DWELL TIME Be sure surfaces remain wet with the germicide for as long as the label indicates.

If you want to give your center's infection prevention efforts an immediate boost, focus your attention on these 5 areas, which continue to be trouble spots for a surprisingly high number of surgical facilities I visit.

1. Unsafe injection practices. You should dedicate multi-dose vials to a single patient whenever possible, yet I continue to see staff draw up medication at the point of use, put the vial back in the anesthesia cart and use it for the next patient. Or I see multi-dose vials of irrigation medication for orthopedic procedures left with the needle and syringe in the diaphragm for many procedures (treat irrigation vials the same as injectables). As a rule: If a multi-dose injectable medication vial enters an immediate patient treatment area such as the operating and procedure rooms, anesthesia and procedure carts, and patient rooms or bays, it should be dedicated for single-patient use only.

This is not to say you can't use multi-dose vials for more than one patient. If you do, keep and access the vials in a dedicated medication preparation area (the nurses station or outside the procedure room) away from immediate patient treatment areas. This is to prevent not only the risk of entering the vial with the same needle and syringe used during the procedure, but also the inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment. The key word to remember is access. If you access the multi-dose vials in the room where surgery is taking place or some other immediate patient treatment area, dedicate the vial to that patient. If you draw up the medication outside the immediate patient care area, you can use the vial for more than 1 patient, provided the anesthesia provider labels it appropriately according to CMS requirements.

You might consider ordering and using prefilled syringes for your anesthetic agents and antibiotics. This would virtually (if not totally) eliminate the risk of a bloodborne pathogen exposure as a result of multi-dose vial usage. It might appear more expensive to use prefilled syringes, but in calculating the risk of bloodborne infection as well as considering using multi-dose vials for single patients, it may be more cost-effective. One additional point to consider: If you're caught using multi-dose vials inappropriately during an unannounced survey, you could create an immediate jeopardy situation for your facility, meaning your facility would be placed on a timeline for termination from Medicare and Medicaid unless an acceptable corrective action plan is submitted and a repeat survey validates that the deficiencies have been corrected. You may also have to close the facility temporarily, depending on the actual practice you violated and the surveyor.

Another unsafe injection practice: Pre-filling syringes at the start of the day and using them for the entire day in place of USP 797's 1-hour rule.

2. Surgical attire. Do your surgeons and staff wear skull caps in the OR that don't completely cover hair because they cut off at the ears? What about masks that aren't tied properly or left to dangle when the procedure is over?

Hair has to be completely covered in the OR, according to AORN standards. Bouffant caps cover the scalp, but many men don't like the look of them. Surveyors will ding you for wearing bouffant caps behind the ears (we shed cells at an alarming rate). The scalp needs to be fully covered (even if you're bald), as does facial hair. You may wear the "surgeon caps," but they must be covered by a bouffant cap.

When you're standing over the sterile field and working on a patient, every time you talk, cough or sneeze, you're releasing microorganisms. A mask can't contain those microorganisms if it's tied tight around the nose but leaves the chin uncovered or is allowed to dangle after the procedure. Of course, you should change your mask between patients.

3. Hand hygiene. With hand hygiene, if it's not observed, it didn't happen. I often see staff come in and out of the OR without sanitizing their hands, particularly when they're coming in. "But I washed my hands at the scrub sink before I came in," they'll say. Or, "I just sanitized my hands with the alcoholic sanitizer dispenser outside the OR before I came in." A surveyor won't accept that. Make sure your OR suites have hand sanitizer dispensers or bottles of sanitizer readily available. And be sure wall-mounted dispensers are always filled.

The proper way to use a waterless scrub preparation is to rub the preparation into and under fingernails, as well as the hands and lower arms. Follow the manufacturer's instructions for use to ensure efficacy of the product. Refrain from wiping the waterless scrub product off hands and arms with a sterile towel, and don't don gloves while the preparation is wet. Other common hand-hygiene breaches include staff not practicing hand hygiene after handling their personal cell phones and other electronic devices.

4. Environmental cleaning. Don't be surprised if a CMS surveyor asks staff for the dwell (or contact, kill or wet) time of the product they're using for surface disinfection and how they know how long the surface remained wet. The number is right there on the container of impregnated cleaning cloths (for example, 1, 2 or 3 minutes), but does the germicide stay wet for the appropriate time before you place the new sheet or cloths on tables or stands? My suggestion: Time it. If the surface dries in less time than it's supposed to remain wet, take another cloth and wipe over the surface again until attaining the required total number of minutes. It's not necessary to begin timing over again, as long as the specified number is reached, that part of the process is optimal.

5. Pre-cleaning. You can sterilize and high-level disinfect by the book, but if your pre-cleaning and cleaning practices are suboptimal, you might as well not even bother. Liquid, steam or gas won't penetrate debris and organic material that remain on or in an endoscope or an instrument, rendering the sterilization process incomplete and ineffective. In addition to stressing the importance of pre-cleaning and cleaning, consider products that validate the cleaning process. After all, there's only so much visual observation you can do with lumened scopes. OSM