1. Unsafe injection practices

• administer medication in the same syringe to more than one patient so long as they change the needle between patients or administer the injection through a length of IV tubing.
• access the same medication vial for more than one patient with a syringe that has already been used to administer medication to a patient.
• use a common bag of IV fluid or saline for more than one patient and to access the bag with a syringe you already used to flush the catheter of a patient.
• use medications packaged as single-use for more than one patient.
• keep multi-dose vials in immediate patient care areas, including operating and procedure rooms, anesthesia and procedure carts, and patient rooms or bays. Those are the don'ts. Ms. Chinnes offers these do's for safe injection practices.
• To access patient medications in an aseptic manner, use a new sterile needle as well as a new sterile syringe to draw up medications while preventing contact between the injectable materials and the non-sterile environment. Other aspects of proper technique include hand hygiene before handling medications and disinfecting the rubber septum of the vial with alcohol before piercing it.
• Use single-dose vials for use on a single patient. Yes, even if the vial contains more medication that's needed for one patient, don't store the vial for later use on the same or other patients. Order the smallest vial necessary for your facility's needs.
• Discard medication vials, whether single-dose or multi-dose, whenever sterility is questionable. Discard a single-dose vial that has been opened or accessed (punctured by needle) per the manufacturer's specific time guidance for opened vials or at the end of the case — whichever comes first. Don't store opened single-dose vials for future use. Discard single-dose vials that haven't been opened or accessed by the manufacturer's expiration date.
• Use fluid infusion and administration sets (IV bags, tubing and connectors) for one patient only. Dispose after use on one patient. Don't use bags or bottles of IV fluid as a common source for multiple patients such as IV flushes.
• You can assign multi-dose vials to one patient, but single-dose vials are the best option for a patient. If this isn't possible, keep multi-dose vials in a dedicated medication preparation area — away from the immediate patient treatment area as noted above — to prevent inadvertent contamination of the vial through contact with potentially contaminated equipment or surfaces. This could then lead to infection in subsequent patients. If the multi-dose vial enters the immediate patient treatment area, discard it at the end of the case.
• Date and discard a multi-dose vial that has been opened or accessed within 28 days unless the manufacturer specifies a shorter or longer date for that opened vial. Discard a multi-dose vial that has not been opened or accessed per manufacturer's expiration date.

2. Unsanitary anesthesia providers

You might not worry much about your anesthesia providers increasing the risk of contamination, but infection from injection is a growing concern, says Chuck Biddle, CRNA, PhD, a full professor and staff anesthetist at Virginia Commonwealth University Medical Center in Richmond.

SAFEST PRACTICE Always enter a medication vial with a new sterile needle and a new sterile syringe.

To illustrate his point, Dr. Biddle explains the "drawer-to-arm phenomenon" as an anesthetist prepares to inject a patient. Every time he touches a drawer on the anesthesia workstation to grab a swab or a vial or a syringe, he's increasing the risk of contamination. "We are the vectors of any sort of biological or bioburden material," says Dr. Biddle.

The way anesthesia workstations are designed makes them incredibly difficult to clean and sterilize effectively, says Dr. Biddle. In a study published in the National Center for Bio-technology Information several years ago, doctors examined 40 anesthesia machines' breathing circuit systems and found evidence of contamination in 17 (43%) of them.

Then there's the issue of contamination in the tools anesthetists use, like the stopcock, which the CDC reports has a contamination rate of 45% to 50% in the majority of series.

"The good news is that researchers are examining how to redesign the way we inject and anesthetize patients in order to cut down on the opportunities for contamination," says Dr. Biddle, adding that redesigns on the horizon include changing the design of the IV portal, changing the design of the stopcock, engineering disinfectable needles and creating a physical barrier to protect your anesthesia machine from contamination.

"But much of that research is still in the works," says Dr. Biddle. "For now, it has to start with us."

What can your anesthetists do now to reduce the risk of cross-contamination? Many providers are split on the topic of prefilled syringes, but Dr. Biddle sees them as a useful way to cut back on the risk of infection by taking the human element out of at least part of the equation. Some say it's worth the added cost to remove the extra step of drawing up a drug, thus running the risk of contamination. Moreover, prefilled syringes hold anesthetists accountable so there is no risk of "double dipping" into a vial, says Dr. Biddle.

If your anesthesia providers want proof of how great the risk of contamination is at the head of the table, ask them to read "Microbiological Contamination of Drugs During Their Administration for Anesthesia in the Operating Room", a study published in Anesthesiology last year that found that inadvertent lapses in anesthetists' aseptic technique contributes to surgical site and other post-operative infections.

3. Unseen residual debris on reprocessed instruments

When it comes to surgical instrumentation, the challenges of cross-contamination are magnified by the increasing complexity of surgical devices, which in turn makes cleaning, inspecting and sterilizing these instruments that much more problematic, says Weston "Hank" Balch, BS, MDiv, CRCST, CIS, CHL, the system director of sterile processing at University Health System in San Antonio, Texas. The solution: tools that allow for greater magnification during the inspection stage.

Take flexible endoscopes, for example. With intense focus on leak testing, flushing and brushing of internal channels, and proper HLD/low-temp sterilization processing, Mr. Balch says processing technicians often overlook and under-inspect the distal tip of these devices. But tools such as handheld lighted magnification devices or table-top microscopes can ensure reprocessed scopes have no residual contamination or damage that could harbor future microbes. New internal borescopes that are long and flexible enough to inspect the length of many large diameter endoscopes let you document cleanliness with time/dated photos and videos, says Mr. Balch.

For some instruments, however, the real consideration should be transitioning from reusable versions to sterile, single-use models that eliminate the possibility of cross-contamination, says Mr. Balch, citing as an example historically difficult-to-clean Frazier and Andrews suctions that are now available as single-use devices. If you're still using first-generation Kerrison rongeurs, you know that you can't remove the blades for cleaning and inspection, says Mr. Balch, adding that new, single-use Kerrison inserts allow for interchangeable sizes and angles that you can safely dispose of after the case.

"Although the science of sterilization is making tremendous strides," says Mr. Balch, "the risks and costs associated with reprocessing complex instruments that have affordable single-use alternatives make conversion to disposables the safer, smarter decision for our patients." OSM