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PACU Infection Control Guidelines
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NEW ENGLAND BAPTIST HOSPITAL
INFECTION CONTROL POLICY GUIDELINES
Section VIII #
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P
Subject: Post Anesthesia Care Unit Infection Control Policy and Procedure
Effective Date:
October 4,2004
Approved By: Infection Control Committee
Author: Pauline Robitaille, RN, MSN, CNOR
Supersedes:
12/01
PURPOSE
To protect the Postoperative patient from cross contamination from other patients,
hospital personnel and equipment. To protect the health care worker from the risk of
contacting infections, such as, Hepatitis and AIDS, or other viruses that are present in
blood and other body fluids.
RESPONSIBILITY: All Post Anesthesia Care Unit Staff
I.
PERSONNEL ISSUES:
A. Dress code for the PACU consists of scrubs that have been laundered by the
hospital laundry facility.
B. Personnel are to follow Standard precautions with all patients.
C. Personnel must follow the Hospital Employee Health / Occupational Health
guidelines regarding their work status following infectious exposures or absences
due to illness. Refer to the Employee Health Guidelines in the Infection Control
Manual.
a. Category 1 Employees must receive a Hepatitis B vaccine or sign a declination
form.
D. All personnel will follow these guidelines to prevent the transmission of infection
to patients, employees and visitors.
E. PACU personnel will be fit tested for a TB mask prior to caring for patients with
known or suspected disease. (Refer to the TB Exposure Control Plan located in
the Safety Manual).
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Policy & Procedure is the OFFICIAL copy.
May 8, 2017 9:26 PM
PACU Infection Control Guidelines
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F. Employee Health
1) Personnel with patient contact who have an infectious process that is in the
contagious state are not allowed to work until the stage has passed. This
includes but is not limited to acute febrile respiratory infections, boils, draining
wounds, rash, diarrhea, and conjunctivitis
a) In the event that a decision has to be made to exclude an employee from
work when there is a contagious disease the Surgical Services
Management or Employee Health shall have this authority.
2) Follow-up of Inadvertent Exposure:
b) All inadvertent exposures to blood or body fluids must be reported
immediately to the Surgical Services Management , or designee.
Inadvertent exposure includes percutaneous needle sticks, puncture
injuries, bites, mucous membrane contamination, and contamination of
non-intact skin.
a) After exposure report to Employee Health or Immediate Care
immediately (or as soon as possible) for evaluation and management.
G. All personnel will follow these guidelines to prevent the transmission of infection
to patients, employees and visitors.
H. Personal protective equipment will be used when contact with blood or body fluid
is anticipated
I.
Handwashing is generally considered the single most important procedure for the
preventing the transmission of infection.
ALL PERSONNEL WILL WASH THEIR HANDS:
1. Before and after direct contact with patients or patient care items.
2. Before eating and drinking.
3. After using the toilet or covering a sneeze or cough.
4. After removing gloves.
5. After contact with contaminated equipment or materials.
6. When visibly soiled.
PLEASE NOTE: This on-line, read-only version of this
Policy & Procedure is the OFFICIAL copy.
May 8, 2017 9:26 PM
PACU Infection Control Guidelines
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J. Standard Precautions
The concept of Standard precautions is based on the understanding that medical
history and examination cannot reliably identify all patients with bloodborne
pathogens such as HIV and Hepatitis. Therefore, it is essential that all blood and
body fluid be considered as potentially infectious. When contact with blood or
body fluid is anticipated, barrier precautions must be used.
Personal Protective Equipment Include:
1. Gloves - Used when you anticipate direct contact with blood, body fluid,
mucous membrane or non-intact skin.
2. Gowns - Used when soiling or splashing of clothing is likely to occur.
3. Mask and goggles, or face shield - Used when eyes or mucous membrane,
(nose, mouth), may be splashed with blood or body fluid.
4. PACU personnel will be fit tested for a TB mask (N95) prior to caring for
patients with known or suspected disease that requires airborne precautions.
Refer to the TB Exposure Control Plan (located in the Safety Manual).
Patients with known or suspected disease will not be admitted to the PACU,
these patients will be admitted directly to the ICU(negative pressure room).
5. Each patient unit contains gloves, face and eye protection. A sharps disposal
container and waste disposal bags are at each patient unit to dispose of
contaminated material.
6. Calstat is at each patient unit.
K. Needles, sharps or contaminated broken glass are to be disposed of in puncture
resistant sharps containers. Use caution when handling or cleaning an area
where sharps are present. Do not recap, bend, or break needles by hand.
L. Education
1. Inservice education is attended by all staff on an annual basis, additional
inservicing or continuing education is provided on the unit as necessary.
Ongoing inservice education is conducted based on needs identified by the
staff and Department Manager.
2. Inservice education provides information on any changes of policy and
procedures as they relate to infection control and PACU clinical practice.
This information is reviewed with the PACU staff by the Infection Control
Coordinator, Perioperative Clinical Educator or Department Manager.
3. Initial orientation is mandatory for all new employees.
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PACU Infection Control Guidelines
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II. WORKPLACE / ENVIRONMENTAL CONDITIONS:
A. Infectious Waste:
1. Medical infectious waste will be disposed of in red biohazard bags. Refer to
NEBH Infection Control Manual and the Infectious Waste Disposal Policy for
more information and the definition of medical infectious waste.
2. Sharp receptacles are located at several sites throughout the unit.
3. Gloves and facesheilds are located at each cubicle.
4. Biohazard waste trash container is located in the dirty utility room.
5. Masks and faceshields are available on the code cart.
B. The PACU Attendant is responsible for cleaning the following items with a
hospital approved disinfectant:
1.
2.
3.
4.
5.
Horizontal surfaces.
Stretchers and beds as needed.
The Clean and Dirty utility rooms.
Blood pressure cuffs (if soiled and unable to clean, they should be replaced)
The medication preparation area (daily).
C. The Housekeeping Department staff are responsible for environmental cleaning
(i.e., curtains, poles, vents).
D. Traffic Control:
1. Visitors may be allowed in the PACU with approval of the Primary Nurse.
2. Parents, clergy, and family members of critically ill patients will be allowed as
appropriate.
III. PATIENT ISSUES:
A. Admission of patients to the PACU:
1. Dressings should be dry and intact.
2. Drainage tubes (Foley catheter, drain tubes, etc.) are left connected to the
drainage system used.
3. Ends of wound catheters which have been connected to continuous wall
suction, are wrapped in dry sterile dressing.
4. Stretcher linen is left in the dirty linen hamper on the patient unit prior to
bringing the stretcher back to the PACU.
PLEASE NOTE: This on-line, read-only version of this
Policy & Procedure is the OFFICIAL copy.
May 8, 2017 9:26 PM
PACU Infection Control Guidelines
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5. Patients with isolation needs must be identified and this information
communicated to the PACU staff prior to the patient’s admission into the
PACU. Postoperative orders for isolation must be written on the Physician’s
order sheet. Patients will be assigned to the appropriate isolation rooms as
follows: # 17 and/or #16.
IV. OPERATIONAL PROCEDURES:
The policies and procedures in the Nursing Department Procedure Manual and
Infection Control Manual are applicable in the PACU.
A. All disposable equipment is for single patient use.
B. The bronchoscope is rinsed by PACU nursing personnel after each use and
returned to the Operating Room for sterilization or high level disinfection.
C. Ventilators are cleaned by the Respiratory Therapy Department personnel (Refer
to Mechanical Ventilation Policy in Respiratory Therapy Policies and
Procedures).
D. Respirometers are sent to the Central Sterile Supply Department after each
patient use for cleaning and sterilization.
E. Laryngoscope blades are returned to the Anesthesia Department for processing
after each use (Refer to Anesthesia Department Policies and Procedures).
F. Pulse oximetry sensors are cleaned after each patient use (refer to the Pulse
Oximetry Policy and Procedure located in the Department of Nursing Policy and
Procedure book).
References:
1.
Federal Register, Vol. 56, No. 235, 29 CFR Part 1910.1030, Occupational Exposure to Bloodborne Pathogens, Final
Rule, pp. 64175-82, December 1991.
2.
Federal Register, Vol. 62, No. 201, Occupational Exposure to Tuberculosis; Proposed Rule, pp. 54160-54307,
October 17, 1997.
3.
New England Baptist Hospital Infection Control Manual.
4.
New England Baptist Hospital Safety Manual.
Reviewed: 7/82, 8/83, 6/84, 5/85, 6/86, 2/87, 9/88, 6/89, 10/93, 10/04
Revised: 6/81, 5/83, 3/87, 9/88, 3/90, 11/91, 11/93, 10/95, 11/97, 11/98, 12/99, 12/01,10/04
Approved by the Infection Control Committee: 11/91, 11/93, 11/16/95, 11/20/97, 12/15/99, 12/19/01
Approved by the Operating Room Committee: 2/6/96
Approved by the Medical Executive Committee: 1/22/96