CENTRAL SOURCE APRIL 2014
2 2 3 4 6 7 Letter from the Editor: Feeling derailed? Take charge now and get back on track.
Video: Envision a better way to manage loaners (see the video preview!)
Link of the Month: Check out the newly-released Loaner Receipt Document now!
Educator Update: Don’t be the missing link in the chain of infection.
Ask the EXPERT
Q: I’m hoping you can help me with a supply
By Natalie Lind, IAHCSMM Education Director
storage issue. I’ve always known it to be that you can store supplies that are packaged in a box (i.e., masks and gloves) in a decontamination area as long as the box they are packaged in is not the outside shipping box in which they were delivered. Can you please point me to the AAMI standards that address this?
A: AAMI section 5.2.1 states that “External
Going Green: Earth Day is April 22. We offer tips for making an impact in CS.
Certification Corner: Get the scoop on our latest legislative efforts
WATCH YOUR MAILBOX FOR THE MAY/JUNE ISSUE OF COMMUNIQUÉ. The May/June issue is filled with articles and news items that will give your CS knowledge and professionalism a boost. Here are just a handful of the many articles and features you’ll find inside: * New requirements for medical gas cylinders * The link between behavior and safety * In CS, timing is everything * Laparoscopic & robotic instrumentation self-study lesson plan * Professional ethics and doing the right thing for quality, safety
shipping containers need to be removed.” Although it would be wonderful not to have any boxes in the department, there are no standards stating that you cannot have internal boxes in the department.
WORTH REPEATING “Measuring Safety Performance by the number of injuries you have is like measuring parenting by the number of smacks you give.” – Dr. Robert Long 1 >
10 STEPS TO MANAGE LOANER INSTRUMENTS VIDEO Click here for a 2-minute clip of the “10 Steps to Manage Loaner Instruments” staff education DVD. The “10 Steps to Manage Loaner Instruments” video previewed here is part of the “Of Critically Important” DVD Educational Series provided by IAHCSMM and Envision Inc. The series includes 17 DVDs in all, each offering CE credits.
LETTER from the EDITOR KEEPING OUR PROFESSIONAL TRAIN ON THE TRACKS Julie Williamson, Editor
Last month, I read with great interest about an Amtrak “internship” program that allows professional writers to board a train, nestle into a private sleeper car for a five-day, no-cost excursion, and use the solitude and passing scenery as a mega-source of inspiration. Letting my mind loose as a silver bullet train clambers along the tracks seemed an ideal antidote for shaking up my routine and pushing me out of my professional comfort zone. It would also allow me to revisit all that I loved about my first (and only) Amtrak cross-country trip when I traveled with my family from Toledo, OH, to San Diego to celebrate my 6th birthday. I can still recall the sliver of blurred tracks beneath our feet as we stepped from one car to the next, how the porter would stroll the aisles and tickle my (and my sister’s) feet when we’d recline in our seats for a nap, and how the golden sunset danced and prismed through the glass dome of the dining car. Although I was too late to apply for the Amtrak program, reading about the opportunity got me thinking. How can I, after 17-plus years working as a journalist/editor, stay fully engaged in my career of choice and, perhaps, even push my love for the profession deeper? It’s a question each of us, regardless of our career, should probably think about more often. After all, if we lack enthusiasm about our roles— or can’t find satisfaction in knowing that our efforts make a difference—then what’s the point?
To learn more about the series (or to preview each video in its entirety, at no cost), visit www.envisioninc.net or www.iahcsmm.org.
Editor’s Note: See the Link of the Month section in this issue of Central Source to access IAHCSMM’s newly-released Loaner Receipt Document template.
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This is especially true of healthcare workers who contribute to patient safety and the delivery of exceptional care. Certainly, it’s not easy to stay 100% in love with our jobs each day, especially when we’re feeling pressured by a ticking clock, ringing telephones and seemingly unending demands and requests. Still, if we can remind ourselves why we chose our profession and how our commitment to doing our very best truly does matter, it’s safe to say that the journey—however treacherous it may seem at times—can still prove inspiring. And if we take a moment to look at the proverbial passing scenery (even in the confines of our offices or departments), we can get a clearer picture of how far we’ve come and where else our careers might take us. As for yours truly, I may not be boarding a train anytime soon, but I do plan to keep my career on track by pushing my professional limits through ongoing education (yes, even writers need that!), voracious reading, and as much professional and creative writing as I can squeeze into my busy schedule. Our lives are one giant expedition and our careers play a key role in that journey. How we decide to travel it is entirely up to us. The sky’s the limit…and there’s no ticket required.
LINK OF THE MONTH Trouble with Loaners?
Download the Loaner Instrument Receipt Document (It’s Free!)
IAHCSMM Orthopedic Council released a template Loaner Instrument Receipt Document, a concise and user-friendly form that healthcare facilities can use to document the arrival of their loaner equipment. The Loaner Instrument Receipt Document serves as an accompanying tool for the IAHCSMM Loaner Policy, and is a compilation of what other facilities have found to work most effectively. “Essentially, we reviewed a significant amount of good content out there and then combined it into one template,” explained Orthopedic Council Chairman Mark Duro, CRCST, FCS. While the Orthopedic Council did its best to include the most vital and pertinent information on the form, Council members acknowledge that facility needs and requirements will vary. “We encourage the Loaner Instrument Receipt Document to be used as a foundational template, with the content customized to best fit facilities’ specific needs.” The Loaner Instrument Receipt form is available for free download at: http://www.iahcsmm.org/CurrentIssues/ images/LoanerReceipt.pdf.
COUNCIL QUERY Q: We have been having issues with our orthopedic power equipment. I was called to the OR by a surgeon who told me he received the same damaged drill twice in the same week. How can we prevent this problem moving forward? A: I have been impressed by a terrific system used by the Hospital for Special Surgery in New York City, which tests power equipment prior to sterilization. During my visit, I saw that electronics and power equipment were tested at a designated workstation that was equipped with accessories used in the OR, as well as monitors for testing scopes. This was a great way to ensure that the products received in the OR were ready and tested before use. I also believe it’s good practice to have a method for flagging or tagging items that are not working properly in the OR and are in need of repair. Many of our vendors have tags that can be attached to damaged items when they go to CS for processing.
Mark Duro, CRCST, FCS, IAHCSMM Orthopedic Council Chairman, CS Manager, New England Baptist Hospital
STILL HAVEN’T SECURED YOUR SPOT FOR THE CONFERENCE AND EXPO? DON’T BE LEFT BEHIND! REGISTER TODAY! < 3 >
Educator Update: Considering the chain of infection in all our actions
By Angela Lewellyn, LPN, CRCST
In the previous Educator Update article, I outlined the foundation of Central Service practices: science. I addressed how each practice performed in the sterilization process is correlated to a science, and I stressed how vital it is for technicians to have a clear understanding of the sciences and the “why” behind each step performed in the department. In this article, I will expand upon the science aspect by correlating practical applications to the chain of infection. Like the sciences of microbiology and chemistry, the chain of infection gives us a good foundation of “why” we do what we do. Upon learning the sciences of sterilization, technicians will gain an understanding of microbial growth and how to deter it. We can better achieve this if we understand how microbes live, move and proliferate. Understanding the chain of infection will not only help reinforce the study of the sciences we practice, it will also assist in developing our critical thinking skills, which will allow us to better troubleshoot issues as they arise. As defined by the Centers for Disease Control and Prevention (CDC), chain of infection is when “…infectious diseases result from the interaction of agent, host, and environment. More specifically, transmission occurs when the agent leaves its reservoir or host through a portal of exit, is conveyed by some mode of transmission, and enters through an appropriate portal of entry to infect a susceptible host.”1 The following information provides a definition for each element in the chain of infection, and how to apply them to practices in CS. Please feel free to copy and share with your CS department.
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CAUSATIVE AGENT The IAHCSMM Certification manual defines a causative agent as “the microorganism that causes an infectious disease.”2 It then elaborates by defining the characteristics that make microorganisms capable of causing disease as: • Invasiveness • Pathogenicity • Virulence • Infectious dose • Viability in a free state. • Ability to develop resistance to antimicrobial agents. RESERVOIR Reservoir2: is a source that allows for microbial growth and survival. These sources could be equipment used, a staff member or even a patient.
Application: A good rule of thumb: Clean stationary equipment and all horizontal surfaces and sinks at the beginning of each shift and throughout each shift while wearing the appropriate PPE.
To apply the chain of infection process, the technician must ask the question, “In what environment(s) does a microorganism survive?” There are several answers to this question, but mainly, the conditions in a decontamination environment are ripe for microorganisms to not only survive, but multiply and thrive. The goal for the technician is to deter growth, so the action for a technician practicing decontamination steps would be to clean the decontamination area before the start of a shift and during their shift. Disinfecting carts, sinks, faucets, computer keyboards/mouse are ways to make the environment less hospitable for microorganisms to thrive.
PORTAL OF EXIT Portal of Exit3 is a means by which organisms leave one host or from where a pathogen can emerge. This can occur via: • Blood • Skin • Mucous membranes • Gastrointestinal and genitourinary tracts • Respiratory Tract
Application: The OR plays a large role in deterring cross-contamination by removing the debris, residual fluids and material left on an instrument. The role of the end-user (surgical technologist) is to remove the excess debris at the point of use and again before transporting the items to the decontamination area. Deterring growth of microorganisms begins at the site of introduction, which is in surgery. The role of the CS technician in the decontamination area is to clean the items using manual/ mechanical means. During the process of cleaning, the technicians must wear proper PPE to protect themselves from any residual debris.
MODE OF TRANSMISSION Mode of Transmission3 • Direct • Indirect • Airborne
Application: • Monitor the positive and negative air flow in the decontamination area by closing pass- through windows. • Deter the use of fans • Clean the area before and during a shift
Mode of transmission is the route by which microorganisms are transmitted in healthcare environments; the same microorganism may be transmitted by more than one route. These routes are contact and airborne. The contact transmission can carry organisms directly or indirectly. Direct contact involves a direct body, surface-to-body, surface contact, or a mucous membrane transfer of microorganisms between a susceptible host and an infected person. Some examples of this may be from the blood of one person to another or from one person to another through unwashed hands. Indirect contact transmission involves contact of a susceptible host with a contaminated object. These may be through a vector or a fomite. A vector is an organism that does not cause disease itself, but spreads infection. An example may be insects like ticks, fleas and lice. A fomite is any inanimate object capable of carrying infectious organisms and transferring them from one individual to another. An example may be cloth, table top, sink, or faucet in the decontamination area. Another form of indirect contact is a vehicular transmission, which occurs through a secondary route. This type of transmission can even occur from food or water. Airborne transmission occurs by dissemination of either airborne droplets or dust particles containing the infectious agent.
Portal of entry is an avenue in which a pathogen gains entry into the body. Examples include respiratory tract, non-intact skin, eyes, mouth, gastrointestinal tract, and blood. Technicians may become exposed to all of the above via blood, bone or residual fluid on instrumentation. This is why proper use of personal protective equipment (PPE) is so critical. A technician should practice, without fail, the use of PPE coverage. Often, I see technicians cleaning instruments with a facial mask worn on their chin. Mucous membranes can be a host reservoir, as well as a mode of transmission, so covering the nose and mouth is essential. PPE is required by the Occupational Health and Safety Administration (OSHA) to protect the technician from potentially harmful organisms, and prevent them from becoming a reservoir to harbor these organisms. SUSCEPTIBLE HOST Susceptible Host3 lacks good health due to inadequate rest, poor nutrition or hygiene, and age (elderly or very young)
Application: • Maintain short finger nails • Follow the department’s nail polish policy • Do not wear rings • Practice good hygiene • Maintain a healthy lifestyle
IN CONCLUSION Central Service technicians play a critical role in infection control and prevention. While many technicians I have had the pleasure of meeting have read, studied and understand the science behind their practices and the applications needed to halt spread of infection, I do still observe shortcuts being taken by some technicians/departments. These shortcuts are not intentionally meant to cause harm. Instead, they may arise out of unrealistic productivity demands or lack of education. I must stress that the applications outlined in this article take less than one minute to complete and go a long way toward reducing the spread of infectious microorganisms. If we CS professionals are to provide clean and sterile instruments, and deliver safe, high quality service to our coworkers and, ultimately, to our patients, we must gain an understanding of the sciences behind our practices and have knowledge of each steps in the chain of infection. With this knowledge, CS professionals can break the cycle of cross-contamination.
REFERENCES 1. Centers for Disease Control and Prevention. http://www.cdc. gov/osels/scientific_edu/SS1978/Lesson1/Section10.html 2. IAHCSMM Central Service Technical Manual, 2007. 3. A NSI/AAMI ST 79: 2010 & A1:2010 & A2: 2011 & A3: 2012 & A4: 2013 Angela Lewellyn LPN, CRCST, serves as Nurse Educator/CSSD Director for Advantage Support Services Inc.
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Earth Day is April 22 – Read on for some easy, eco-savvy tips
While a commitment to human health and the environment is demonstrated at most healthcare facilities every day, Earth Day serves to build even greater awareness around that commitment. Earth Day activities in hospitals and other healthcare settings may include tree planting, park clean-up, educational lectures, fairs, departmental “green” competitions, and more. But as one CS professional pointed out, CS departments can embrace some simple, yet smart approaches to further the efforts all year long. Here, Ann Young, CS Manager for Fletcher Allen Health Care in Burlington, VT, shares her department’s creative approach to recycling: • C ards that are in both the Bowie Dick challenge pack and the biological challenge packs are saved for use as “note paper.” Containers that house the department’s steri strips are used to hold the note paper cards, and these containers/cards are placed at each workstation and by each phone. “We have saved on Post-It notes and white copy paper.” • Complete Delivery System (CDS) boxes from Medline are folded and stored inside one of the same size (6 sizes available) and advertised for use for moving, storage, etc. These boxes are in great demand and can be had for a small donation to our annual Fundraiser for the Children. “In two years, we have raised more than $10,000 in donations.” • Open, unused gowns from OR packs are used for visitors to the department. • Disposable towels from gown packs are saved and used. • Open, unused drapes are kept and used as table covers and for other projects. • Ice packs that come in shipping containers are also reused.
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Ann Young, CSPDT, CRCST, CIS, CS Manager, Fletcher Allen Health Care
ADDITIONAL “GREENING” TIPS Even small efforts can give environmental efforts a big boost (while also saving the hospital valuable green in the process). • Maintain your instrumentation: Preventive maintenance keeps instruments and equipment working better and longer, which prevents costly repairs and premature replacement. • Cut the waste: Hospitals in the U.S. use an average 27.5 kilowatt-hours (kWh) of electricity and 110 cubic feet of natural gas per square foot (ft2) annually. In a typical hospital, lighting, heating, and hot water represent about 72% of total energy use, making those systems the best targets for energy savings. Although it may seem like a simple measure to take, remember that every 1,000 kilowatt-hours (kWh) saved by turning things off equals $100 off your utility bill (assuming average electricity costs of 10 cents/kWh). Turn off lights when not in use. Occupancy sensors can help, but training staff to turn off lights when they leave unoccupied rooms is a less expensive option. • Install water-saver kits on autoclaves and sterilizers. A continuous supply of cold water is often routed down the drain to cool the high temperature condensate, even though these devices tend to be run intermittently each day. In 41 laboratories across its campus, Colorado State University installed water-saver kits to monitor the temperature of the drain line and inject cold water only when needed. The university achieved annual water savings of over 15 million gallons, annual cost savings of over $59,000, a 1.4-year payback, and a return on investment of 72%. • Stick to proper ratios. When it comes to solutions/ chemistries, following manufacturer Instructions for Use (IFU) to the letter is prudent. Don’t assume that if a little is good, more must be better (it’s not), and don’t try and conserve products by using less than what’s outlined in the IFU. If products aren’t used as intended, quality and safety can easily become compromised. Another word of caution: Never attempt to repurpose plastic containers. This is one recycling effort that can lead to extremely dangerous product mixups, thereby posing a serious safety risk to staff and patients.
CORNER By Government Affairs Director Josephine Colacci
Q: What is the status of our legislative efforts? A: On February 26, 2014, the Oklahoma House Economic Development and Financial Services Committee did not pass our bill. We only garnered two ‘yes’ votes out of this committee. We did not have a lobbyist in Oklahoma, but it would not have made a difference even if we had. I spent several days in Oklahoma over a two-week period and lobbied the bill myself. The Oklahoma Hospital Association was adamantly opposed to our legislation because they did not want to be told what to do. In the history of this state hospital association, we were told they have never supported a “mandate.” We will not be reintroducing legislation in Oklahoma next year. On February 27, 2014, the Connecticut legislature introduced our certification legislation (SB.300). The language in the bill was introduced incorrectly and we will be amending it before it passes the legislature. On March 11, 2014, our bill had a committee hearing before the Joint General Law Committee. On March 18, 2014, our bill passed out of the Joint General Law Committee unanimously and was sent to the Joint Public Health Committee. On March 21, 2014, our bill passed out of the Joint Public Health Committee unanimously and was sent to the Senate floor. Our Connecticut bill will be amended on the Senate floor. This bill has to pass the Senate and then pass the House of Representatives. Once it clears both of those Chambers, it goes to the Governor. Connecticut members, please keep an eye on your email inboxes for action alerts related to this bill. The Connecticut legislature ends May 7, 2014. As you will recall, our Massachusetts certification bill had a Public Health Committee hearing in November 2013. This bill had to pass the Public Health Committee by March 19, 2014. Our bill did not pass, but it is still alive. The committee agreed to study the issue for the next couple of months, so we still have a chance to be voted out. On March 12, 2014, I, along
Government Affairs Director Josephine (Jo) Colacci, JD, on the Connecticut Senate floor.
with our lobbyist and a local member, met with legislators and their staff in Boston. We were told that the Public Health Committee had 280 bills pending before the committee. Also, since this was our bill’s first year, they explained that our bill did not have priority. There is a good chance that our bill will not pass this year. Massachusetts is going to take us a couple of years because of the fact that this state operates under the notion that a bill should not be passed right away. If you live in Massachusetts, we are going to be doing a major grassroots initiative. What does this mean? It means that I need members on the ground in Massachusetts helping us with this effort. If you are willing to help us, please email me at jo@ iahcsmm.org. The Pennsylvania legislature introduced our bill (HB.2105) on March 17, 2014. It was assigned to the House Health Committee, and on April 9, 2014, the committee will vote on the bill. Be sure to check Twitter and Facebook for updates. We have until November 30, 2014, to get the bill passed. This will be difficult to accomplish by the legislature’s deadline. We do not have a lobbyist in Pennsylvania, which makes it even more difficult. My hope is to at least get a committee hearing on the bill. If the bill fails to pass by the Nov. 30, 2014, deadline, we must reintroduce the bill in January 2015 and enter a new two-year legislative cycle. To stay up to day on legislative actions, please follow IAHCSMM on Twitter and Facebook for the most up to date information on our legislative activities.
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BREAKING NEWS You Can Use One in 25 patients battling hospitalacquired infections, CDC reports An eye-opening one in 25 hospitalized patients (4%) is battling an infection acquired in a hospital or other healthcare facility, according to a new survey by the Centers for Disease Control and Prevention (CDC). That number translates to more than 600,000 hospital patients each year -- roughly 74,000 of whom will wind up fighting more than one hospital-acquired infection (HAI), researchers note. About half of those infections are either linked to a device, such as a catheter or ventilator, or to a surgical site. The new study, led by Dr. Shelley S. Magill of the CDC, and published in the New England Journal of Medicine, was based on an analysis of 11,282 patients treated at 183 hospitals in ten states. The survey in each hospital was done over the course of a day, involving as many as 100 patients per facility. Pneumonia accounted for about 22% of the HAIs. Another 22% were infections at the surgical site, and 17% were stomach or intestinal illnesses. Urinary tract and bloodstream infections ranked fourth and fifth, respectively. The most common bacterium responsible for infection was Clostridium difficile, which kills an estimated 14,000 people in the U.S. each year. It accounted for 12% of the HAIs and was responsible for 71% of gastrointestinal infections, in particular. Despite ongoing concern about hospital-acquired infections, especially drug-resistant ones, the U.S. does not have a national system for collecting information on the problem. n
AAMI Sterilization Standards Week Set for April 14-16 —Most Meetings Open to Public The Association for the Advancement of Medical Instrumentation (AAMI) will hold its Sterilization Standards Week in Baltimore, MD, April 14-16, 2014. Members of the healthcare and infection prevention community are encouraged to attend. Most of the meetings will be open to the public and are a good way to understand the AAMI standards program. Meetings will take place at the Sheraton Inner Harbor in Baltimore. For the meeting schedule, CLICK HERE. For more information, call (703) 525-4890, extension 1250. n
18 Exposed to Fatal Brain Disease Novant Health’s Forsyth Medical Center in Winston-Salem, NC, has notified 18 patients of possible exposure to Creutzfeldt-Jakob Disease (CJD), according to a report from CNN. CJD is an incurable neurodegenerative disease caused by prions. The exposure occurred after a Jan. 18 operation on a patient who was later found to have CJD. While the instruments used in the patient’s operation were sterilized, they were not subjected to the enhanced sterilization procedures used for suspected or confirmed CJD cases, according to a hospital release. While the hospital believes the risk to the patients on whom the instruments were subsequently used is minimal, it is in the process of notifying the patients. Since the realization, the hospital has performed enhanced sterilization on all brain surgery surgical instruments, working with the Centers for Disease Control and Prevention (CDC) to prevent future incidents, according to the hospital release. In related news, The Joint Commission has published an addendum to its sentinel event alert #20 on exposure to CJD. The original sentinel event alert was published in 2001, and included exposure risk factors, risk reduction strategies and recommended policies. The addendum addresses the recommended practice of quarantining equipment. Specifically, TJC recommends using evidence-based sterilization guidelines from the CDC, World Health Organization (WHO) or American National Standards Institute/Association for the Advancement of Medical Instrumentation (ANSI/AAMI). These guidelines will help providers minimize the risk of using neurosurgical instruments that were potentially contaminated during procedures on patients later diagnosed with CJD, according to the alert. n