Questions and Answers from Recent Infection Control Webinars
Question #1: What are your suggestions for training "after- hours" cleaning crews?
Answer: Do not leave it to that outsourced company for the sole training.
You should train
them and conduct an observation to make sure that they are following your instructions/training.
They need to have all the knowledge about cleaning products and procedure to answer the
questions of the surveyors.
Follow-up question: Does the cleaning staff have to dress out to enter the O.R.?
: Yes, they do need to dress out.

Question #2: Are the multi-dose medications allowable on the anesthesia cart? Is this
considered a direct patient contact area?
: Yes it is ok that they are there but the staff have to monitor them, account for them and
keep the cart locked.

Question #3: Does the autoclave have to show pressure for documenting, we have an older
autoclave that does not document pressure.
: The only way that you can document that is the older level 5 chemical indicators.
Contact your sterilizer repairman/vendor to see what he can give you to determine the
temperature. You do need to have some kind of documentation.

Question # 4: What type of things should an implant log include? What about keeping a
log for implanting spinal cord stimulators?

Answer: Have to have a patient label that has all the pertinent patient information; the sticker
from the stimulator needs to be on the log, the date of service, 30-day follow-up, etc. You will
have to send a follow-up letter to the provider to see if there has been a post-surgical infection.

Question 5: Do we have to lock up non-controlled drugs when we leave the OR? Drugs
like antibiotics, decadron, neostigmine?

Answer: Yes; they should not be out where any unauthorized person could have access to it or
where an authorized care giver could steal it when unattended between cases; in relation to
infection control, you want to reduce the chances also that an unauthorized person is rummaging
through the cart and contaminating the vials/packaging.

Question 6: Can you give us a specific policy about how to store and document our break-
room refrigerator?
AORN’s Recommendation on Environmental cleaning includes this:

V.a.3. Refrigerators and ice machines have specific cleaning requirements. Patient refrigerators should be cleaned weekly and outdated food removed. Cleaning should be logged on log sheet. Ice machines with a dispenser are preferable to ones that require the use of scoops. Scoops should not be kept in the ice compartment. Scoops should be cleaned on a weekly basis I am not aware of a specific policy or procedure for employee refrigerators but it is a good idea to create one. You may adapt your patient food refrigerator policy to be the break-room refrigerator. I would suggest also posting a sign on the refrigerator that it would be cleaned out weekly. Put the sign upon on Monday and simply state that everything would be thrown away on Friday if not consumed. Then the refrigerator should be washed out thoroughly with soap and water. Question #7: Is it required to clean the B/P cuff and patient chairs in between cases?
According to AORN’s Environmental Cleaning Standards; II.b.1. Mattress covers,
pneumatic tourniquet cuffs, blood pressure cuffs, and other patient equipment, should be cleaned
and disinfected with an EPA-registered hospital disinfectant between patient use. This policy
also comes from the CDC.
Question #8: If we are doing only a few surgeries per month requiring a completely sterile
OR, do you recommend terminal cleaning DAILY even without using the OR?
AORN, CMS, Joint Commission and AAAHC have recommendations and guidelines
about environmental cleaning. What it boils down to is this. Terminal Cleaning needs to be done
daily even if the room is not use. Their reasoning is that even if the room is not use there is dust
that accumulates on all the horizontal objects. The evening housekeepers really do need to go in
and clean as well.

Question #9: I would also like some clarification on the single use syringe. We inject 0.5 cc
of Epi into a 500 ML bottle of BSS. Each Epi has 1 cc. We draw them up and put half in a
bottle and the other half into a separate bottle. Is this okay? Do we need to change the
needle and syringe for every Epi we open?
First, what does your epinephrine ampule or medication vial say? If it says single dose
then you can’t draw up 1 ml and put 0.5 ml in one BSS or IV bag and the other 0.5 ml in another.
CMS, Joint Commission, USP and AAAHC do not permit the use of single dose ampules or vials
for multiple patient use. If your vial is a multiple dose via, then yes you would need to change
the needle and the syringe for each does of epinephrine you draw up. This is to prevent cross
contamination and medication errors. According to CMS survey tool under injection practices

for multiple dose vials, medication is always entered with a new needle and syringe. Single dose
medication is used for only one patient.
Question #10: Can you supply information on anesthesia carts being locked in between
Joint Commission’s Medication Management MM 2.20 requires that medication,
specifically controlled substances be secure from access by unauthorized persons. It also
requires that medication be locked or stored in a locked room with constant surveillance to
prevent access from unauthorized persons. This includes all the everyday medications we use in
healthcare; local anesthetics, antibiotics, eye drops, P.O. meds, and so on. AAAHC has some of
the same requirements as well. But CMS also requires the medications be secure at all times.

Anesthesia providers will argue that the O.R. is a secure location. CMS, Joint commission, USP and AAAHC would disagree especially after the recent article from Colorado involving the surgical tech that stole Fentanyl, injected in to her leg through her scrubs, and replaced the contaminated syringe with a clear fluid on the anesthesia cart. 6000 patients had to be tested for Hepatitis C and about a hundred or so acquired Hepatitis C. This was from a so called secure location! I am not saying that your staff would do this but in today’s environment why provide the temptation to take any drug.

Source: https://www.excellentiagroup.com/skin/frontend/default/excellentia/documents/Q&A_3_8_2010_newsletter.pdf

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