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​Aseptic technique

All healthcare workers (e.g. physicians, nurses, allied HCWs, students, volunteers and others) are responsible for complying with routine practices (hand hygiene, glove use, aseptic technique, etc.) and for tactfully calling infractions to the attention of offenders. No one is exempt from complying with routine practices (PHAC, 2012).

The Foundation Principles and Safeguards of ANTT (The-ASAP, 2015)

Principles:

  1. Asepsis is the aim for all invasive clinical procedures, including the maintenance and use of invasive clinical devices ('for surgery to community care').

  2. Asepsis is achieved by protecting Key-Parts and Key-Sites from microorganisms transferred from the healthcare worker and the immediate environment.

  3. ANTT needs to be efficient as well as safe; therefore Surgical-ANTT is used for complicated procedures and Standard-ANTT for uncomplicated procedures (see detailed description in Appendix A).

  4. The need for Surgical or Standard-ANTT is determined by ANTT risk assessment that is based on the technical difficulty of achieving asepsis (see Appendix A for more details).

  5. Aseptic practice should be standardized.

  6. Safe aseptic technique is reliant upon effective healthcare worker training and environments and equipment that are fit for purpose. 

Safe Guards:

  1. Basic infective precautions such as environmental controls, hand cleaning and disinfecting medical devices significantly reduce the risk of contaminating Key-Parts and Key-Sites.

  2. Key-Parts are the critical parts of the procedure equipment that if contaminated are most likely to cause infection. Key-Sites are open wounds and medical device access sites.

  3. Non-Touch Technique is a critical skill that protects Key-Parts and Key-Sites from the healthcare worker and the procedure environment. It is essential in Standard-ANTT and desirable in Surgical-ANTT

    For more information on the Aseptic Technique refer to:

Sterilizations of medical and surgical instruments and equipment

(Ontario Agency for Health Protection and Promotion, 2013)

  • It is the shared responsibility of each person involved with each surgical instrument or piece of medical equipment throughout the process of care to ensure that effective reprocessing will take place.

  • Prior to purchase, the way that a device will be reprocessed must be taken into consideration.

  • Reprocessing must be carried out in a centralized area (medical device reprocessing centre - MDRC) by trained staff, with monitoring and quality control parameters built into the process.

  • Contaminated equipment/devices must be cleaned and then disinfected or sterilized according to defined procedures that are based on accepted standards and best practices.

  • In the event of equipment failures or emergency situations, there are recalls and safeguards built into the system to protect the end user.

  • Finally, there should be observations at point-of-use to ensure sterilization indicators demonstrate that effective sterilization has occurred. All of these components must be in place to achieve success

    Effective reprocessing of medical equipment/devices is a process comprised of many components

  • Trained Staff

  • Written Policies and Procedures

  • Quality Monitoring

  • Contingencies for Equipment Failures

  • Point-of-Use Observation

  • Equipment Purchase

  • Centralized Reprocessing

    For full details on sterilizations of medical and surgical instruments and equipment refer to:

Prevention of inappropriate operation

1. Implement the Surgical Safety Checklist:  Effective communication and teamwork are foundational to improving safety in surgical care. A tool specific to surgical care that is intended to strengthen communication and teamwork is the Canadian Patient Safety Institute's Surgical Safety Checklist (CPSI 2009).Surgical teams can use the checklist to ensure that key care information is communicated throughout the patient's surgical journey and to enhance teamwork. The checklist has three phases:

  • Briefing – before the induction of anesthesia
  • Time out – before skin incision
  • Debriefing – before the patient leaves the operating room

2. Implement Universal Protocol for Prevention of Wrong Site, Wrong Procedure, and Wrong Person SurgeryTM (Joint Commission, 2012):

A. Conduct a pre-procedure verification process. Address missing information or discrepancies before starting the procedure:

  • Verify the correct procedure, for the correct patient, at the correct site. 
  • When possible, involve the patient in the verification process.
  • Identify the items that must be available for the procedure.
  • Use a standardized list to verify the availability of items for the procedure. This list may vary by jurisdiction. At a minimum, these items include:
        • Relevant documentation (Examples: history and physical, signed consent form, pre-anesthesia assessment)

        • Labeled diagnostic and radiology test results that are properly displayed

          1. (Examples: radiology images and scans, pathology reports, biopsy reports)

        • Any required blood products, implants, devices, special equipment

  • Match the items that are to be available in the procedure area to the patient.

B. Mark the procedure site. At a minimum, mark the site when there is more than one possible location for the procedure and when performing the procedure in a different location could harm the patient.

  • For spinal procedures: Mark the general spinal region on the skin. Special intraoperative imaging techniques may be used to locate and mark the exact vertebral level.

  • Mark the site before the procedure is performed.

  • If possible, involve the patient in the site marking process.

  • The site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed.

  • In limited circumstances, site marking may be delegated to some medical residents, physician assistants (P.A.), or advanced practice registered nurses (A.P.R.N.).

  • Ultimately, the licensed independent practitioner is accountable for the procedure – even when delegating site marking.

  • The mark is unambiguous and is used consistently throughout the organization.

  • The mark is made at or near the procedure site.

  • The mark is sufficiently permanent to be visible after skin preparation and draping.

  • Adhesive markers are not the sole means of marking the site.

  • For patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (see examples below): Use your organization's written alternative process to ensure that the correct site is operated on.

         2. Examples of situations that involve alternative processes:

  • mucosal surfaces or perineum
  • minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice
  • teeth
  • premature infants, for whom the mark may cause a permanent tattoo

C.   Perform a time-out. The procedure is not started until all questions or concerns are resolved.

  • Conduct a time-out immediately before starting the invasive procedure or making the incision.

  • A designated member of the team starts the time-out.

  • The time-out is standardized.

  • The time-out involves the immediate members of the procedure team: the individual performing he procedure, anesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning.

  • All relevant members of the procedure team actively communicate during the time-out.

  • During the time-out, the team members agree, at a minimum, on the following:

      • correct patient identity

      • correct site

      • procedure to be done

  • When the same patient has two or more procedures: If the person performing the procedure changes, another time-out needs to be performed before starting each procedure.

  • Document the completion of the time-out. The organization determines the amount and type of documentation.

3. Reduce Distractions in the operating room (Pennsylvania Patient Safety Authority, 2014).

A.    Environment / Equipment

  • Reduce noise level in the OR whenever possible, especially during critical phases in the procedure (e.g., limit conversation not relevant to the current procedure; lower the volume of background music; adjust surgical equipment settings to reduce excess noise, as able).

  • Customize alarm settings for individual patients, and use smart alarms, when available, to reduce distraction from false or nuisance alarms.

B.    Rules / Policies / Procedures

  • Assemble multidisciplinary teams to identify critical phases in operative procedures, specific to individual teams and procedure types that should not be interrupted.

  • Implement a "sterile cockpit" or "no interruption zone" protocol during critical phases of operative procedures.

  • Use preoperative and procedural checklists.

  • Design and implement a multidisciplinary briefing tool.

  • Use a structured communication tool, such as SBAR (Situation, Background, Assessment, Recommendation), especially during critical phases of a procedure.

  • Minimize communication by members of the OR team that is irrelevant to the current procedure, and limit interruptions from outside staff and other visitors to the OR.

  • Establish guidelines and expectations, applicable to all members of the surgical team, for the appropriate use of cell phones, pagers, smartphones, and other PEDs in the OR, and monitor for compliance.

  • Provide teamwork training, such as Crew Resource Management (CRM); Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) (AHRQ, 2017), or TeamSTEPPS Canada™ (CPSI, 2018) using case study scenarios specific to the OR.

  • Engage surgeons in patient safety teamwork training and quality improvement projects targeted to reducing distraction.

  • Ensure that surgeons and other OR team leaders promote a culture of patient safety, encouraging all team members to practice skills necessary for situation monitoring and to voice concerns at any point during a procedure.

C.   Training

  • Educate staff about electronic distraction and its potential detrimental effect on patient safety.

D.   Audit and Feedback

  • Encourage the collection and audit of local data for continuous quality improvement (Dr. G. Papia, personal communication, October 24, 2017)

Endotracheal tube placement

Ensure correct positioning of endotracheal tube placement during anaesthetic procedures:

  1. Ensure the endotracheal tube is placed so that the cuff is visualized just past the vocal cords and approximately 2-3 cm above the carina (Miller, 2015).

  2. Perform bilateral auscultation to ensure breath sounds are equal and bilaterally over the chest wall and there is a lack of breath sounds over the epigastrium (Miller, 2015; Sitzwohl et al, 2010).

  3. Observe for symmetrical chest movements and condensation in the endotracheal tube (Sitzwohl et al, 2010; Miller, 2015).

  4. Identify carbon dioxide in the expire gas using continual end-tidal carbon dioxide analysis from the time of intubation until extubation or transfer to a postoperative care location using a quantitative methods such as capnography or capnometry (Committee on Standards and Practice Parameters, et al., 2015; Miller, 2015; Dobson, et al. 2017).

  5. Ensure that the end tidal CO2 alarm and the oxygen saturation alarm is visual and audible at all times to the anesthesiologist or the anesthesia care team personnel (Committee on Standards and Practice Parameters, et al., 2015; Dobson, et al. 2017).

  6. When ventilation is controlled by a mechanical ventilator, there shall be in continuous use a device that is capable of detecting disconnection of components of the breathing system. The device must give an audible signal when its alarm threshold is exceeded (Committee on Standards and Practice Parameters, et al., 2015; Dobson, et al. 2017).

  7. If patient remains ventilated in the post-operative period, a chest X-ray should be considered to ensure correct placement of endotracheal tube.

    For additional Mitigation Strategies for Wrong Patient/Site/Procedure, please refer to the HIROC Risk Reference Sheet (HIROC, 2016).

    For mitigation strategies for the Prevention of the Performance of Unnecessary/Obsolete Procedures refer to the HIROC Risk Reference Sheet (HIROC, 2016).

Conduct Clinical and System Reviews

Given the broad range of potential causes of complications from serious events, in addition to the recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

If your review reveals that the healthcare facility's serious event cases are linked to specific processes or procedures, you may find guidelines related to the specific procedure here:

Clinical and System Reviews, Incident Analyses

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

    To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.

    Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the Hospital Harm measure. Chart audits help identify quality improvement opportunities.

    Useful resources for conducting clinical and system reviews: