prepare skin
o Approved scrub agent
o Select based on location and patient’s
sensitivity
o Follow instructions
• Drape
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• Sterile items – check processing and package integrity
o Peel packs
• Package integrity
• Not wet
• Completely sealed
• Not punctured
• Check for outdates
• Flip technique to place on field
o Wrapped
• Inspect package
• Ensure integrity
o Instrument pans:
• Locks
• Filter in place
• Tracking tag in place
o High level disinfection
• Monitor field once sterile items are opened
Clean Technique (Medical Asepsis)
• Supplies, Instruments and Utensils:
o Have established protocols for handling all supplies and instruments
o Manually remove debris from instruments with damp gauze or flush with water
immediately after use to facilitate cleaning
o Place grossly soiled instruments in a rigid leak resistant container with appropriate
soaking solution and cover.
o Hands are never used to retrieve objects from opaque solution since liquid may
obscure reusable sharps.
o Rinse grossly soiled utensils and place in designated soiled receiving area for future
processing, which is to be ideally done by Central Services.
o Use processing solutions which are approved by the Infection Control Committee and
for their intended use only.
• Equipment:
o Surfaces should be cleanable
o Clean equipment with a disinfectant before use by another patient, i.e., cautery unit,
etc.
o Items are cleaned with a disinfectant before return to central storage area, and before
repairs or preventative maintenance.
o Large equipment returned to CS is wiped down before transport.
• Trash
o Bag all trash and disposable items to prevent leakage.
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o Gather trash at the end of the procedure by personnel wearing gloves. Trash is
typically removed with the liner but small amounts from non-patient care areas may
be dumped into another larger container. Trash is never removed by reaching into
containers by hand.
o Place all infectious waste in biohazard labeled red bags.
o A biohazard bag is available in patient care areas to use during procedures.
o Drainage units that have a drain port are emptied in the Decontamination area in
Central Services using engineering controls or not emptied at all. Place emptied
drainage units in infectious waste container for disposal. Every attempt must be made
to use available engineering controls to empty drainage units. This may include use
of closed drainage systems or hopper shields. If Engineering Controls are not
available, the appropriate personal protective equipment must be worn.
Room cleaning:
• Daily and terminal cleaning of the exam/procedure room is performed consistently, including
prompt cleanup of body substances and/or spills by gloved personnel using an EPA approved
disinfectant.
• Daily disinfect frequently touched surfaces with an EPA approved hospital disinfectant.
There is a continuum between clean technique and sterile technique.
Surgical Asepsis (Sterile technique)
• Assessed prior to the procedure - Patients are assessed prior to the procedure for any signs or
symptoms of an infectious process. The following are reported to the surgeon and
anesthesiologist for final decision if the patient is a surgical candidate:
o Core temperature > 38.5 Celsius
o Productive cough, runny nose, sore throat, and any other symptoms of a respiratory
infection.
o Pyuria > 10 WBCs/hpf
o Elevated WBC
o Diarrhea with abdominal pain
o Any purulent material or lesion of the skin or subcutaneous tissue in proximity to the
operative site. This includes any abraded or burned skin
o Any recent exposure to communicable disease that may lead to subsequent disease
(e.g., chickenpox exposure to those w/o immunity).
• Skin preparation
o The patient is instructed to bathe the night before and/or the morning of surgery
according to an established protocol.
o Pre-surgical scrubs and clips are preformed only if necessary and then according to
individual surgeon preference for that specific procedure.
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o Consider decolonization of patient with known methicillin resistant Staphylococcal
aureus (MRSA) colonization or infection.
• Patients requiring transmission based precautions
o Established protocols for patients with a multiple drug resistant organism (MDRO) or
any other infection requiring Contact or Droplet Precautions
o Place patients with uncontrolled drainage from wounds in Contact Precautions.
o Patients requiring Airborne Infection Isolation (AII) Precautions should be scheduled
in surgical suite with a negative pressure anteroom and recovered in the same
operating room or in another Airborne Infection Isolation (AII) room. Staff must
wear the appropriate personal protective equipment during isolation. Respiratory
protection should not have an exhalation valve or exhausted without a filtration
system in place to protect the patient from pathogens from the health care workers
upper respiratory tract.
o Regardless of isolation status – all patients entering the surgical suite should have
freshly laundered linens donned after their evening/morning shower or bag bath. Hair
will be covered just prior to entering surgery. Trend to make a slight revision for
Ophthalmology patients. They may wear their street clothes from the waist down and
a clean patient gown if they are cocooned in freshly laundered linens. This only
applies if the patient will remain on the eye cart throughout the surgical procedure.
o All patient contact requires Personal Protective Equipment (PPE), typically gown and
gloves. It is important that hands are washed after removing the gown, gloves, and
other PPEs. Mask and goggles should be added with anticipated contact with blood or
body fluids with possible splash, splatter or spray to the face or eyes..
o After the patient is draped in the OR, the circulator does not have to wear the
isolation gown and gloves. Anesthesia should continue to wear gown and gloves
when in direct contact with the patient.
o Avoid contaminating items in surgery suite while wearing gown and gloves.
Surgery Scrub – Hand Antisepsis
• Wash hands at the beginning of the shift prior to and after performing the procedure, prior to
entry into semi-restricted or restricted areas, and on exit of semi-restricted or restricted areas.
• No artificial fingernails or nail extenders
• Remove jewelry, don eye and face protection and do a final check to be sure all hair is
secured.
• Clean nails under running water
• Apply antiseptic per posted manufacturer recommendations. Specific manufacturer
instructions are to be posted by the scrub sink for easy reference.
• Dry with sterile towel completely before gloving
• When using an alcohol-based surgical hand rub product (with persistent activity), the hands
and forearms should be pre-washed with plain lotion soap and dried completely.
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Clean Attire
• Before donning surgical attire, all persons entering the perioperative suite should wash their
hands with soap and water, antiseptic and water, or an antiseptic hand rub if visible soil is not
present upon arrival.
• Facility-approved, clean, and freshly laundered surgical attire should be donned in a
designated dressing area of the perioperative suite before entry or reentry into the
semirestricted and restricted area.
• All individuals who enter the semirestricted and restricted areas of the perioperative setting
should wear freshly laundered or disposable surgical attire intended for use within the
perioperative setting.
• All non-scrubbed personnel should wear a long-sleeved jacket snapped closed with the cuffs
pulled down to the wrists
• All attire is changed daily or more often whenever they become visibly soiled or wet. The
two piece pant suit should be sized appropriately to prevent pant legs from dragging and
provide adequate coverage. The top should fit snuggly at the hips or be tucked in to the pants.
• Wearing clean attire is limited to the inside of the institution. This does not include the
grounds of the institution or residential housing. Clean attire should be completely covered
with clean jumpsuit if worn outside during the course of job-related duties (e.g. walking from
hospital to pack room, etc.).
• Duty shoes are kept clean and not worn outside. Shoe covers are only worn with reasonable
anticipation of exposure to blood or potentially infective material. Shoe covers are removed
following the procedure upon leaving the room. Shoe covers should not be worn as a
substitute to having duty shoes. Hose or socks are worn.
• Long sleeved jackets or warm-up jackets should be worn by all non-scrubbed personnel in
the central core or the operating room. Long sleeved jackets should be snapped close and
changed daily or whenever possible contamination may have occurred. Clothing that cannot
be covered by the clean surgery attire should not be worn.
• All jewelry is contained within scrub attire.
• All possible head and facial hair, including sideburns and neckline, should be covered. A
hood is worn if scrub caps do not cover hair. Reusable hair coverings should be laundered
after each use by an accredited laundry services. Single use hair covering is discarded at the
end of the shift.
• Surgical attire helps contain bacterial shedding and promotes environmental control. An
individual sheds millions of skin squames daily. Five percent to 10% of skin squames have
bacteria.
• Surgical attire that has been worn during one shift has higher bacterial colony counts at the
end of the work shift when scrub clothing is removed, or when stored in a locker and used
again. Worn surgical attire should be placed in an appropriately designated container for
laundering and should not be hung or placed in a locker for wearing at another time.
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• Wearing the warm-up jacket snapped closed prevents the edges of the front of the jacket
from contaminating a skin prep area or the sterile surgical field. Long-sleeved attire contains
skin shedding from bare arms. When in the semirestricted or restricted areas, all nonscrubbed
personnel should wear a long-sleeved jacket snapped closed with the cuffs pulled
down to the wrists.
• Surgical attire should be laundered in a health care-approved or accredited laundry facility.
• Surgical attire should not be washed in the home.
• Wash hands after removing gown and gloves or any personal items.
• Shoe covers should be changed whenever they become torn, wet, or soiled and discarded in a
designated container before leaving the surgical area.
• Protective shoes must be worn in the perioperative environment. Shoes should have closed
toes, low heels, and non-skid soles.
• Shoes worn within the perioperative environment should be cleaned regularly and have no
visible soiling.
Masks
• The need and the type of mask selected (e.g. surgical, PAPR, N95 respirators, HEPA) should
be selected based on the infectious agent involved and the anticipated level of exposure.
Medical PAPRs typically are not approved for use in a surgical setting with an open sterile
field.
• Masks are worn during invasive procedures or when the sterile items are open.
• Masks are worn to completely cover the nose and mouth and secured to prevent venting at
the sides.
• Masks are either on or off; they are not to be tucked into a pocket or worn hanging around
the neck.
• Masks are generally changed between cases. Exceptions can be made for supervising staff or
others that are in several rooms for brief periods of time.
• Masks are worn by staff cleaning between cases due to the short turn-around time of rooms.
• When removing the mask, touch only the strings to reduce contamination of the hand from
the nasopharyngeal area.
Health care workers should know their status for possible infection with Blood Borne
Pathogens (BBP) if they are at risk of exposure
All surgeons and surgery staff that scrub-in should know their baseline status for
Hepatitis B (HBV), Hepatitis C (HCV) and human immune-deficiency virus (HIV)
infection. All possible exposures to blood borne pathogens should be promptly reported.
It is not uncommon to have a dual exposure during a surgical procedure whereby the
patient becomes exposed to the health care worker's blood. There should be a system in
place to handle dual exposures. Surgeons and surgery staff with known HBV, HCV or
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HIV infection should consult with an advisory panel for ongoing follow-up. (Reference:
Infection Control and Hospital Epidemiology March 2010, Vol. 31, No. 3)
Skin Prep
• The operative site and surrounding areas should be cleaned before entry into procedure room
(i.e., pre-op shower & shampoo).
• Hair should be removed prior to transport to operative/procedure area. Hair removal should
be done only with a clipper or a chemical depilatory and only when absolutely necessary to
facilitate wound closure and dressing. Hair removal should occur as close to incision time as
possible.
• There should be a documented assessment of the operative site, which notes the presence of
skin lesion.
• The operative site and the surrounding area should be prepped with an approved surgical
scrub agent.
• Surgical scrub agents should be selected based on patient sensitivity, incision location, and
skin condition.
• Surgical scrub agents should be used according to the manufacturer’s recommendations.
• Skin lesions or open areas should be prepped according to established protocols.
• Antimicrobial agents should be applied using sterile supplies and sterile gloves. Scrub jackets
should be worn during the prep as long as this does not contaminate the prepped area. The
antimicrobial agent should be applied proceeding from the incision site to the periphery with
the exception of Chloraprep. Surgical scrub agents should not be allowed to pool under
patient.
• Documentation of the skin prep should include assessment of the skin integrity, hair removal
process, area prepped, solutions used, abnormal reaction to prep, and name of person(s)
performing the task.
Sterile Gown
• Sterile gowns and gloves should be worn by scrubbed personnel.
• Sterile gowns should be available with various levels of protection. The standard surgeon
gown is classified per ANSI/AAMI PB270:2003 standard as a Level 2 Barrier. Level 2
barrier gowns are appropriate for short procedures with little or no anticipated exposure to
blood or body fluids. As the length and physical contact of the procedure increases there
should be consideration to select a gown with greater barrier properties.
• Scrubbed personnel should don a sterile gown and sterile gloves from a sterile field other
than the instrument table.
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AAMI Classification Levels of Barrier Performance
Level Test Result Exposure Risk
1 Impact Penetration

Gloves
• Gloves are inspected after donning.
• Double gloving is recommended for most procedures.
• Blue indicator polyisoprene surgical gloves are available as the under glove when double
gloving. The blue indicator glove allows for easier detection of holes in the outer surgeon
glove. Perforation indicator systems results in significantly more innermost glove
perforations being detected during surgery.
• It is generally recommended to change the outer glove every two hours.
• Double gloving may reduce the rate of surgical site infections if perforations are detected
sooner or the barrier remains intact.
Draping
• Inspect for holes as establishing the sterile field
• Handle as little as possible
• During the draping the process the sterile drape is held folded and compact above the
operative area, then placed and unfolded from the operative site to the periphery starting with
the side closest.
• Cuff drape over hands during draping process
Sterile field
• All items used within the sterile field should be sterile.
• All items presented to the sterile field should be checked for proper processing and package
integrity.
• Items introduced onto a sterile field are opened, dispensed, and transferred by methods that
maintain sterility and integrity.
• Wrapped supplies should be opened by un-scrubbed personnel by opening the wrapper
farthest from them first and the nearest wrapper flap last.
• All wrapper edges are secured when supplies should be presented to the sterile field to
prevent contamination.
• Tables are sterile only at table level.
o Anything over the edge should be considered unsterile, such as a suture or the table
drape.
o Should use non-perforating device to secure tubing and cords to prevent them from
sliding to the floor.
• Sterile items should be presented to the scrubbed person or placed securely on the table.
• Objects that are sharp, heavy or difficult to handle should be presented to the scrubbed
person or opened on a separate surface.
• Solutions should be dispensed by:
o Pouring the entire contents into the receptacle or the remainder is discarded.
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o The receptacle is placed near the edge of the table or held be the scrubbed person, and
the fluid is poured slowly to avoid splashing.
• The sterile filed should be constantly monitored, once unguarded it should be considered
contaminated
• Opened instruments should not leave room of intended use.
• Do not cover sterile field to save until later because it is difficult to remove drape without
contaminating the sterile filed.
• Once the patient enters surgical suite, all items should be considered contaminated to that
case
• Scrubbed persons should keep their arms and hands within the sterile area at all times
• Movement around the sterile field should be done in a manner to maintain the integrity of the
sterile field.
• Conversation should be kept to a minimum once the sterile items have been opened. There
should be no gum chewing under the mask.
Sanitation
• Patients should be provided with a safe, clean environment free from dust and organic debris.
• Cleaning should be done on a scheduled basis to prevent cross-contamination.
• Furniture, lights, and equipment should be damp dusted with approved disinfectant before the
first scheduled case.
• The area should be visually inspected before the instruments are brought into the room.
• External packing containers used during shipping should be removed before materials are
transported into the procedure/operating room. The integrity of all packages should be
maintained.
• Equipment from outside the procedure room should be damp dusted with an EPA approved
germicidal agent prior to entry into the procedure/operating room. This includes but is not
limited to items stored in outer corridor.
• Patients should be brought into the procedure/operating room with freshly laundered linens
and gown.
• During the procedure, all activities should be directed at confining and containing
contamination.
• There should be a prompt clean-up of contaminated surfaces with an approved disinfectant.
• Spray bottles should not be used during the procedure or set up.
• The patient's bed from the nursing unit should be cleaned with an approved disinfectant and
freshly laundered linen should be applied.
• Items that come in contact with the patient and/or sterile field are considered contaminated.
• Disposable items with squeezable, dripable, pourable blood are placed in closeable, leakproof
containers or red bags that are labeled with the biohazard symbol. Used/unused or
soiled disposable items are placed in the properly defined disposal receptacles.
Basic Asepsis Page 19

• Gowns and gloves should be removed in a manner that contains contamination and gowns
and gloves placed in the proper receptacle prior to leaving the procedure/operating room.
• Contaminated linen should be handled as little as possible. Linen from any open packs,
whether soiled or not, should be placed in linen hampers for the laundry.
• Instruments should be placed by the gloved scrub person directly into instrument trays and
placed in case cart.
• Disposable suction containers should be sealed and either sent to central processing area for
disposal or emptied in designated soiled area by an individual wearing the appropriate PPE.
• All needles, sponges, instruments should be counted when there is a likelihood of items to be
retained before disposal.
• Sponges should be discarded into or onto impervious surface for counting.
• Personnel should use gloves in handling sponges, organic material, and specimens.
Between Case Cleaning
• All surfaces should be disinfected between cases – know wet contact time claim
• Clean from the top to bottom (cleanest to dirtiest)
• Disinfect all surfaces that could be possibly contaminated
o Includes area for circulator
o Lead aprons/shields
o Keyboards
o Door panels
o Phone
• Remove all debris from floor before mopping/wet vac (includes bone chips)
• The area mopped is dependent upon the likelihood of contamination. Some procedures are
minimally invasive and there is no blood loss therefore floor disinfection is not necessary.
Floors are cleaned with an approved disinfectant. A mop- head is used only once and not
double dipped. It may require several mopheads to clean the floor.
• Scrub sinks should be cleaned after the scrub for each case
Term cleaning
• Terminal/daily cleaning of the procedure/operating room should be done at the conclusion of
the day’s schedule.
• The areas to be cleaned include; lights, ceiling mounted equipment, all furniture including
the wheels and casters, handles and pushes plates, face plates and vents, all horizontal
surfaces, the entire floor, kick buckets, and scrub sinks.
• Thermostats should be set at 72 degrees Fahrenheit or warmer. Terminal/daily cleaning is
also done in the related locker rooms, corridors, rest-rooms, workrooms and storage areas.
• Break rooms should be cleaned at least daily but typically need to be cleaned more often to
keep trash to a minimum. Doors to break rooms should be kept closed at all times.
Basic Asepsis Page 20

Weekly/Monthly Cleaning
• Weekly damp dusting should be done for refrigerators, crash carts, supply carts, med carts,
desks, tables, and case carts in the restricted areas..
• Monthly cleaning of clean storage areas/shelves should be done with monthly checks for
outdated supplies. This includes refrigerators, freezer, crash cart, etc. and med cart. The
following should be cleaned monthly: gas tracks, light fixtures, and the vents in the clean
storage areas and corridors.
Ventilation
• The surgical area should have positive ventilation pressure in relationship to the adjacent area
• There should be a minimum of 4 outside air changes per hour
• There should be a minimum of 20 air changes per hour
• The relative humidity should be 30-60%
• There should be no air recirculation unity in the procedure room
• The temperature control should be 68-75 degrees Fahrenheit.
• Guidance ASHREA/ASHE Standard Ventilation of Health Care Facilities
o Check for duct cleanliness
o Check for balance of the ventilation system.
Syringes, Needles and Disposables
• Safety devices should be used whenever appropriate and available (blunt suture needles,
blunt needle system, safety syringes, etc.).
• Safety device should be activated before disposal.
• Sharps may be place in a rigid, plastic leak-resistant, with a closable container.
• Needles should not be broken, bended, or recapped before disposal.
• Sharps containers should be sealed when two-thirds full and placed in designated area for
pick up.
Injection Safety
• Injection safety includes practices intended to prevent transmission of infectious diseases
between one patient and another, or between a patient and healthcare worker and also to
prevent harms such as sharp injuries.
Laboratory Specimen
• All blood, body fluids and tissue specimens should be placed in a clean impervious container
for transport.
• Specimens from all patients are handled with care.
• The outside of a soiled specimen container is cleaned with a disinfectant.
Basic Asepsis Page 21

• All specimens must be bagged in a clean leak-proof clear bag for transportation to the lab.
Any specimen that is not in recognizable standard specimen container needs a biohazardous
label before transport. Visibly soiled containers may be rejected by the laboratory. All
specimens leaving the institution need a biohazard label.
• Specimens that require other precautions in addition to Standard Precautions are labeled (i.e.
AFB/ Airborne Infection Precautions on lung tissue from a known/suspect TB case).
• Hands are washed after transporting specimens to the laboratory.
• Specimens sent through the tube system should be sealed and double bagged. Liquid
specimens are sealed in containers with a screw-on lid and bagged.
• No specimens should be given directly to the patient. All requests for specimens should be
processed following the approved protocols and the physician before being allowed to leave
the institution.
• Amputated limbs, appendages or fetus are not considered infectious waste although they do
need to be handled with precautions. Limbs should be placed in an orange bag for special
handling by Pathology or Central Services.
Care of Instruments
• Immediate use sterilization should not be used as a substitute for sufficient instrument
inventory or late delivery of loaner sets.
• Instruments should be used only for the specific purpose for which they were designed.
• Instruments should be kept free of gross soil during the procedure.
• A sponge moistened with sterile water should be used to wipe debris from the instrument
during the procedure.
• Lumens should be kept patent by sterile water irrigation.
• All items in contact with the patient and/or sterile field should be considered contaminated to
that specific case. This includes but is not limited to: instruments, sponges, drapes, suture,
equipment, and furnishings. All contaminated items should be cleaned at the end of the case.
If the case cart has been assigned to a specific case, it should be used to return the
contaminated items back to the central processing area. Suction canisters should be secured
in a manner in the case cart to prevent spills during transit (e.g. place canister in basin).
Laundry and trash bags should be removed from procedure room through the outer corridor.
Transit should not occur through sterile storage areas.
• Reuse of single use devices is prohibited unless reprocessing is done by an FDA approved
facility. Open and unused items should be kept to a minimum but may be reprocessed by an
FDA approved facility.
• The decontamination process should begin immediately after completion of the invasive
procedure. Disinfection practices outside of the central processing area should be consistent
with practices within the central processing area.
• Personal protective equipment (PPE) should be used during the decontamination process.
Basic Asepsis Page 22

• Manual cleaning should be done in a manner to limit aerosolization and splashing of
infectious material. Spray bottles of disinfectant should not be used during the case although
disinfectant wipes may be used.
• Prolonged soaking of dirty instruments should be avoided to prevent damage of instrument
surfaces. Enzymatic soaking of instruments is generally considered safe for several hours.
• Decontamination should be done in a designated soiled area.
• Manufacturer’s written instructions should be followed for the detergent selection and the
proper use, care, and maintenance of the instruments.
• Instruments with movable parts should be lubricated after every cleaning and according to
the manufacturer’s written instructions.
• Instruments should be inspected and prepared for storage and/or sterilization following the
cleaning process.
• Instruments should be checked for cleanliness, proper functioning and alignment, freedom
from defects, sharpness of cutting edges, looseness of pins, and chipping of surfaces.
• Instruments should be dried and then stored.
• Instruments with removable parts are should be disassembled and placed in trays designed
for sterilization. Ring-handled instruments should be secured in a manner that retains an open
position.
• Delicate sharp instruments should be protected during the decontamination process.
Endoscope Reprocessing (See presentation on Endoscope Reprocessing for more details.)
• Endoscopes should be inspected, tested, and processed according to design and type and
manufacturer’s written instructions.
• Endoscopes should be handled so as to prevent damage to lenses and fiberoptic components.
• Endoscopes should be disassembled, thoroughly cleaned manually, and dried before
sterilization or high level disinfection.
• Disinfected endoscopes should be thoroughly rinsed with sterile water and dried before
storage.
• Accessories should be decontaminated, cleaned, and sterilized according to the
manufacturer’s written instructions.
• The disinfected endoscope should be rinsed again immediately before use.
Powered Instruments
• Powered surgical instruments should be decontaminated, cleaned, and sterilized according to
the manufacturer’s written instructions.
• Powered surgical instruments should be inspected, tested, and used according to the
manufacturer’s written instructions.
• Powered surgical instruments should be packaged and sterilized before use according to the
manufacturer’s written instructions.
Basic Asepsis Page 23

• Exposure times for steam and EtO sterilization of powered surgical instruments should be
done according to the manufacturer’s written instructions.
References
Perioperative Standards and Recommended Practices, 2011 Edition by AORN
Basic Asepsis Page 24

Remove all jewelry and piercings before surgery
You cannot wear jewelry of any kind during
surgery. You could be injured. Even if you
have a new piercing that has not fully healed,
it must be removed before surgery. These are
some of the risks of leaving jewelry and body
piercings in place.
• Some tools use electricity to close blood
vessels and perform other functions. Metal
jewelry can conduct current and cause
burns.
• Piercings in and around your mouth might
come loose. When a breathing tube is put
into your throat, you might swallow or
breathe in part of a piercing set.
• Your skin or tissues could be damaged if
you lie on jewelry. You will not feel pain or
be able to shift your weight to relieve
pressure.
• Jewelry that appears on x-rays and other
tests can disrupt the correct reading of
images needed for your care.
• Infection can occur if the piercing site is
new or not well healed.
You will be asked to remove all of your
jewelry before surgery. The pre-op nurses can
help you if needed. If you have a new piercing
and do not want to remove the piercing for a
long period of time, you may be able to use a
plastic, metal-free retainer. You must talk with
your surgeon to make sure this is okay.
In pre-op, the nurse must see and record that
all jewelry has been removed. All pieces will
be placed in a plastic bag and put in a safe
place. It will be returned to you after surgery.
You may put your jewelry back on if it is not
near the incision.
• Jewelry can catch on something and be
ripped out.
• A staff member who must place a urine
catheter will have trouble working around
jewelry in your genital area.
This content supports the care you receive from your health care team. It does not replace medical care or advice. Talk to your doctor or others on your
health care team before you start any new treatment. Content goes through routine review by experts on our staff.
08/20/2010
PE 001301 The right information for our patients
Page 1 of 1

Methicillin-Resistant Staphylococcus aureus (MRSA)
Staphylococcus aureus is a common type of
bacteria. It is better known by its nickname,
“staph” (staf). For most of us, staph is harmless
most of the time. It can live on your skin or in
your nose without causing problems. But if it
infects a wound, your blood or your lungs, it can
make you very sick.
Methicillin-resistant Staphylococcus aureus
(MRSA) is a strain of staph that resists some
antibiotic treatment. Some call it a “super bug”,
but it is no joke. Few drugs can control MRSA
after it infects someone.
Does everyone exposed to staph
or MRSA become infected?
No. Some become colonized. Being colonized
means staph bacteria are on your body but do not
infect you. They may live and grow in your:
• Nose
• Sputum (what comes out of your throat
after deep coughs)
• Urine and sex organs
At least one-third of the general population is
colonized with staph. Of these, only a small
number are colonized with MRSA.
Why and where do “staph”
infections occur?
Staph can infect people with injured skin or
chronic illness. One type of staph is more
common in places where there are large groups of
people. These include hospitals, nursing homes
and dialysis centers. Healthcare associated MRSA
(HA-MRSA) may infect:
• Wounds
• Urinary tract
• Blood
• Lungs
11/19/2008 continued...
PE 000490
About half of those who have a chronic illness
are colonized. They tend to be in the hospital
more often than people whose immune systems
are strong enough to resist staph.
What is community-associated
MRSA (CA-MRSA)?
This type is found in places other than hospitals
and health care buildings. It can infect people
who have not:
• Been cared for in a hospital within the past year
• Had surgery, dialysis, catheter placement or
another procedure.
CA-MRSA can cause red or infected bumps on
your skin. Your health may be fine except for
what looks like a severe skin problem. If you
have this symptom, do not take it lightly. See a
doctor. You may need tests as well as treatment.
CA-MRSA can spread among children in day
care, athletes who play contact sports and health
club members. CA-MRSA may be a problem
among those who live in crowded places like
shelters or prisons.
Where are staph and MRSA
found?
If you carry staph in your nose or on your skin
with no sign of illness, you are colonized. If
germs increase in number or your immune system
weakens, you may break out in pimples or boils
as described above. These may be:
• Red or swollen
• Painful
• Draining pus or other fluid.
Severe infections are more likely when your body
is weaker due to illness, injury or recent surgery.
The right information for our patients Page 1 of 2

How is it spread?
The most common way to “get” MRSA is
through skin to skin contact with:
• Someone with a staph-infected wound
• Someone whose mouth, nose, throat or lungs
are infected with staph
• Someone who has colonized MRSA (large
numbers of these germs on or inside the body)
You can get MRSA by touching things that have
been worn or used by someone infected with
MRSA. These items may include:
• Towels and washcloths
• Sheets and other bedding
• Wound dressings
• Clothes
• Sports equipment
How can you prevent the spread
of staph and MRSA?
Clean hands are key to prevent illness. If you
have direct contact with an infected person or
things he or she has touched:
• Wash your hands with soap and water for 15
seconds – OR
• Use an alcohol based gel unless you can see
dirt or other matter on your hands.
Cover any wound with a clean, dry dressing. All
persons who enter the hospital room of a patient
with MRSA must wear gloves and a gown. Staff
will clean the room daily with
disinfectant.
How is staph or MRSA treated?
Most staph infections can be treated with
antibiotics. There are fewer choices for MRSA.
Lab tests show which drug should work. A doctor
may be able to treat a staph skin infection by
draining an abscess or boil without using
antibiotics. Never try to do this at home by
yourself or with help from a family member or
friend. Chances are high that you will spread the
disease or create a wound that is slow to heal.
How long will the effects of
MRSA last?
This depends on:
• How severe the infection is
• Whether MRSA responds to the chosen
antibiotic
• The health of the infected person
Even after an infection is cured, MRSA may stay
on a person for many years.
What can I do at home?
Wash your hands the correct way and wash them
often. Always wash with soap and water after
you:
• Use the toilet.
• Touch a wound.
• Handle and throw away items soiled with pus,
sputum, blood or other body fluids
Use your own towel, washcloth and razor. Wash
dishes and flatware with hot water and soap.
Clean counters and surfaces with soap and water.
Follow up with bleach or other household
products that kill germs. Wash clothes in hot
water and laundry soap. When you wash white
underwear, washcloths, towels and sheets, think
about adding bleach. Dry wet laundry right away.
Never leave wet clothes in the washer.
This content supports the care you receive from your health care team. It
does not replace medical care or advice. Talk to your doctor or others on
your health care team before you start any new treatment. Content goes
through routine review by experts on our staff.
PE 000490 The right information for our patients
Page 2 of 2

Shower or Sponge Bath Before Surgery
For your safety, follow these steps to
help prevent infection.
Let your nurse or doctor know if you are allergic
to any soaps.
A shower is better than a sponge bath. A tub bath
is not recommended.
The night before surgery, take a shower or a
sponge bathwith a liquid antibacterial soap. The
more contact this soap has with your skin, the
more germs it will kill.
In the morning before you leave for the
hospital, shower again or give yourself
another sponge bath with the antibacterial
soap.
Do not shave your skin in the surgical area. For a
cesarean, hysterectomy or any other abdominal
surgery, do not shave the abdomen or pubic area.
Nurses will remove hair as needed with special
clippers when they prepare you for surgery.
Shower – Lather and rinse twice
1. Use freshly laundered towels and washcloths.
2. Stand on a safety mat or wet towel to avoid
falling. Wet your skin and hair.
3. Use 1 ounce of antibacterial soap on your
body and 1 ounce of antibacterial soap on your
hair. Work up a good lather all over your body
and hair. Be sure to wash your abdomen
(belly) and pubic area thoroughly.
4. Turn off the water. Leave lather in place for at
least 30 seconds. Stand still while you wait.
5. Rinse.
6. Repeat steps 3, 4, and 5.
7. Gently towel dry.
8. Do not put any oils, lotions or conditioners
on skin or hair during or after your shower.
9. Put on clean nightclothes before you go to bed.
10. Sleep on sheets that have been freshly laundered.
11. In the morning, shower the same way. Lather,
wait 30 seconds, rinse and repeat. Wear clean,
comfortable clothes to the hospital.
Sponge Bath (body only, not hair)
1. Add 1 ounce of antibacterial soap to each quart
of
warm water.
2. Use 8 clean washcloths. Soak them in the warm,
soapy water.
3. Use a separate washcloth for each area:
• Face and neck
• Chest and abdomen – wash thoroughly
• Pubic area – wash thoroughly
• Back
• Each arm and shoulder
• Each leg
After you use each cloth, set it aside. Do not put
it back in the soapy water.
4. Rinse your skin with clean water and a separate,
fresh washcloth. Gently towel dry.
5. Do not put any oils, lotions or conditioners
on skin or hair after bathing.
6. Put on clean nightclothes before you go to bed.
7. Sleep on sheets that have been freshly laundered.
8. Take another sponge bath in the morning. Wear
clean, comfortable clothes to the hospital.
If you have questions or the soap
causes a rash, hives or itching
Call Telephone Nurse Advisor
(608) 775-4454 or (800) 858-1050
This content supports the care you receive from your health care team. It does not replace medical care or advice. Talk to your doctor or others on your
health care team before you start any new treatment.
10/21/2011
PE 000172 The right information for our patients
Page 1 of 1

Prepare Your Skin for Surgery
You can reduce your risk for infected wounds
by wiping your skin with special washcloths.
They are moistened with CHG, a liquid that
kills germs.
Tell your nurse or doctor if you are allergic
to CHG. We will give you some other
product.
Clean a work surface with soap and water.
Tear the flap line of the CHG packet or cut it
open with clean scissors. Lay each cloth foam
side down on the clean surface. Use the first
cloth to:
• Gently wipe back and forth for about 1
minute all over the area circled on the
picture.
4 days before surgery
• Stop shaving the area circled on the picture
4 days before surgery.
The night before surgery
Take a shower or bath and shampoo your hair.
Thoroughly rinse your skin and hair. Do not
use any skin lotion or hair conditioner. Wear a
clean robe or put on clean clothing. Wait 2
hours before you use the CHG cloths.
For your safety and the best results:
• Do not warm the package in a microwave
oven.
• Do not touch your eyes, ears, or mouth
when you are using a CHG cloth. If you get
CHG in your eyes, ears or mouth, rinse with
cool water right away.
• Rinse your hands right after you finish
wiping your skin with the CHG cloth.
• Do not rinse off CHG unless your skin
itches or seems to be irritated.
• Do not put lotion or powder on skin that
you have wiped with CHG.
• Be sure to get under skin folds. Hold folds
open to let air dry your skin. This will keep
it from being irritated.
• Do not touch your sex organs with the CHG
cloth.
• Repeat the process with the other cloth.
• Wipe all of the same places for 3 minutes
this time. Be sure you push the cloth under
skin folds and hold them open to air dry.
Throw away used cloths.
08/17/2010 continued...
PE 000933
The right information for our patients Page 1 of 2

Prepare Your Skin for Surgery
Your skin will feel tacky for a few minutes.
Do not rinse off. Wait until your skin is
completely dry, including skin folds. Put on
clean night wear (pajamas or nightgown).
Sleep on sheets that have been freshly
laundered.
Note: If your skin reacts to the CHG by
turning red or itching, it is OK to rinse off
the CHG. Let your skin air dry before you put
on clean nightwear.
For Your Health
If you have any questions about
your skin prep
On weekdays from 8 a.m. to 4:30 p.m., call
the department where you received your
packet of CHG cloths. After 4:30 p.m. or on
weekends or holidays, call Telephone Nurse
Advisor at (608) 775-4454 or (800) 858-1050.
On the morning of surgery
• Do not bathe or shower.
• Do not wipe or rinse off your CHG skin
prep.
• Your skin will be scrubbed again when staff
prepares you for surgery.
This content supports the care you receive from your health care team. It does not replace medical care or advice. Talk to your doctor or others on your
health care team before you start any new treatment. Content goes through routine review by experts on our staff.
PE 000933 The right information for our patients
Page 2 of 2