IACUC Semi-annual Rodent Surgical Site Inspections - updated 1/4/17

• IACUC Semi-annual Surgical Site Inspections

• Building / Room:

• IACUC Designated Inspector:

• Conducted on

  Date

• Is surgical site accessible for inspection?

  Yes

  No

• Contact the IACUC Office (xxx-xxxx) and have them call the PI to get access.

IACUC Surgical Site Inspection

Surgical/Procedure Area:

• Is the procedure area for survival surgery, non-survival surgery, or both?

  Survival

  Non-survival

  Both

• Is the surgical space dedicated for animal procedures?

  Yes

  No

• Is the space used only for surgery when animals are undergoing procedures?

  Yes

  No

  Not Applicable

• Is the site free from drafts, windows, and laboratory traffic?

  Yes

  No

  Not Applicable

• Have dirty cages been removed?

  Yes

  No

  Not Applicable

• Is there a biohazard waste container (with an autoclavable liner) present?

  Yes

  No

  Not Applicable

• Is there a sharps container present?

  Yes

  No

  Not Applicable

• Are all work surfaces clean, and can they be disinfected?

  Yes

  No

  Not Applicable

• Are disinfectants appropriate?

  Yes

  No

  Not Applicable

• Examples of acceptable disinfectants:
  Quaternary Ammonium (Santi Cloths, Quatricide, Rocal, Tec-Surf II
  10% bleach (must be made fresh daily)
  Chlorine dioxide (Clidox, MB-10, check instructions for expiration)
  Glutaraldehydes (Cetylcide, Cide Wipes)
  Phenolics (Lysol, TBQ)
  Chlorhexidine (Nolvasan, Hibiclens)

• Are disinfectants within their expiration date?

  Yes

  No

  Not Applicable

• Is there evidence that aseptic technique is used?

  Yes

  No

  Not Applicable

• Do supplies and equipment appear to be clean?

  Yes

  No

  Not Applicable

• Are there any additional comments for this section?

  Yes

  No

• Additional comments/observations for section

• Is photographic documentation needed for this section?

  Yes

  No

• Photographic documentation of procedure space(s)

Photographic documentation item

• Photographic documentation of procedure spaces

  Media

Instrument/Equipment Sterilization:

• Are instruments and equipment cleaned prior to sterilization?

  Yes

  No

  Not Applicable

• How are instruments, equipment, and supplies sterilized?

  Steam

  EtO

  Chemical

• Was the appropriate procedure followed for duration of exposure and removal sterilizing chemical?

  Yes

  No

  Not Applicable

• Are internal integrator strips used?

  Yes

  No

  Not Applicable

• Required. Autoclave tape on the inside of the pack is not acceptable. It must be a sterilization indicator strip.

• Do instruments and tools have the sterilization date on the packs?

  Yes

  No

  Not Applicable

• Not required if used within 24 hours.

• Are sterilized instruments and tools stored to prevent exposure to moisture and dust?

  Yes

  No

  Not Applicable

• If multiple animals undergo surgery in one day, how are instruments re-sterilized between animals?

  Dry Bead Sterilizer

  Re-autoclave

  Separate Sets of Tools

• Are there any additional comments for this section?

  Yes

  No

• Additional comments/observations for section

• Is photographic documentation needed?

  Yes

  No

• Photographic documentation of sterilization of instruments and supplies

Sterilization of instruments/supplies

• Photographic documentation of sterilization of instruments/supplies

  Media

Drugs/Sutures/Reagents:

• Diluted or mixed drugs or reagents should be stored in injectable vials or uncoated/untreated blood collection tubes.
  
  The expiration date of mixed drugs and reagents is the drug/reagent with the expiration date the will occur first. If the drug or reagent has no expiration, then it is 2 weeks from the date it was made if stored in the refrigerator.
  
  Avertin can be stored up to 2 weeks in the refrigerator, or 1 year in the freezer if protected from the light (I.e. - it must be stored wrapped in foil). It is considered expired if there are crystals in it, or it has turned yellow.

• Are all anesthetics, drugs, and reagents within expiration date?

  Yes

  No

  Not Applicable

• List expired drugs:

• Are absorbable sutures used for muscle layer?

  Yes

  No

  Not Applicable

• Note: Types of absorbable sutures include - catgut, chromic cat gut, PGA/Dexon, PDS, Vicryl

• Are non-absorbable sutures, PDS, or Vicryl used to close skin?

  Yes

  No

  Not Applicable

• Note: types of non-absorbable sutures that are acceptable - Nylon (Ethilon), Polypropylene (Prolene)

• Are all sutures within their expiration date?

  Yes

  No

  Not Applicable

• List sutures that are expired:

• Are other supplies within their expiration date?

  Yes

  No

  Not Applicable

• List supplies that are expired:

• Note: Expired sutures and supplies (drugs and reagents may never be administered to animals) may be used for non-survival surgeries if they are clearly labeled as "Expired - For Non-survival Surgery Only". They must be stored in a separate location from the unexpired stock.

• Are all anesthetics, analgesics, antibiotics, other drugs and reagents pharmaceutical grade?

  Yes

  No

  Not Applicable

• Are controlled substances stored correctly?

  Yes

  No

  Not Applicable

• Note: DEA Regulations require all controlled substances to be stored behind 2 locks at all times.
  
  Schedule I and II drugs must be stored in a wall or floor mounted unit (unless the container weighed over 750 lbs) with two doors each with their own independent lock.
  
  Schedule III, IV, and V drugs can be stored as above, or they can be stored in a single lock box that is stored in a cabinet or desk drawer secured by a padlock and hasp, or the can be stored in a single lock lockbox that is kept in a room that is locked at all times (no exceptions).

• Are volatile anesthetics used for surgical procedures?

  Yes

  No

• Is a vaporizer used to administer the anesthetic?

  Yes

  No

• Has the vaporizer been re-calibrated or re-certified in the past year?

  Yes

  No

  Not Applicable

• Are the anesthetic gases scavenged?

  Yes

  No

• How are the anesthetic gases scavenged?

  Fume Hood

  Dedicated Exhaust System

  Scavenging Canisters

  Other

• Has the scavenging canister been weighed and labeled with its initial weight and date it was put into service?

  Yes

  No

  Not Applicable

• Does the canister, or a log sheet near the canister have a periodic record of the date of use and a measurement of the canister's weight?

  Yes

  No

  Not Applicable

• Are there any additional comments for this section?

  Yes

  No

  Not Applicable

• Additional comments for drugs/reagents/ sutures section:

• Is any photographic documentation needed for this section?

  Yes

  No

• Is any photographic documentation needed for this section?

Drugs/Reagents/Sutures

• Photographic documentation for Drugs/Reagents/Sutures:

  Media

Record Keeping:

Surgical Records

• Are surgical and anesthesia records available?

  Yes

  No

• Are surgical and anesthesia records kept for each animal?

  Yes

  No

  Not Applicable

• Note: Surgical and Anesthesia records can be combined.

• Complete surgical and anesthesia records should include:

• Date of surgery

• PI name

• Animal Protocol number

• Animal ID

• Species

• Animal weight

• Procedure

• Anesthetic(s) used

• Time of induction

• Time of recovery

• Analgesic agents given (day of surgery)

• Monitoring of animals until recovered

• Time, dose, route analgesia given (day of surgery)

Post-surgical Monitoring Records

• Are post-surgical monitoring records available?

  Yes

  No

  Not Applicable

• Monitoring should occur every day for 5 days post-surgery, including weekends and holidays.

• Post-surgical monitoring should include:

• Date/Time/Route of analgesia administration

• Date wound closures are removed

• Pain assessment

• Surgical site appearance

• e.g.- heat, excessive swelling, purulent discharge, wound closure, tight sutures

• Activity

• e.g.- normal vs. decreased activity

• Are there any additional comments for this section?

  Yes

  No

  Not Applicable

• Additional comments for record keeping section:

• Is any photographic documentation needed for this section?

  Yes

  No

  Not Applicable

• Is any additional photographic documentation needed for this section?

Surgical/Monitoring Records

• Photographic documentation for record keeping:

  Media

• Surgical site inspection is complete.

IACUC Semi-annual Non-USDA Surgical Site Inspection Report

• Thank you for facilitating the IACUC Semi-annual Non-USDA Surgical Site Inspection of your lab. The Office for Laboratory Animal Welfare (OLAW) requires all laboratories performing either survival or non-survival surgery to be inspected by the IACUC every six months. Thank you for your cooperation in helping us fulfill this mandatory compliance requirement.
  
  This report is a summary of the surgical site inspection for your laboratory. Any deficiencies will be listed in either the Minor deficiency section or the Significant deficiency section. Corrective actions will be given for any deficiencies listed and a deadline will be given for notifying the IACUC Office that the corrective actions have been completed.
  
  Please contact the IACUC Post-approval Monitor (by phone at xxx-xxxx or by e-mail at {e-mail address}) if you have any questions, concerns, or comments.

Minor Deficiencies

• Are there any minor deficiencies?

  Yes

  No

• List Minor Deficiencies:

• There are no minor deficiencies.

Significant Deficiencies

• Are there any significant deficiencies?

  Yes

  No

• List Significant Deficiencies:

• There are no significant deficiencies.

Corrective Actions

• Are there any corrective actions?

  Yes

  No

• Per OLAW regulations and IACUC Policy, corrective actions for Significant Deficiencies that affect the health or safety of the animal and/or the safety of personnel must be completed within a specified time which is to be determined by the Institutional Official (IO), the IACUC Chair, the Attending Veterinarian, the IACUC Office Director, and other OAR Clinical Veterinarians.
  
  Corrective actions for Minor Deficiencies are to be completed by (insert date) and the IACUC Post-approval Monitor should be contacted by e-mail (e-mail address) and informed that the corrective actions have been completed.

• List the corrective actions:

• There are no corrective actions to complete.

Recommended Actions

• Are there any recommended actions?

  Yes

  No

• List recommended actions:

• There are no recommended actions.

Comments/Notes

• Surgical Site Inspection Rating:

  Outstanding

  Excellent

  Good

  Needs Improvement

• Comments/Notes