Title Page
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Hospital Name
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Date/Time
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Prepared By
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Location
Policies and Procedures
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• A policy/procedure (P&P) for Infection Prevention and Control (IPC) exists for anesthesia practices.
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• Staff are trained upon hire/appointment and annually on IPC P&Ps.
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• Anesthesia staff are able to articulate and practice per the anesthesia P&P, or hospital policies should a focused anesthesia one not exist.
Hand Hygiene and Glove Use
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• Approved hand hygiene products are readily available and easy to access.
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• Staff verbalizes understanding of when waterless products may not be used.
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• No jewelry on fingers, hands, wrists in semi-restricted/restricted areas or for sterile procedures
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• Nails. Adherence to facility P&P.
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• Hand Hygiene (HH) consistently used during movement from dirty to clean.
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• Gloves in various sizes are available and easy to access.
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• Gloves are worn for procedures where contamination is likely (e.g. intubation, suctioning) Gloves are then removed and HH performed prior to contact with clean environment (meds, keyboard).*
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• HH is performed before donning sterile gloves (e.g. central line placement).
Personal Protective Equipment (PPE)
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• Staff adheres to surgical attire P&P.
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• Staff properly uses PPE for self-protection (gown, mask covering nose and mouth, eye protection, gloves).
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• In addition to Standard Precautions, staff adheres to requirements for isolation per P&P. Mechanism in place for anesthesia to know which patients are on precautions.
Environment
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• Clean and dirty spaces are clearly defined and treated as such.
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• Staff responsible for room turnover are trained on steps involved in the process. What to discard and where, surface cleaning & disinfection.
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• Method is in place that indicates that the OR/procedure room turnover is complete for the environment and medications and room is ready for the next patient. (A technician may be responsible for room turnover and the anesthesia staff for the medications).
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• Sharps containers and trash bins are easy to access, not overfilled and are located away from clean areas.
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• Laryngoscope blades are bagged in storage until use.
Workflow
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• Efforts are made where feasible to limit staff turnover during the implant phase of a surgical procedure.
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• Staff does not eat or drink in room.
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• Clear separation of workflow between dirty and clean activities/spaces.
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• No expired medications or supplies.
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• Anesthesia workroom is clean and orderly and items are at least 6 inches off floor. Solid bottom shelves on any storage carts.
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• Nonessential personal equipment is not brought into work area/room. (e.g. backpacks, computers).
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• If visitors (e.g. parents) are allowed into Operating Room (OR), a consistent plan is in place for what they wear (scrubs or covering apparel) and when and where in the room they should and should not be.
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• Frequently used supplies are easily accessible within the OR suite to minimize traffic in and out of the room.
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• Needed supplies are pulled prior to the case so as to limit need to go into the clean cart after case has started. If need to get more supplies from the cart, HH is to be performed prior to accessing the supplies.
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• If products used to obscure inhalation mask odors are used (e.g. scented lip balm, scented extracts) a process is in place to keep product hygienic.
Injection Practices and Medications
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• Single dose vials/syringes are used whenever possible.
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• Sharps safety devices are in use and being used accordingly.
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• Syringes are not used between patients (even if the needle has been changed). Changing the needle for such a purpose is unacceptable.
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• Multi-dose vials are avoided when possible but when used between patients are not stored in the “immediate patient care” environment.
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• After penetration of the rubber stopper, multi-dose vials require a beyond use date of 28 days unless the manufacturer’s expiration date will be reached before 28 days or the product labeling (package insert) states otherwise.
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• Inspect vials and medication syringes for any signs of contamination or tampering.
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• A new syringe and needle is used when accessing a vial.
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• All medication and flush syringes are appropriately labeled.
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• Controlled medications are securely stored (locked) when not overseen by anesthesia staff. Non-controlled medications may be left unlocked in a secure area in the immediate perioperative period. Individual facilities are to define the secure area and the term immediate periop period.
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• Medication storage and preparation area is maintained as a clean space.
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• Used medications are not stored back on the clean preparation area.
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• Vials/syringes should not be stored or transported in clothing or pockets except when an organization specifically allows for this for the purposes of facilitating premedication or to have rescue meds readily available when transporting a patient.
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• Diaphragms of vials are cleansed using friction and sterile 70% isopropyl alcohol, ethyl alcohol, iodophor or other approved antiseptic swab and allowed to dry prior to accessing.
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• Ampules are disinfected and allowed to dry prior to opening. Filter needles are used when accessing contents.
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• Aseptic technique is used when handling and administering medications.
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• Plans for consideration for drug shortages are in place.
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• Process to prevent medication diversion in place.
Intravenous (IV) Supplies and Intravenous Therapy
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• Infusion supplies such as needles, syringes, flush solutions, administration sets, or IV fluids are not used on or for more than one patient.
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• Chevroning an IV site with tape prior to application of a dressing is not recommended. Utilize securement techniques after a sterile dressing is applied.
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• Staff priming IV tubing have been educated and periodically observed to assure proper aseptic technique. Process is performed in a clean work space. Tubing labeled with date/time/initials.
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• If priming IV lines >1 hour before use, should incorporate a risk assessment and process/procedure/staff education to limit contamination during the process. Priming should be performed in a clean space and product stored in a secure location to avoid tampering. Tubing should be labeled with expiration date/time/initials per P&P.
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• When patients are receiving a new central line during the case, new IV solution and tubing should be used for this line.
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• Streamline type of IV tubing and IV dressing with hospital P&P whenever possible.
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• Stopcocks and manifold devices are handled using aseptic technique.
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• IV caps/hubs are disinfected with sterile 70% isopropyl alcohol, ethyl/ethanol alcohol, iodophor or other approved antiseptic and allowed to dry before accessing.
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• Stopcocks and manifold ports are covered with a sterile cap when not in use.
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• Methods are in place to assure timely re-dosing of surgical prophylaxis, when indicated.
Neuraxial Procedures
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Epidural, spinal, or combined spinal-epidural administration of anesthetics, analgesics, or steroids; lumbar puncture (LP) or spinal tap; epidural blood patch; epidural lysis of adhesions; intrathecal chemotherapy; epidural or spinal injection of contrast agents for imaging; lumbar or spinal drainage catheters; or spinal cord stimulation trials.
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• Cap, mask, sterile gloves and eye protection are worn during these procedures noted above. (Glasses for vision do not constitute full eye protection) Note: an LP in anesthesia is usually used to instill medication hence included in this PPE use.
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• Sterile drape, skin prep w/ dry time, sterile occlusive dressings are used.
Respiratory care procedures/equipment
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• Breathing circuit – use filter with efficiency rating of 95% for particle micron sizes of 0.3micron.
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• IV bags or bottles are not to be used as a common source (e.g. saline flushes) for multiple patients.
Disinfection
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• Proper disinfection with hospital-approved product at end of case includes but is not limited to: anesthesia med/supply cart, anesthesia machine (knobs, surfaces, cords, keyboard, monitor, Adjustable Pressure Limiting (APL) valve), IV pole, laryngoscope handle)
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• Single patient use items are discarded at the end of each case (e.g. circuits, airway bags, suction tubing).
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• Stethoscopes are disinfected per hospital P&P.
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• Are anesthesia staff responsible for cleaning and high-level disinfection and/or sterilization of any reusable equipment? If yes, competencies in place and all quality control measures performed and documented?
Exposure Management
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• Staff can articulate when and how to handle and report exposures to blood/body fluids (Human Immunodeficiency Virus (HIV), Hep
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*An exception for HH not being performed between changing of gloves can be made when an urgent patient safety need arises.
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Miscellaneous Comments/ Observations
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Completion
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Assessors Name and Signature
