From the moment patients arrive in pre-op until they are discharged from PACU, they add microbes to an environment already swirling with potentially harmful bacteria left behind by other patients and your staff members. With an eye toward protecting patients from those invisible dangers that lurk throughout your facility, let's review the keys to preventing common causes of cross-contamination at key stages of the perioperative process.

1. Focus on safe IV starts.
The microorganisms that are present on a patient's skin or shed onto nearby inanimate objects are easily transferred to a caregiver's hands. If your hand hygiene practice is inadequate or neglected entirely, your contaminated hands may spread an earlier patient's microbes by direct contact. To reduce this cross-contamination risk, perform hand antisepsis before and after contact with any patient or object in close proximity to a patient. If your hands are visibly soiled, wash them with soap and water for a minimum of 10 to 15 seconds.

After your patients' vital signs have been taken and an assessment has been made, they're ready to have an IV started. While some microorganisms are resident to the skin, those same microorganisms may cause infection if introduced to the vascular system. As a result, properly prepping the skin before IV insertion is essential. There are a variety of acceptable skin preps, including alcohol, povidone-iodine and chlorhexidine. Whichever solution is used, it's critical to let it dry completely for full antiseptic effectiveness before inserting the IV.

Additionally, be careful while inserting, handling and maintaining the IV to avoid accidentally contaminating yourself with the needles. As with any sharps, utilize available safety devices and dispose of used needles and syringes in the appropriate receptacles.

2. Maintain medication infusion safety.
The transmission of bloodborne viruses and other microbial pathogens to patients during routine procedures continues to occur in healthcare settings due to unsafe and improper injection, infusion and medication vial practices. Follow published guidelines to ensure that your patients remain safe from cross-contamination risks posed by IV and medication delivery. A position paper published earlier this year by the Association for Professionals in Infection Control and Epidemiology recommends the following safe injection practices:

• Never use intravenous solution containers (bags or bottles, for example) to provide flush solutions for more than 1 patient.
• Never use such infusion supplies as needles, syringes, flush solutions, administration sets or intravenous fluids on more than 1 patient.
• Begin administering spiked IV solutions (that is, IV bags entered by the tubing spike) within 1 hour of their preparation. If administration is not begun within 1 hour of spiking the bag, discard the IV and tubing.
• Disinfect IV ports using friction and 70% alcohol, an iodophor or an approved antiseptic agent, making sure the solution is dry before the port is accessed.
• Never administer medication in a syringe to more than 1 patient, even if the needle is changed between patients. Changing the needle but not the syringe is unacceptable.

3. Clean ORs thoroughly.
Patients arrive in the OR shortly after the turnaround that followed a previous case, a previous patient and the room's previous occupants. In addition to a routine post-op cleaning, wipe down surfaces closest to patients, all surfaces touched by your surgical staff and any item that came in contact with a previous patient's skin, blood or body fluids with an EPA-approved disinfectant. These surfaces include instrument tables, kick buckets, OR equipment, patient transport vehicles, non-disposable straps and table attachments.

In order to minimize the risk of cross-contamination or accidental injury to patients and staff, carefully check the OR and the surgical table for any items, such as sharps or small supplies, that may have been lost during the previous case and lie concealed. Place all disposable items contaminated with waste or caked with dried blood or body fluids in disposable, leakproof containers or bags, then remove and handle them appropriately.

Technology has brought new cross-contamination hazards into many modern surgical suites, with computer keyboards providing a potential source of microbial contact. A circulating nurse who frequently makes electronic entries during a case might leave (or pick up and transfer) microorganisms from a patient or the environment on the keys. Regularly scheduled cleaning of keyboards (and also touchscreens or other equipment controls) can reduce this risk. Some manufacturers even offer submersible keyboards that can make routine cleaning easier.

4. Execute effective skin preps.
Once you've reduced the possibility of cross-contamination from transient microorganisms in the environment, it's time to cut down the microbial counts of resident flora. Effective skin preparation is fundamental in preventing those microorganisms living on a patient's skin from causing a post-operative surgical site infection. Decreasing the risk of such an outcome depends on applying a prep in accordance with its manufacturer's instructions. Pay special attention when applying the solution to areas such as the armpit or groin, which are loaded with sebaceous glands and frequently damp with sweat, and be sure to allow the antiseptic sufficient contact and drying time before you apply a sterile drape.

5. Preserve surgical instruments.
Before instruments reach the OR, your reprocessing staff was busy preparing them for sterilization cycles by thoroughly cleaning their surfaces and crevices. A conscientious reprocessing staff knows that decontamination is the first and most critical step in breaking the chain of disease transmission and that cleaning is the first step in the decontamination process.

They must take care, though, to avoid cross-contamination during this critical process by wearing the appropriate barrier garments: gloves, aprons or gowns, masks and protective eyewear. It is also advisable, to neutralize the risk of a particular bloodborne pathogen, that central sterile and your entire staff receive the hepatitis B vaccine.

Since sterile instruments look just like non-sterile ones, carefully examine the integrity of an instrument's package before opening it in the OR and check the external chemical indicator to make sure it changed color during reprocessing. This indicator ensures that the pack has been put through the sterilization process and has been exposed to sufficient sterilization conditions.

Use safety sharps when possible, but if your surgeons aren't using the specially engineered scalpels and needles, they should handle sharps with the utmost care and staff should use a "neutral zone," passing tray or other non-hand-to-hand passing protocol. As mentioned previously, sharps should receive an appropriate and safe disposal.

6. Perform conscientious surgical scrubs.
You will, of course, wash your hands and forearms with a powerful and long-acting antimicrobial soap before coming in contact with the sterile field, sterile instruments or equipment during procedures. The process of scrubbing should take longer than typical handwashing does. While institutional policy usually designates an acceptable minimum length of time for a scrub, the Centers for Disease Control and Prevention recommends at least 2 to 5 minutes.

Thorough drying is essential, as moist surfaces invite microbes. Since fluid — a potential medium for pathogenic transmission — flows in the direction of gravity, keep your hands lower than your elbows during the surgical scrub and higher than the elbows afterward.

7. Wear appropriate PPEs.
When assisting other OR team members and surgeons in donning sterile surgical gowns, take deliberate care not to touch their sterile external surfaces or other non-sterile objects. Despite a careful scrub, bare hands are always considered a potential source of infection. Also put on such protective accessories as sterile gloves, surgical gowns, facemasks, goggles and transparent eye or face shields. All of these items serve not only as barriers against the microorganisms to which you may be exposed, but also as barriers to protect patients against potential contamination by your hands and clothes.

The practice of donning surgical garb should include covering facial hair, tucking head hair inside a cap or bouffant and removing jewelry or other dangling objects that may inadvertently harbor microorganisms.

Once you don sterile gloves, avoid touching non-sterile items to prevent cross-contaminating the surgical site with microbes from elsewhere. You might find it helpful to keep your fingers interlaced when standing idle to avoid inadvertent contamination. In the event that a glove breaks, is breached or touches a non-sterile surface, you must immediately remove it and don new gloves.

In the OR, equipment, monitors and carts should be arranged to minimize the risk of accidental contact and contamination. Only scrubbed-in personnel are allowed into the sterile field. Their arms must remain within the field at all times, and must not reach below the level of the patient or turn away from the sterile field. Unscrubbed personnel are assigned to the perimeter of the room. They remain on hand to obtain supplies and facilitate communication with personnel outside of the OR.

Closing the circle
When procedures end, patients are transported to the PACU to recover and meet discharge criteria. Despite the fact that there are potential sources of cross-contamination there, too — most notably direct contact with post-op providers' hands — following the same infection prevention guidelines that govern the pre-op area will neutralize risks to patients in recovery, sending them on their way after a safe journey along your entire surgical circuit.