This live webinar will provide an overview of the essential steps taken to prevent infection in an ophthalmic surgical environment. During the first half of the presentation we will review infection control standards, TASS, sterile processing, and accreditation preparedness in a post-covid world through the lens of the ophthalmic nurse in a surgical environment. The second half of the webinar will be a panel discussion and exchange of viewpoints on infection control. Questions received from registration and during the webinar will be presented to the panel.
Lecturers: Dianne Bourque, RN, CNOR, Lori Pacheco, RN, CRNO, Monte Goldstein, MD, CMO & Tom Terranova, JD, MA, MBA
MS BOURQUE: I think it’s really important that you identify a person who has an allotted amount of time to continue throughout the year to stay updated, to regional recommendations. And also to… You know, have more time to read up. And communicate with the staff. Like you said, the monitoring — very important with hand hygiene. Monitoring that staff is utilizing the PPE effectively. Performing environmental rounds. We really do believe that if you can do that at least monthly, you’re going to see the holes of where your staff is not enacting the infection control plan appropriately. So that’s very important. And like you said, on training and education, it’s really important to validate competency for the staff members that are performing really high risk practices, like your sterile processing. So you want to make sure, like that new — the new hire, you would watch what they’re doing. And really validate their competency in all these key areas. And then also that infection control coordinator is going to be speaking with the surgeons in your facility and making sure that they are monitoring for any surgical site infections on a monthly basis, and if there’s any implants, making sure that they’re actually looking throughout an annual period of time. One year to make sure that those infections are being reported, so that you can track anything that’s going on in the facility, and then do some performance improvement, actually, changing some things to make sure that the facility has safe practices. Just wanted to add that just a little bit. Because that infection control coordinator is just a key member of the team.
MS PACHECO: You’re right. It’s so important to make sure that the person has the time to coordinate and has the time that’s needed and necessary to put into a program. Giving the role of infection control coordinator to your director of nursing or someone that may not have the time to really monitor and put into it — you want to make sure that that person has that time. That they can set aside to put into it. Excellent point.
MS BOURQUE: We also want to make sure the infection coordinator meets with every new hire and goes over it with them, makes sure that they understand the plan. Especially if it’s a new nurse or a new staff member, just making sure they understand. Putting in that time. Thank you so much.
MS PACHECO: Thank you. Let’s talk a little bit about hand hygiene. Okay? Your availability of soap and water, or your alcohol-based hand rubs, in all your patient care areas. They have to be accessible to you. And let’s talk a little bit about when it’s performed. These are things you can have in your program. Things you can monitor for. Make sure you’re monitoring your staff. Before and after direct patient contact. After removing your gloves. If you have contact with bloodborne pathogens, even if gloves are worn. Okay? When your hands are visibly dirty there’s always that difference between soap and water and alcohol-based rubs. If your hands are visibly dirty, you’re washing with soap and water. Okay? After using the restroom and after any type of cleaning in your facility. So these are some of the components of hand hygiene. And then you have handwashing audits. Dianne, thank you for this audit tool. This is just an example of what you can use to audit and make sure that your facility is following hand hygiene. Observation. You can assign it. It doesn’t have to be the infection control coordinator all the time walking around. Because of course, everyone is gonna know that that coordinator is there, walking around. Making sure you’re following handwashing. You can assign it to a different staff member every month, however often you do your audits. Your operating theater, pre-op, recovery — don’t just make it all about the operating room. Hand hygiene is important in every aspect of perioperative care. So anesthesia. Your physicians. Make sure you’re monitoring everyone. You can use different types of compliance monitoring tools. Here’s one for reference. At the top, we’ll give you some means for contacting us, if you like the examples of any one of the tools we’re using here. AAAA is great at offering their resources. And how often should you be doing your audits? That’s up to you. It’s in your policy. There’s no standard. Some people do it once a month. Some people do it quarterly. Especially if you find that you may have problems with handwashing audits, you may want to do it more often than not. And then you’ve got your tracking and your trending. Okay? Your compliance. Let’s look at your percentage of compliance. And then you can report it. You can report it to whichever regulatory body that you have. Whether it’s the board of directors, board of management. I’m used to a patient care assessment committee. Anything like that. But you want to make sure that you’re reporting the outcomes. You’re looking at your percentage of compliance. And then you’re auditing, to make sure that… Okay. How did we do? Talk to your staff members. Say… All right. You don’t have to call anyone out, throw anyone under the bus. But say… You guys, the handwashing, it’s great. It’s not so great. Include your team. Right, Dianne? Put everyone together and include everyone in that.
MS BOURQUE: Absolutely. And if you see that someone is really needing a little help on that, a little reminder, sometimes a peer coaching can be effective. Especially… And just to say if there is a physician or surgeon that needs a little reminder, sometimes that comes a bit better from a peer. You know, it’s great if the infection coordinator can be effective. But… It just happens. And we just want to make sure it is addressed. So that we don’t have problems with that. But you should be in the very high 90th percentile. You know. Thank you.
MS PACHECO: And education is so important. Infection control training and education. So how often should you be doing your training in infection control? Upon hire, always. When that person comes in, as Dianne had mentioned. That person is gonna sit down with an infection control coordinator and look at your plan, discuss infection control. So they have the right expectations of what is expected of them. And what your policy is in your facility to keep infections down. You have annual continuing education. You can do that… You know, once a year, beginning of the year. Everybody has to undergo training. Also when your compliance is low, if you do have a low percentage, let’s say, of handwashing, let’s start that training again. And any new protocols that are put in place. New disinfectants, new equipment. Anything like that. You want to make sure that you’re as well going through training to make sure everyone’s expectations are correct.
MS BOURQUE: And Lori, what we learned in the last two years is… When new protocols are put in place, it’s really important to bring the staff together. When COVID happened, my goodness… That just changed our world. And we had new equipment that we weren’t used to using. I mean, obviously we were handwashing and we were doing environmental disinfection. But we put it into hyperdrive. So those are the things… You know, if there’s any new emerging infectious diseases or anything like that, we really need to have staff meetings and emails that are sent out, or posters that are put out. Communication books. Whatever we can do to make sure that infection control training is just going through the entire staff. You don’t want to miss anyone. If they don’t show up for the meeting, we need to have a way to communicate with people that maybe aren’t present in that shift or on that day.
MS PACHECO: Yeah. Think outside the box for these meetings. Everyone is so used to having… After office hours. But honestly, we used to do our fire training and our infection control training in the morning. Before the day even started. We used to have everyone come in a little bit earlier. Because no one could stay after. So we had to think out of the box. It’s so important. Take the time. I know we’re all so busy. Especially some of these centers, the high volume centers. But you need to take the time.
MR TERRANOVA: Lori, Dianne, if I could just insert a little bit of awareness that we gained through COVID — conducting surveys, really kind of around the world — keep in mind, from a management perspective, that any time you add a new process or policy, or when there is a new risk that comes up, you’re already taking a staff that has a compressed amount of time and compressing it even more. So when Dianne is talking about that knowledge transfer and that knowledge retention for your new staff, the same thing applies here, when you’re talking about a new process for your existing staff. And that’s why the training and reiteration and tools are so important, because you’re breaking a routine that people have developed over ten years of practice. Or maybe longer. And shoving it into a really limited time frame. And so people are now more rushed, trying to remember a new step or a new process. And that’s where we really saw the highest frequency of breakdowns in COVID-19 precautions. In infection control precautions during COVID. It was because it was a brand-new thing in much less time that people were trying to retrain themselves on the run, and that’s where those gaps happened. So reinforcement and kind of retraining and retraining is really important here. It’s not just a matter of sending it off once and everyone now knows it and does it perfectly every time. As we all know, that’s not how the world works.
MS BOURQUE: And also, you know, to reinforce that, what we found was really effective: Lots of visual cues and visual reminders, posters. I mean, everyone saw that: Please wear a mask. Social distancing. But they do that because it’s very effective. You know, handwashing. The hand rub. Putting that signage everywhere. It really does help reinforce things that we’re trying to get into the muscle memory. It’s not… We disrupted the muscle memory and we’re having to add to that now. So Tom, that’s really great information.
MS PACHECO: Excellent. Thank you. So let’s talk about a training method. You know, how are we doing our training? We want to choose a simple way to deliver the training. It doesn’t have to be complex. It doesn’t have to be a complex system. You could do a PowerPoint presentation. You could do videos. Please ensure that your content is up to date. Okay? Make sure everything you have is updated. And that it can be assessed by the individual at a convenient time. Okay? Sometimes… You can choose training on web-based videos that they can do from home. Or they can do early in the morning or they can do after hours. You want to really work with your employees and make sure that you’re providing them training that they can do, and they can easily access it. It can be kept at the health care settings, for reference. But again, you could have meetings. You could have somebody come in and do a training. You could have web-based videos. However you do it, just make sure it’s a simple way that you deliver the training and it’s easily accessible for your staff.
MS BOURQUE: Lori, I’m just gonna interject one other thing. We’re mostly talking to nurses and physicians today, but there’s also other members of the health care staff. There’s our support staff, housekeeping. We need to make sure — yes, and all this information needs to get down to everyone. In the facility. So sometimes we often, when we go in and do a survey, we’re asking for the infection control training: Is it done differently for different members of the staff? And that’s okay. The information just needs to be able to be received. So you may have different types of training, and that’s okay as well.
MS PACHECO: Yes. You’ve got your personal protective equipment. These are the specialized clothing or equipment worn by employees for protection against infectious disease. Things like your gloves and your gowns. Your shoe and head covers and your masks of course, and your face and eye protection. What is worn for PPE? According to your policy and your procedure that you have in place. So these are just some examples of personal protective equipment. And this is again something you can put in your infection control program. And then the key factors determining your appropriate PPE — what’s appropriate for different intraoperative settings? Your anticipated exposure. The durability of that PPE. And how it fits as well. You want to be sure that everything is fitting appropriately, so you can prevent infection not only to your patients but also to yourselves. So the staff knowing the right PPE for the job and being available and accessible in all the clinical areas — that is key. You want to make sure that all your protective equipment is available.
MS BOURQUE: And Lori, that is really important. Because during COVID, we found that some of the supervisors — and they had to — were locking up the N-95s or KN-95 masks. So we need to make sure that it is really accessible to the staff on all the shifts, on all the days.
MS PACHECO: This is just an example of a grid. Dianne, you provided this. Can you give us —
MS BOURQUE: Yes, this is a risk assessment. And basically what we do is we like to take the areas of the facility and the staff members that may be in that facility, and what’s their anticipated risk. So if you have someone that… You can see right here for administration — if someone is working in the front office, they really don’t have a lot of… You know, a lot of risk for blood and body fluids. And then — but you take someone that’s in the OR, you’re gonna see, like here the yellow — their risk is very high. And in that column, if they are in an area where there is a high risk, it just suggests: You need eye protection. You need a mask. You need a gown. You need gloves. So basically as we’re training people, you can kind of give them something to look at, that says: Okay. Here’s the grid. When you go into this area, please utilize every piece of this personal protective equipment. Because when we talk about PPE, we’re always talking about protecting the patient. But here we’re really talking about protecting our staff members. Because if they get ill, we don’t have them on our team any longer. So we really need to do a great job of protecting the team and reminding people. If you have a peer that’s not wearing their mask or not wearing their gloves, just gently saying: Hey, come on. Let’s do this. You need to be safe for yourself.
MS PACHECO: This is such a great tool, especially for new hires too. This is such a wonderful tool to have. And then you’ve got your medication injection practices. Definitely something that you should be putting in your infection control program. Instructions for use. I’m sure you’ve heard this many, many times. But it really is key to so much of what we do in the health care setting, instructions for use. Your manufacturer’s instructions. These are things that you really need to be looking at. Really taking into effect especially things like single dose vials versus multidose vials. Take a look at your vial. Not every vial can be accessed multiple times. Single use vials have to be discarded after every patient. Then you have multiuse vials. They can be used more than once if they’re labeled and stored according to IFU use. You have to see how they have to be stored. Do they need to be refrigerated? What you need to do to make sure that you’re using it safely on multiple patients. Check your use state. If the vial is opened, you’re in the beyond use state. Should not be stored in the immediate treatment area. The multidose vials should not be in the operating room. Anything that you have in the immediate patient care area, and that includes the operating theater. Exam rooms, bedsides, things like that. Multidose vials — you want to remove them from any patient care areas. If it is taken into immediate treatment, it should be considered a single dose vial and discarded. I know that sounds a little harsh and tough sometimes on the resources, but if you want to prevent infections, these are things you need to look at. Single dose vials are not meant to be used on multiple patients for a reason. And that’s something we need to look at for infection control.
MS BOURQUE: Lori, this is really important. This is something that infection preventionists have been looking at for the last decade, and really trying to push this message. Single dose vials, if they’re just accessed multiple times, they don’t have any preservative, and they really can start to grow organisms that you don’t want to inject into someone else. One of the things that I think is really important is: If you see on this photo, we have Xylocaine in both vials. And they look somewhat similar. But I will tell you that… I’ve seen many staff members that really don’t know how to understand which one is multiple dose and which one is single dose. So I like to, as an infection control coordinator, show an example and say: Look at that small, small print at the bottom. These look very similar. But if you open the one on the right, you have to discard it. If it’s the one on the left, we can use the recommended practice of 28 days, label it, but it has to be stored and accessed in a neutral area. So in your facility, you want to find — is that the nurses’ station? Is there a little room adjacent to the operating theater in which you can access those medications? And working with the staff members. Because this may be something that they’re not used to. We may need to talk with anesthesia and come up with a plan of how we can store these and utilize them effectively. Especially with emergency medications, anesthesia wants those right next to them. And we certainly understand why. But just talking with them about this kind of new practice. Because for many people, this is something a little bit new. Especially in the immediate treatment area. They don’t understand this new protocol. So we just want to talk with them and make sure that we can facilitate their needs. But also stay safe.
DR GOLDSTEIN: Dianne, I’m just gonna interject on this one. Thank you. It really is great advice. One of the keys to implementing these recommended practices is getting the leadership of the various disciplines to buy in. So in the case of anesthesia, and I’ll readily admit — I’m a anesthesiologist by trade — it is very difficult, unless you have a leader that buys in and understands the protocols, and really makes it his or her responsibility to disseminate that information to the anesthesia staff along with the nursing staff.
MS BOURQUE: And sir, let me say one other thing. I say it very often. It’s that peer-to-peer conversations tend to be more easily received. So if you do have leadership that gets involved, sometimes it’s a conversation surgeon to surgeon, anesthesiologist to anesthesiologist, that tends to be very helpful. But yes, you’re right. Bringing all the stakeholders to the table and talking about the safe practices is so important.
MS PACHECO: It is, definitely. And as I’m looking at these flip tops, an important thing to remember when you’re working with vials is that so often — everyone flips that top off and immediately accesses that vial, thinking: It hasn’t touched anything, so I don’t have to alcohol it. That is not the case. The tops come off, you alcohol no matter what. The tops have been on that rubber all this time. That’s not clean. So make sure even when it’s brand-new and you’re taking that top off that you’re alcoholing that vial right away. You have environmental cleaning. Your standard cleaning. Beginning of the day — you want to do a visual inspection of your area. And this is all areas, including the operating room. Everywhere — anywhere you have a patient care area. Clean all horizontal surfaces with a germicidal wipe. I want you to take a look at these pictures pretty carefully. These wipes have dry time to them. And that dry time is very important. So if you notice, this says the 3 minute germicidal wipe. And that means that after you wipe something down with this wipe, you have to wait 3 minutes before you can put anything on that horizontal surface, before you can consider it clean. This germicidal wipe works within 3 minutes. If you’re already wiping down or you’re already placing stuff on there after 30 seconds, it’s not really considered clean. And every one of these germicidal wipes has a dry time. Some of them are 5 minutes. Some of them are 3 minutes. I’ve seen more than that. So really pay attention. Because that’s really, really important. Is this dry time. So once you wipe something down, I know 3 minutes can seem like a long time, when you’re turning over rooms. But wipe it down, and then do something else. Do whatever else you need to do in that room. To prepare for the next case. Let that dry for the allotted amount of time that it says on the manufacturer’s instructions. Okay?
MS BOURQUE: And Lori, may I interject really fast? That’s one of the reasons we love wipes, because a lot of the wipes are a 3 minute dry time or kill time, as I like to say. But in the older times, we would use a lot of spray disinfectants. And they’re very wet, very, very wet. So if you are gonna use a spray, making sure that people understand… Getting everything everywhere. But you have to let it dry on its own. And if you start wiping it dry, you’re taking away what it’s doing. The other thing is: Sometimes you will have disinfectants that are a lot less expensive, but like you said, they may have a 10-minute kill time. And you can’t afford that time on a turnover of a room. So just be aware of that.
MR TERRANOVA: If I can interject really quickly, this was another big one with COVID. Not knowing which cleaning agents originally… You know, if we could think back two-ish years… There was some question about what we needed to surface clean, due to COVID. How long the virus lived on surfaces of varying types. And one of the other things we saw was, again, people being really quick to wipe. Whether they were spraying down… And some countries were requiring fogging of the OR. You know. Kind of every day, which could have led to respiratory issues. All of that being said… It’s important to know the agent you’re using. If there’s an emergent need. If there’s a different agent you’re using than you normally are. So again, you’re disrupting your routine and going from 3 minutes to 7 minutes to 10 minutes, and just being always aware of the purpose of your cleaning, if there is an emergent need, what that has changed in your life, and being aware of that. Because you can’t just go… I’m gonna use one of Dr. Goldstein’s favorite words — rote. You can’t do it based on rote, a routine. You have to put some thought and some conscious decisions into it. Because our environment does change and our circumstances do change. And that can lead to a lot of infections, if you’re not aware.
DR GOLDSTEIN: I’m gonna give everybody a quick tip for education purposes. And Tom — we can always quote the AAAA standards. But the best practice is always to know what that cloth is effective against. Some are not fungicidal. Some have actually been shown not to be effective against COVID. So on the AAAA accreditation site, we look when we go into a facility, that people know. But what I’ve educated staff to do is to look at that drying time and actually take a Sharpie, and put a big either — 3, in this case, it would be a 3 over that container. So that everybody knows when they pick up that container that it’s a 3 minute drying time. When we’ve got to facilities as a surveyor, we’ve seen 3, 4, or 5 different wipes. And that have different drying times, and staff is not aware.
MS PACHECO: That’s a great piece of advice. I like that. To write with the Sharpie how many minutes it’s good for. I like that. I never thought of doing that.
MS BOURQUE: And another thing we saw during COVID is, when these were in short supply, people were utilizing — I know in the US, I saw many times clinics and such were using the household cleaners. And unfortunately, those are great for your kitchen surfaces, but not necessarily — they’re not hospital grade or health care grade. So just being aware… I mean, they were just desperate. And I understand that. But in our operating theaters, we have to use health care grade.
MS PACHECO: You can see here — look at all those. It kills bacteria listed. You can see all of them there. So important. And make sure you’re getting all your horizontal surfaces. Your back table. Your mail stand. Your OR chair. And again, your anesthesia equipment. That blood pressure cuff, that pulse ox that’s being used probably patient to patient to patient. So make sure that we’re really cleaning our anesthesia equipment well. Okay? Don’t forget that.
MS BOURQUE: And please also, on all of the cords, when you clean them, put them up. So they’re not on the floor. We see that kind of regularly. If we want to make sure that there’s a process that when they’ve been cleaned… How do I walk into that room and know that everything is clean? We like to tell people if you have a hook to put it on or something —
MS PACHECO: Simple plastic hook.
MS BOURQUE: Yeah. It’s been cleaned. It’s ready for the next patient.
MS PACHECO: And every facility I know I’ve seen as well — they have their own protocol for showing that it’s ready for the next patient. So they hang it a certain way or they do something to show: It’s been cleaned and it’s ready for the next patient. So whatever you want for your protocol, there’s no right or wrong answer. It’s however you want to do it. And then just train your staff to know and understand that: Yep, this has been cleaned and it’s all set for the next patient. Don’t forget to look down. Don’t forget those wheels and casters and the mayo stand.
Make sure… We’re cleaning our microscopes, our sinks, our countertops. Make sure — I always tell people look up and look down, for sure. If you’ve got vents in your operating theater, don’t forget those vents. They get so dusty. Those vents get to dusty. Make sure at the end of the day, you’re pulling out your furniture. Pulling out those anesthesia carts, get them away from the wall, make sure — you would be surprised what Weck-Cels and things can accumulate behind some of these pieces of furniture. So make sure you’re pulling things out and cleaning them.
MS BOURQUE: Dust bunnies. And like you said, up at the top, look at those vents. We see that pretty regularly. Also ceiling tiles sometimes. They’ll start to crumble a little bit. They get dry. So just what you’re saying… Look down. Also look up.
MS PACHECO: Also look up. And you’ll appreciate this as a surveyor — I know for years, and with good intentions, oxygen tubing used to be put across the ceiling. And then come down, so that you wouldn’t… Hazards.
MS BOURQUE: Trip on it.
MS PACHECO: But how do you clean it? Those things are gonna collect dust. How do you get up there and clean that oxygen tubing that’s up there? You have to dust up there. So just be really careful and look up. Going into receiving and storage, this is really important infection control. You want to prevent outside contaminants coming into your operative area. Okay? No corrugated boxes. And I put this little guy on here, because this is something I’ve actually seen myself. This is a silverfish. I was opening boxes. It was a box of equipment and supplies to bring into the operating room. I’m not in the operating room. I’m opening it out in the supply area. And lo and behold, these little guys were on the bottom of the box. They’re there. It happens. Those little guys can make their way into these corrugated boxes. They’re coming from who knows where. Debris, dirt, insects, they can all gather in these corrugated boxes. Do not bring cardboard boxes into your operating theater. Tom?
MR TERRANOVA: Yeah, sorry, this is one I love as an example. Because some people listening here may be in an area where there are a lot of invasive species. And some people who are listening to this may be in an area where they don’t get a lot of insect life and bug life in general. And I remember actually being in a clinic in the UK. And we were talking about this very issue. And the center said… Well, we don’t have a lot of kind of… I don’t know what exotic bugs are. But they said… We don’t have a lot of exotic bugs or things like that here. I said… Okay. I understand that. But what region of the world did this box originate? So not only are you potentially talking about bugs that you’re not familiar with — you’re talking about transplanting bugs and invasive species from elsewhere in the world, no matter where you are. With the global supply chain, you have things coming from Europe to Southeast Asia and vice versa. So no matter what might have laid eggs inside that box, it’s probably not native to where you are. So for those who may be listening to this, thinking “that’s not really an issue for me”, that box came from somewhere else. And it may be an issue where that box came from, where it was shipped through, or just the planes that it was on.
MS PACHECO: Or the truck.
MS BOURQUE: The truck it was sitting on. How long has it been sitting on that truck? Yeah.
MR TERRANOVA: So I think this is something that some folks in some areas of the world may tune out. Because it may not seem like a local issue for them. But basically this is a local issue everywhere.
MS BOURQUE: Yeah. And Lori, this is a personal picture of mine. We see this so commonly. You know, and people… They’re just in a rush. They’re trying so hard. And most people have an issue with storage. But we always just say… Whatever you can do, just get it out of those containers. Put it in a clean container that you have control over. And if you have a clear container, that’s even better. But get it off of the floor. That’s quite important as well.
MS PACHECO: Yes, absolutely. Check your sterile packs. Okay? All the sterile packs that you have sitting in your storage closets. Make sure those packs — check for evidence of damage, holes, moisture, things like that, that could get in there, if it’s been compromised, if sterility has been compromised, if there’s a tear in there. And you want to make sure you’re storing items according to manufacturers’ instructions. So check the IFUs. It’s gonna tell you exactly the environment that it wants you to store this piece of equipment. This type of supply in. Clean, dry conditions, as Dianne said. Off the floor. Away from things that could cause potential damage. Try not to overstack things on top of each other, especially sterile packs. You could certainly compromise the sterility when you start to pile things up on top of each other. Definitely keeping things off the floor. So these are just things to keep in mind. Not reusing single use items. We did go through this. Ensure that all your fluids, your supplies… Check your expiration dates. I know some facilities, they have in their policy to check expiration dates, let’s say, monthly. The beginning of every month, the end of every month. They go through their cabinets, they go through their checklists, they have all their items and supplies, and they check off — this is within date. This is within date. Making sure the items way in the back of the cabinet that you don’t see every day, something that’s been sitting there and we haven’t used in months… You have to pull them out and make sure they’re all within date. There’s a use by date and a date it was manufactured. Make sure you’re looking at the correct date. But you want to document it. Have some type of monthly log. You can assign it to each person in the operating theater. The pre-op and recovery room is so important. A lot of times discovering things in there. Anesthesia as well. Don’t forget anesthesia. They have their crash carts and all their meds in there. You want to be continually checking expiration dates and making sure everything is within date.
MS BOURQUE: And it’s also very important that this little 2 with the slash in it — it’s quite important to show people this. And also, on those new hires, making sure that they understand the messaging that’s on the packaging. You know, so… At the bottom, the use-by date, the date of manufacture. I’ve actually seen people see the date of manufacture, thinking that’s the expiration date, and throwing away things. And that’s so costly. So having in that orientation of new hires — helping them understand what to look for. And of course, obviously I love what you said about having a little log, where someone has a process, and we see that process and it’s assigned to someone. They can delegate it out. But somebody has responsibility to do that, so that we’re turning over our stock. We also really — just another aside — with our inventory, having our first in and first out, making sure that our inventory is rotated, so that you don’t have something way in the back that’s expired. Because it costs you money. And our resources are so important in the organization.
MS PACHECO: Check your refrigerators. Everyone always forgets the refrigerators. These are things that are in there. Your viscoelastics that have to be refrigerated, your Viscoats. Things like that. Make sure you check the refrigerator as well. You can keep the log on your refrigerator. Just make sure you’re checking your refrigerator for outdates as well. So catch all those different areas of your operating area.
MS BOURQUE: And on that note, we need to look at the temperatures of the refrigerator and making sure that everything in there is being stored according to the manufacturer. And that we have a process to see over the weekend if the refrigerator breaks down — do we know that everything was maintained? Or if the electricity went off. That happens! So how do we know what happened? And we also have to have a protocol that if it does exceed the temperature, because the electricity went down, what do we do with those medications? Do we call the manufacturer and say… Hey, we believe our temperature… The power was off for 24 hours. Do we need to discard this and replace it? Or is it still good?
DR GOLDSTEIN: One thing we see on surveys a lot, especially in the anesthesia world, but also surgical world as well — single use items that have been opened and not used. And that are either put back in stock or reprocessed in some way. With the rationale saying… Well, it says not to use twice. But it doesn’t really say what to do with it if it’s opened and not used. So… It’s very important to understand that once it says no 2, even if you open it, if it’s been exposed to anything — that is no longer usable as a sterile item in surgery. Or anywhere else in your facility. So it has to be discarded.
MS PACHECO: Nice thing you can do as well, if you’re looking at manufacturers’ instructions for how to store things in the fridge, what we have done in the past is we’ve taken a look at the items that do get stored in the fridge. We have a little supply list. And next to each one, what the temperature — the temperature that it’s supposed to be kept at. And we actually keep it in the refrigerator. So in the fridge, we have Viscoat, this, that, and so on and so forth. And next to it, it has to be stored at this. So whoever is going in there knows that each item and what the manufacturer is saying it needs to be stored at, as far as the proper temperature — it just gives them a little indication, so they know every time they go to it that they understand that it’s been stored in the correct place. Some people have only four or five things that they keep in the fridge. If you have five things written on the piece of paper, put down what their temperature requirements are, and you can put it on the refrigerator. Hot topic always: Decontamination of instruments. I know this is always something that everyone is eager to learn. Talk a little bit about decontaminating your instruments and how we can prevent infection. Remember that decontaminating instruments begins immediately at the point of use. This can begin at your back table. Instrument wipes that you have back there. Just make sure you’re preventing things from getting debris and things that can cake on your instruments. I know it’s ophthalmology. Everybody always thinks… Oh, it’s eyes. We don’t have a lot of debris or bloodborne pathogens or blood or things like that. There are cases where we do. Even though you can’t see it doesn’t mean it’s not there. Transport it in a closed, puncture proof container, marked “biohazard”. Make sure you’re decontaminating all your instruments. Not just the one that you used. I can’t believe I still see to this day people separate the instruments that come out of the operating room and tell those in sterile processing that these were used, these weren’t. Somehow they think that only those instruments that are used are gonna get washed and decontaminated. If it’s open —
MS BOURQUE: They touched them with their hands!
MS PACHECO: If it’s open on that table, you opened it on your back table, used or not, it is getting washed with everything else. Doesn’t matter if it was used. If it’s on your back table, it gets decontaminated. Okay? Using critical water. All critical water is… Is treated water. Just a fancy term for it. Sterile, distilled, some type of filtered water. Just making sure that last rinse of your instruments is with treated water. Multipart instruments get disassembled. Jaws, hinged instruments are opened. You want to make sure you’re flushing your lumens and visually inspecting your instruments. I have some thoughts here. So this is saying IA tip — you see on the top left, multipart instruments. Something to remember. If it didn’t come to you that way, it doesn’t get sterilized that way. In other words, these instruments come apart. They’re not fused together. Those tips, it comes apart even one more piece. That back piece can come apart as well. These particular instruments are in three pieces. That part was purchased, that’s how it came to you, that’s how it gets washed and sterilized. Even though you put it together for surgery, it comes apart to disassemble and decontaminate. Very, very important. They’re not meant to be decontaminated and sterilized together like that. They have to be taken apart. Especially because you’ve got to get that steam and you’ve got to get that sterilant in all the little crevices.
MS BOURQUE: All surfaces, absolutely.
MS PACHECO: All surfaces. Flushing your lumens. Making sure you’re flushing your lumens. Viscoelastic. This is big, and we’re gonna talk about TASS. Viscoelastic can get stuck in there, lens fragments can get stuck in there. Making sure you flush out your lumens. It can be done with a machine or a syringe. Copious amounts of water. Just make sure after you’re flushing you follow with air. Don’t let fluid accumulate in the lumens. The fluid can stay in there, the nucleus pieces can stay in there. Get thrown in the sterilizer — the next patient, it’s gonna get pushed out into someone else’s eye. That’s how we get infections. Make sure you’re flushing your lumens. All those instruments — you see the jaws, the hinged instruments, we’ve got to open them, make sure the jaws aren’t stuck together. Open them up. Let the sterilant, the steam, get to all the surfaces. Transport in a closed, puncture-proof container. It doesn’t have to be complex and you don’t have to spend a lot of money on it. These are simple items that you could use. One of them literally is a regular bin that you have to cover. It has a biohazard symbol on it. It keeps everyone protected. You can buy one, like the one on the left from the instrument manufacturer company. Whatever you have to use, just make sure it’s closed and you have a biohazard so that everyone knows that what’s in there is dirty. Visually inspect all your instruments. I always tell everybody: You wouldn’t want a family member coming in and that instrument on the left is being used on them. That is rust. Okay? That is not sterile. I hear so often, Dianne I’m sure you’ve heard — oh, it’s gone through the sterilizer, so it’s sterile. Think about it. So all that rust, what that’s doing is preventing your sterilizing agent, which is typically steam, from actually making contact to that instrument. Okay? That is prohibiting. It’s not sterile. That is prohibiting the sterilant reaching that instrument. Look at that debris. If you look inside the handle — that’s a great picture, Dianne.
MS BOURQUE: I see this. I mean… A lot of times, I’ll ask people… Is it okay if I see something and it looks a little strange? May I just go ahead and open this pill pouch? And I open it, and I let them see this. I was like… Just like you said, would you want this utilized on your mom’s surgery? Or your child’s surgery? And of course, they go no. But I think the visual inspection gets lost. People are just… They’re cleaning. They’re cleaning.
MS PACHECO: They’re in a rush.
MS BOURQUE: They are in a rush. Everyone is in a rush. But that’s part of it. That’s one of the steps that needs to be taken. You know, and also we need to make sure when we’re doing that, we’re inspecting… Is the instrument in good repair? Do we need to send things out, have things sharpened or reapproximated? That is a step that gets lost in a rush, but we need to slow down just a little bit. Or at the end of the day.
MS PACHECO: I would never want to give a surgeon that instrument. Never. That’s why it’s so important to be opening things. I’ll give you a little hint. If you do get things like that, just simple rust… That can be repaired. That can be repaired, and one of the things that takes that rust is pencil eraser. It works. Incredible. Pencil eraser works wonderful for rust. Get those hinges apart and you can actually use a pencil eraser and really get that.
MS BOURQUE: Learn something new every day. That’s fabulous. That’s fabulous.
MS PACHECO: Just a little hint for that.
MS BOURQUE: May I add one more thing? As you’re visually inspecting, we see this sometimes in office-based settings. That instruments that are disposable instruments sometimes get into pill pouches, or into packs. And we need to make sure that we’re utilizing instruments that can be reprocessed. You know, if you’re seeing things that don’t have the manufacturer’s stamp on there, you may want to investigate and see if it’s something that really should have been discarded.
MS PACHECO: Very true. Absolutely. Reprocessing items that are not meant to be reprocessed. That’s how we run into trouble. Lawrence, I’ve got a couple of poll questions, if you would like to throw those up for us. So I would like to know from those of you watching if you use immediate use sterilization. Which is flash sterilization. At your facility regularly. I don’t mean those once in a while, every now and then. Who out there uses flash sterilization in your facility regularly? I’ll give it a minute or so, just to make sure everybody can get on. Okay. All right. So that’s very good to know. All right. That helps. And I think you have another question, Lawrence? Something I would like to know, because I do see this quite often, when I give these talks… Do you use biological indicators? Spore testing. I do know most facilities use indicator strips. But I would like to know if you do biological indicators. If you’re actually doing what we call bug testing. So monitoring your sterilization process. Okay? This is an actual spore testing.
DR GOLDSTEIN: Lori, I think you’re gonna have to do a whole separate session on the pencil eraser. Everyone is very interested in the pencil eraser.
MS PACHECO: It works, it works. Okay. So good. I’m glad to see that we do have quite a few people using spore testing. Because I do see very often that it is not used. And that they would just be utilizing indicator strips. So I do… I’m very happy to see that. So let’s go into sterile processing. Really important is that you’re using the correct settings for that sterilizer. This is not an area where it’s one size fits all. Okay? This is where your instructions for use are really important and come in handy. Compatibility. Let’s make sure that your temperature, duration, everything — the instruments and the instrument cases are compatible. I’ll give you a quick example of what I mean. It’s that — and I’ve seen this happen. It’s that you have… Let’s say a rigid container to sterilize your instruments in. And you have an instrument hit the floor. Let’s say it’s one of those situations where immediate use sterilization is appropriate and would come in handy. And you clean that instrument. You need it right away. You popped it in one of your rigid containers. And you put it in for that flash cycle. Which is typically what is called a gravity displacement cycle. It’s a very quick three minute cycle. You sterilize an instrument. You put your indicator strips in there. And you’re done. It comes out. You open it up, and that indicator strip did not change. Those instruments were not sterilized. That’s because that rigid container is not validated for gravity displacement. It can only be used in prevacuum settings. So you have to take a look at your manufacturer instructions for both your instruments and your trays, everything, and make sure they’re all compatible. The steam did not penetrate, because it was not meant for that type of setting. So that’s just an example. And then you’ve got your validation. You have your chemical indicators. There are different types. Okay? Doesn’t mean one is better than the other. It’s just what’s more appropriate. There’s type one through six. Type five and six is typically what we want to see used in health care settings. And you have your biological indicators. And you can do those… If you’re using biological indicators, your bug testing, at a minimum, weekly. You have to think… How can I go back, if I had a problem… Let’s say we did have some type of infection… How can I go back and make sure that my sterilizers were working properly? So at least a minimum of weekly. Best case scenario would be daily. But I do know that that type of equipment can be expensive if you’re doing biological… The incubator can be a little bit of money. But something you want to see at least done weekly. Dr. Goldstein?
DR GOLDSTEIN: Yes. So Lori, that’s a great point. At AAAA, it is one of the requirements of accreditation, that you do the biological testing at least weekly. And one of the things I just wanted to add to this is you’re required to have a log of your sterilization processes. And that log needs to contain all the parameters that were used. But also the instrument sets that were used. And for your facility, should there be a problem or an infection, you really want to be able to identify where that breach occurred. Without a proper log, identifying what actually was sterilized, whether that be by number or how the sets are named… There’s no way to be able to know that and protect your patients.
MS BOURQUE: Because you need to be able to track the patients. So that log allows you to go back and see which cases were performed on Tuesday or Wednesday, and be able to track and just look for things. And notify patients, if you need to.
MS PACHECO: Exactly. And most sterilizers will have printouts that will come up. And you can also go back, you can put it in their medical record. However you want to track it. You can just have a simple log. But make sure that you’re tracking also the load. Each sterilizer will have a load number. Some are as simple as the date and one, two, three. But make sure you’re doing that tracking so that if you do have a problem, you can go back and make sure. Everything should be able to match up. The number of the log, the load number that you have for your sterilizer matches what was given to the patient. Matches… Okay. I looked on that day. You can go back to the log and see that the biological indicator was negative. Everything should be able to match up. So really being able to track… It’s a key to… Not so much infection prevention, but being able to go back and look. If you do have a problem, did have an infection, would be able to identify possibly…
MS BOURQUE: I’m so sorry to interrupt. I apologize. But if you have multiple autoclaves, that’s really important as well. In some places, there are two. So we need to identify on pill pouches or on packs or on kits.
MS PACHECO: Sterilizer A, sterilizer B. However you want to do it. There’s no right or wrong. However you want to label it. But if you do have multiple sterilizers, very important — you’re putting down not only that load number, but what sterilizer it came out of.
MS BOURQUE: And just tracking, being able to identify and track. That’s quite important.
MS PACHECO: Exactly. So procedures for processing ophthalmic instruments. They can differ from those of general surgery. If you’re a multisurgical facility, where you’re doing other cases besides ophthalmology, please be sure you’re separating these instruments. Cleaning intraocular instruments from general surgical instruments. It can help that cross contamination from that bioburden, from really heavily soiled instruments that you can get in regular general surgery. Okay? Because most instances of TASS, toxic anterior segment syndrome, can be related to instrument processing. So let’s make sure we’re really taking care of these ophthalmic instruments and not cross contaminating them with things that can happen in general surgery, where you get those really heavily soiled non-ophthalmic instruments. The guidelines for decontaminating instruments. We talked about this. Immediately after use, or even during the procedure. You want to wipe those instruments down. Sterile water. Sterile lint-free sponge or cloth. Flushing, immersing your lumens in sterile water. Make sure you’re using the IFUs. Cleaning your intraocular instruments in a designated cleaning area, separately. Okay? Use those single use disposable cannulas when you can. I know they can be expensive. And that’s okay. If you can’t use the disposable ones, you can use the reprocessing ones. As long as you’re reprocessing them according to the instructions for use, and you’re taking the time that you need to flush these instruments, and to rinse these instruments as well. At the close of the procedure, use critical water. That’s that filtered sterile treated water to flush your phaco handpieces, and irrigation and aspiration points, your cannulas, your Simcoes, reusable tips, anything like that — you want to be sure you’re flushing, flushing, flushing with copious amounts of fluid. I know typically in the past, I’ve seen 120CCs. If you’re using a machine, most machines actually do flush with 120CCs of fluid, followed by air. If you don’t have that, at least get that good syringe. A copious amount of fluids — get through there, and make sure you follow with air. Don’t leave fluids inside these lumens. Okay? After your cleaning, you had that final rinse. Including those lumens. With critical or sterile water. You want to use that air. If you’re using an ultrasonic cleaner, making sure that you’re cleaning that ultrasonic cleaner. You’re changing the water. Typically you’re changing the water after every use, IFUs will tell you. But we want to make sure we’re changing that water out, disinfecting, rinsing, and cleaning that ultrasonic cleaning. According to the manufacturer’s instructions. Make sure you’re using whatever supply it’s telling you to. Don’t put anything in your ultrasonic cleaners that don’t belong there, because that’s when you’re gonna have infections. If you’re using cleaners that don’t belong inside the ultrasonic cleaner. Make sure you’re using the correct cleaner. If it’s not contraindicated by the manufacturer’s written instructions, 70% alcohol, dry with a lint free cloth — that’s usually acceptable. And just make sure we’re really looking at our instruments afterwards. Those magnifying glasses are wonderful. These are small little microinstruments. We want to make sure we’re taking a peek and looking at them and making sure they’re in good condition. All right. It’s that dirty word. It’s TASS. Toxic anterior segment syndrome. It’s that acute severe intraocular inflammation in the anterior segment that can happen after intraocular surgery. It usually presents within 12 to 24 hours after surgery. Different from endophthalmitis, which can often happen two to seven days after surgery. So we kind of want to make sure we understand the distinction there. So we have quite a few things that can cause TASS. Contaminated BSS. Irrigating solutions that have abnormal pHs to them. Viscoelastic agents. Topical ointments. All of these things can cause TASS. Typically what we see with TASS is inadequate flushing of instruments in between cases. That results in that build-up of vasc solution inside those cannulas, that build-up of foreign material, that stays in there during the sterilization process and is used in another patient. COVID-19. Dianne, I think I’m gonna have you do this particular slide. Because I think you will do a wonderful job. At really talking about COVID-19. This COVID-19 area. Yeah. Please.
MS BOURQUE: Thank you. It was such… You know, we’ve learned so much in the last two years. And I just really want to thank all of the communities that we’re speaking with today. Because it was hard. And it was a burden on staff. But we did it. And we’re doing a great job. One of the things that we just have learned from this is that training is important. We need to help people understand with not only COVID-19, but any type of emerging infectious disease that we’re getting out in front of our staff, and we’re talking about the newest information in the most timely manner. So we’re going to train the staff about new symptoms and how we’re gonna mitigate the disease transfer. So like we said, training, signage, however we can to push the information. Emails. Posters. Just even in the break room, we want to put information right in front of people. Visual cues are very, very important. But then… What we learned also is: If we have new equipment, we have to monitor and make sure that we have a good inventory of supplies. We saw PPE being so sparse. When we needed it. But it was kind of interesting. Because before COVID, I think when we looked at inventory, we kept a lean inventory all the time. So what we need to think about now is: Do we need to keep a 2 to 4 week supply of inventory if we can? For masks and gloves? But also, rotate that, so that we don’t have N-95s way in the back, and the little elastics, you know, when you put them on, that they pop. So we want to keep rotating that inventory. To be able to safely provide care to our patients, but also to protect ourselves. That’s quite important. So one of the things we want to make sure that we’re doing — and I think hopefully that this is gonna continue beyond COVID-19 — is that when patients come into our facilities, we’re gonna talk with them. You know, do you have a fever? Have you been feeling unwell? If you are… We need to stop. We need to say… You know, perhaps today is not the best day to bring you into the facility. Because you’re not at your best. So we’re gonna start that on the phone, maybe, the day before, as we call a patient, and talk with them. Just say… If you’re not feeling well, in the next morning, when you’re coming, give us a call before you come in. We’re also putting signage at the front door of the facility to say: If you’re coughing or you feel feverish this morning, why don’t you give us a call before. Or knock on the door, and we’ll come meet you outside, to kind of do some infection surveillance.
MS PACHECO: The days of coming in sick are long gone.
MS BOURQUE: No. Yes, that ship has definitely sailed. But that reinforcing of the culture too. With our own staff! If you don’t feel well in the morning…
MS PACHECO: Stay home!
MS BOURQUE: It’s just not worth it anymore. We’ll work a little bit harder today so that you can stay home and come back. So whether it’s COVID-19 or the flu… You know, whatever it is… Just stay home. But also that… Enhancing the disinfection of the environment… You know, we used to I think sometimes just take it for granted. We would wipe down here and there… But now we’re going to the doorknobs. On the hour, or when COVID-19 was really at its height, we were doing it between every patient. But making sure restrooms and waiting rooms, that we’re disinfecting them more frequently. For couches and things that are in the waiting room, that can’t be wiped down, that have a spray disinfectant that we’re using. But that’s really important. It was like our environmental disinfection on steroids… You know, we need to keep doing that. Keep doing that. Yeah. But our infection control coordinator and the medical director and members of the team — we really want to monitor our Department of Health and regional Departments of Health. Of your state or your country or your region — to see, because a lot of times in our community we’re seeing enhanced transmission of infectious diseases. I was remembering back to the old days, when we would get a fax from our Department of Health. Saying oh, we’ve got this in the community. In Texas, we had an outbreak of measles a couple of years ago. We were getting that via fax. Now via email and sometimes via text. But someone that’s looking at this, and going to whatever your leadership is, and saying… Hey, you know, this is upticking… What do we want to do? Because with COVID-19, we were testing our patients before surgery. Now we’ve abandoned that. But… Our decision is that if we see it rise up in the community, the community transmission increases, then we’re gonna go back and start testing again. So that’s really important. And then also just flexing our protocols… Whatever we need to do. Sometimes we were just doing… We’re now just kind of asking people what… We see that a lot. What are your symptoms? But maybe we need to go back to temperature checks. Whatever you need to do — just communicate with the leadership. And decide what’s appropriate.
MS PACHECO: Updating those policies. How many times you go in a facility and you look at these policies and you think… How old is this? 20 years old. You have to look at these policies. Signing off on these policies. Updating them. Keep them up to date.
MS BOURQUE: That leadership…
MS PACHECO: Did you have something, Dr. Goldstein?
DR GOLDSTEIN: I did. I found it very interesting in our world, the accreditation world. The ophthalmologists and the ophthalmology world… The ophthalmology staff were the canaries in the coal mine, when it came to COVID-19. Any of the facilities that we surveyed… We noticed that it was the ophthalmologists or the retinal specialists who were the first to come down with COVID-19 in the beginning of this. Because they were really so close to the patient. Face on face to the patient. And we saw the greatest effect or adherence to the appropriate policies and personal protective equipment, which is PPE. Made a huge difference. And once we paid attention to these protocols, there was very low transmission in the facilities that were accredited.
MS PACHECO: Excellent. Very good. We’re getting into our one hour mark. So I appreciate everyone sticking with us. Because we have so much wonderful information to share with you. You know, we talked about our signs. Dianne, these are all the signs that you have mentioned. Putting around your facility. And reading the following, stating whether any of these apply to you. Bringing your staff, doing this as a team approach. But look at all these great signs. Just things that you can have around. Just reminders of all the things that we should be doing. Social distancing. Face masks required. All right. I’m going to go into a little bit of a panel discussion. Tom?
MR TERRANOVA: Just two quick things. One on the previous slide. I know we’re two plus years into COVID. So sometimes when we’re talking about COVID, I think people can kind of say… Yeah. We figured out how we want to handle that. But I think the important takeaway from everything that we’re talking about with COVID is… Planning. Establishing a plan gives you a point at which to divert when the next thing arises. The next thing is not going to be COVID-19. It’s not going to be some variant of some other zoological disease that jumps to humans. There’s going to be a respiratory of some sort. There’s gonna be some other infectious communicable disease that requires something that is a deviation from what we did for COVID. And so the takeaway here isn’t that you have to do exactly this. It’s that these are all of the things that we put in place for COVID, that provide a great starting point for the next. That as it evolves, as it adjusts, as the next thing comes up, you will have these tools and resources at your hands to then shift. And I think with the last talk that Dr. Goldstein and I did about a year, year and a half ago, we shared — AAASF came up with a 50-page resource guide for COVID. Both in English and Spanish. Sorry, those were the only two languages we were able to get it in so far. But they had the signage from World Health Organization and CDC. It had scripts for your staff to be reviewing with patients beforehand. It had processes and policies and logs. And all of these things are great. And if you haven’t used them, I think the Cybersight website has them. Our website has them. But again… These are great to keep in your storage for the next time you need these resources, because you can adjust them. And you’re not starting from the beginning. Because obviously the next thing is going to require some variation. The other point that I wanted to it bring up — and I’ll try to keep it short — is someone asked in the chat about staff strength and that being so important to infection control. And it dovetailed nicely with a point that I wanted to make. And it’s this. Everything we talked about here today is even more important in a transient environment. So if you are in a developing country or an underdeveloped country, where perhaps the level of training for nurses or for other techs or non-clinical staff isn’t as robust as it might be in other parts of the world… All of the communication, all of the training, all of the signage and the tools that we’re talking about become that much more important. Because you have to raise the level of expectation and almost do that educational component within your center. And so if you’re working with nurses or techs or assistants that may not have had such a robust training environment as they might have in other countries, then it becomes incumbent upon the leadership of the facility to make sure they have resources like the ones at Cybersight. Like online learning modules and others. And it’s not only important in developing countries and underdeveloped countries. If you’re in an environment where you’re bringing in staff from around the world, even if their training is robust, it’s different than another staff member’s training. We do a lot of work in the Middle East and UAE. And in UAE, a lot of the population comes from five or six or seven different countries. And so if your staff is trained in… If you have seven staff members that are trained in a different learning environment in seven different countries, the expectation of each person as to their role and their duties and where the hand offs from one function to another function go… May be different. So pulling your staff together and having very clear communication about the expectations and roles of each person and each job description is super important. Because a nurse trained in the Philippines may think something very different from a nurse trained in Pakistan than a nurse trained in China. So if you have nurses from the Philippines, China, and Pakistan on your staff, you just want to make sure you’re all having the same conversation about what the duties entail, because they may have different expectations. And you want to be really clear with that.
MS BOURQUE: That’s a great point. I mean, that is really a good point. We don’t think about that all the time in the US. But you’re right. We need to make sure… And I think that’s why those protocols, visual signage, reminding people… So that these things become muscle memory. If it’s in your face constantly, it becomes muscle memory. That’s a great point.
MS PACHECO: Excellent. Thank you, Tom. We had some great questions that came in. I know we still have some time. We’re gonna go through each question, each one of our panelists is just gonna take one and go into it in detail. So one of them was: How can infection cause eye damage? What are the major things that we have? And I think Dr. Goldstein… Would you be able to provide us with an overview of some of the damage that infection can cause in your eye?
DR GOLDSTEIN: I am. And I’m gonna go back to the basics. I’ll see if I can share my screen here.
MS PACHECO: I can shop sharing and you can share yours.
DR GOLDSTEIN: There’s probably a way to do that. So can you see that one?
MS PACHECO: There we go. Excellent. Perfect.
DR GOLDSTEIN: I really want to get back to the basics on this one. Because it’s all about endophthalmitis. As an anesthesiologist, I’ve witnessed thousands upon thousands of eye surgeries over the years. And that’s always been the dreaded complication that we worry about. And I think the way endophthalmitis causes damage is the inflammation and infection inside of the eye. The eye is a pretty… The inside of the eye really — there’s not a lot of infection fighting capabilities. You know, inside the eye. So any introduction of any kind of pathogen can cause severe damage very quickly. And I wanted to comment on one of your slides. Because the difference between TASS and endophthalmitis is something that we really need to be aware of. You know, a little later on, we talk about eye pain being one of the first features of endophthalmitis. And it all goes to education of our patients to make them be able to report back to us when they’re feeling symptoms or… That really reflect upon whether they had endophthalmitis or not. So that’s how it causes damage. It causes damage to the vitreous and also causes damage to the retina. And unless treated effectively, very quickly, can and will lead to blindness. So in that sense, it’s essential that we take care of it very quickly.
MS PACHECO: Thank you, Dr. Goldstein. All right. So how long can an autoclaved box remain sterile? I thought this was a really good question. I don’t know… Tom, did you want to take a stab at this? Or Dianne?
MR TERRANOVA: Sure. The quickest and the least satisfying answer in history is “it depends”. Right? And that’s true. So there’s a lot of factors that impact how long a box can stay sterile. Some of it being the packaging. And the easiest thing is to look at the manufacturer’s guidelines. Whether it’s boxes, wrapping, containers, peel-apart packaging. All of that is going to have its own manufacturers’ guidelines. And some of them may have time related, and some may be event related. And so some small studies have shown items remaining sterile for 12 to 24 months. But this is all… Presuming that you don’t have a packaging that says that it remains good for three months, six months, whatever that is. But it’s also presuming the environment and the processes are good. And that’s really the biggest takeaway here. You can pay attention to the manufacturer’s guidelines very easily. And as you’re bringing in supplies, especially with the supply chain issues, again, being aware of the new packs that you might have to bring in, because your manufacturer’s out, or whatever the case may be… Is super important. But equally important is auditing your process on an ongoing basis. If the temperature doesn’t stay right in your storage, if the humidity doesn’t stay right in your storage, if things are overpacked, so you’re opening a drawer with sterile supplies in it, and they’re overpacked, and all of a sudden they become… Snagged… All of this would impact the sterility and violate sort of any time periods that are there. So… These audits of the process and the policy are super important. I can tell you… I have some pictures that I keep in a different presentation. Where the autoclave is on the shelf. And above the shelf in cabinetry are all the sterile packs. So as soon as the autoclave vents, all the steam goes directly up into the packs. So none of those packs are sterile. So the packaging might say it’s good for a year. But none of them are good. Because the process and the storage capacity was wrong. That’s the unsatisfying answer that I’ll give.
MS PACHECO: Thank you. Dianne, let’s talk a little bit about needle stick injuries.
MS BOURQUE: Well, one of the things we really want to do is have your staff evaluate… If you have mechanical devices, mechanical safety devices, that you can utilize with syringes or IV catheters, that’s kind of the best practice. If you don’t have that, if you’re utilizing just direct syringes or IV catheters that don’t have mechanical caps, you want to just be very aware. You want to use a scooping method. After you have a needle that’s exposed. Telling our… What we used to do 20 years ago… It’s horrifying. But we used to stick things in mattresses or foam or whatever. We don’t want to do any of those things anymore. It’s very important that if we can’t properly scoop a needle, we put it in a neutral area, and we use kind of that pen scooping method that we use, or a box scooping method. And if you’re on a sterile field, just communicating that you’ve got suture material, and putting things to a neutral space. I think that’s quite important.
MS PACHECO: Awesome. Thank you. How to prevent infection within 48 hours? So Dr. Goldstein, give us some ideas.
DR GOLDSTEIN: So that’s a great question. You know, I pondered over this one for a bit. And I think the best answer to this is… Go back to the basics. So preventing infection for the first 48 hours starts when the patients are booked. Or scheduled to have surgery. So it’s all about education for them. Making sure that they’ve performed all the proper instructions, whether that be preoperative eye drops, antibiotics before surgery, and when a patient arrives… One of the things we noticed throughout the world in our accreditation is… There can be language difficulties and interpretation difficulties. And Cybersight and Orbis obviously are experts in trying to bridge those gaps. But the key is to have the patient and the staff understand what needs to be done and that instructions can be followed, both before, during, and after surgery. Obviously attention to detail is the key. And this presentation has given a lot of it. And there’s a lot more out there. And I really do believe in the KISS principle. Which is “keep it simple, stupid”. You know, we have already illuminated everybody about basic infection control practices. And the other thing I just want to point out, which is a requirement of accreditation, is that there be active surveillance for infections postoperatively. So there’s no good way to prevent infections unless you know that you actually have them, and that you have a problem. So that’s key in the first 48 hours as well.
MS BOURQUE: And Dr. Goldstein, I would just like to add — I love what you said about tracking your infections. It’s also quite important that your leadership, if they become aware of infections, that they sit down and they look at… Kind of looking at the risk: What are we seeing? What’s the trend? If we have a trend, let’s get together and talk about it. What can we interject? Do we need better post-op instructions for family members? Do we know that we have an infection that’s coming out of OR1 versus OR2? But really doing some performance improvement studies. Looking… Doing some corrective action, and just making sure that if we have a trend with a surgical site infection that we can address that properly. But I love what you said about patient education. Because that’s really quite important. Making sure that they’re not going to be in a bath or rubbing their eyes or things like that. And also that their caregiver has good instructions, and acknowledges that they understand the instructions.
DR GOLDSTEIN: Very simple items like having patients understand, or their caregivers, giving their postoperative drops — they need to wash their hands. Most people don’t understand that. So that is essential. And I don’t think… I think if these pieces don’t all come together, then surgery needs to be delayed. Until we can communicate effectively.
MS PACHECO: Agree, agree. So in an outreach setting, when there’s not an operating theater to work in, how do you ensure proper infection prevention? Tom?
MR TERRANOVA: So this one is gonna depend on the facility. And the services being provided. But in general, again, we’re talking about a lot of the same thing. So improved hand hygiene is obviously going to be critical. Making sure supplies are readily available throughout the center. However it’s laid out. So that there’s alcohol stations, frequently, or handwashing stations, frequently. And again, to be monitoring hand hygiene throughout. Because as you come in contact with membranes or non-intact skin or contaminated equipment, all of a sudden you have another transmission issue. So again, PPE is really important. Don’t wear the same gloves. Don’t wash gloves for reuse. I know some folks talked about needing to really be cognizant of those supplies in some countries. In some parts of the world. But again… When we’re talking about the singular focus of infection prevention… Going through gloves and not reutilizing them is really important. Environmental surface cleaning, equipment cleaning… And again, if you’re not talking about an operating theater, injection and medication safety probably take a bigger piece of the pie here, right? If you’re using multidose eye drops, again, not making contact with the patient is super important. Because now you’re not just talking about contamination of a single patient, but cross contamination. If you’re doing eye drops, all that hand hygiene that Dr. Goldstein just talked about is really important. But also not making contact with the eye. Using the single syringes to administer medication. Reinserting needles into medication vials. And preparing medications away from the patient care area. These all become that much more important, because you’re not doing surgery. So all of that area of surgical infection control tends to kind of fall away. Because you’re not doing those services. One of the bigger risks is injection and medication safety. And then again… Just keeping potential exposures to a minimum, using respiratory hygiene, cough etiquette, again, with COVID and other respiratory diseases, MERS, things like that, you want to make sure when you’re face-to-face with your patients that everyone is kind of aware of the risks involved in being sort of that close to respiration. So I think those are the key takeaways there.
MS PACHECO: Excellent. Thank you, Tom.
MS BOURQUE: Lori, can I say something also? Back to what he was saying. When you’re talking about the eye drops and multiple dose vials, discarding STVs — I think it’s really important to speak with your staff and talk about: Self-reporting of a breach is so important. And you’re not gonna get in trouble. We really need you to be very aware of aseptic technique. And if you have a problem or you see something, you need to speak up. Nobody is going to be upset with you. We’re all protecting patients. But if we don’t have that culture of safety, you may have a problem.
MS PACHECO: That’s how we learn.
MR TERRANOVA: I wanted to say that in the last question too. Whether it’s the leadership and the monitoring… There’s a tendency to want to cover up breaches or cover up problems. And the issue is that the cover up is often worse than the crime, right? So if you have a breach, maybe no one is going to have an infection. But you had a breach. And if there is not a willingness to open up and to learn and to improve at the individual level and at the leadership level, then you’re sort of doomed to eventually having a catastrophe. And I think it’s super important to have an open culture that fosters the desire to improve, because you don’t have a tendency then to try to hide your mistakes.
MS PACHECO: It’s so important. We’re here together. We learn from each other. It’s really just a process… Even things like needle stick injuries. I’ve had a needle stick injury.
MS BOURQUE: I have as well.
MS PACHECO: It’s just one of those things that has happened. And we learn from them. But we don’t hide them. It’s nothing to be embarrassed about or worried. It’s just… You approach it head on and you learn from it. Class B autoclaves. So the question was: Is a class B autoclave a must for use? I would say in ophthalmology, yes. We have different types of sterilizers. There are class Bs, class Ns, class Ss. So basically a class B autoclave… What those typically use are prevacuum settings. And they can be used on instruments that come in multiple parts. They have lumens in them. They’re hollow. You can use them on pretty much anything. The steam penetrates well. But the key is that it’s prevacuum. With prevacuum, you’re using pumps that push air out of the chamber. Those little alternating pumps. And that’s how you get the air out and you get the sterilizing agent to meet every little crevice. When you’re working with sterilizers that are class N, these are more gravity displacement sterilizers. You can use them, but they’re meant for solid instruments. Very simple solid instruments. You might find these in some of the dental offices. No lumens. Nothing hollow. Nothing multiple parts. Or things you have to take apart. You can’t use them with these sterilizers. You don’t have enough steam penetration to contact. Same thing with class S. Somewhere in between. A class S is somewhere in between a class B and a class N. But same thing. It’s not meant for these complex instruments. So I would say yes. The class B is certainly needed for ophthalmic instruments. Is it good practice to wash surgical gloves with lactated ringers to get your excess powder off? What do you think?
MS BOURQUE: I would say current recommended practices are that we use powder-free gloves. I think that’s really important. We don’t want to put any type of sediment or anything into the surgical field. We’re really concerned about TASS. We’re really concerned about just irritation. So I think it’s really… You just need to just try to get the correct type of glove for the surgeons and for the assistants.
MS PACHECO: Thank you. Is it safe to resterilize phaco tubing? What do we think?
MS BOURQUE: Oh. Well… Basically you always just have to go back to the manufacturer’s instructions for use. And you’re gonna look at that tubing and look at the label that’s on there. Most of the time, it is single use. If you have something that says it is approved for reprocessing, then you must meet all of the parameters for reprocessing. So I would say just go back and look at the label. Look at the manufacturer’s instructions.
MS PACHECO: Simple, simple, simple. Absolutely. Is just prepping with povidone-iodine enough for prevention? Must it be left on for several seconds? Dr. Goldstein, can you give us a thought on that?
DR GOLDSTEIN: If I can share for one second, Lori… Okay. Let me get to that. And it’s about… I think this is gonna answer a few questions. Because there were a number of questions in there. I wanted to just go back. Is it just enough? There’s all the other protocols too. For infection prevention. Right? It’s the preoperative antibiotic drops that patients take. It’s the skin. Really should be cleansed before they even arrive to where they’re gonna have surgery. So that’s all part of patient education as well. But I want to talk a moment about Betadine. Because it’s important that we understand that that is still the best alternative in ocular surgery for prepping the eye and the surrounding areas. So I put up… Actually, I took this slide right from the manufacturer’s instructions for use. Which is the way… When you try to do everything, and we understand that there’s limited availability in some places… Because one of the questions that was asked is: You know, how long does the Betadine have to stay in? And I’ve been in practice for about 32 years. And I still come from a time when there was no such thing as phaco. And there are still places doing it without phaco, I guess. But I understand that for as many times as I’ve seen eye surgery, there are as many different recipes to be able to prevent infection in how the eye is prepped. But the key is to use Betadine effectively. It starts working immediately, as it says on the slide, and continues working for some time afterwards. So I want to bring that out as well. And it tells it to prep it about three times. There are specific instructions. Some people wipe it off with alcohol afterwards. I don’t know that that’s the best practice out there. Lori… And Dianne, you probably would both be able to comment on that a little better. But the key is to let Betadine work according to its instructions for use, and allow somewhere between the two and three minute drying time. And to do that effectively, along with the appropriate postoperative drops or postoperative antibiotic implant, or an injection, those are what you do to prevent infection.
MS PACHECO: I’ve always been taught to let it sit there and dry. Don’t touch it. Don’t pat it dry. That’s the best you can do for Betadine effectiveness. Just to let it sit there and dry.
MS BOURQUE: I agree.
MS PACHECO: So infection protocol, when you’re recommissioning an operating theater after renovations. Prolonged closure. Tom, Dianne, I think both of you had some thoughts on this.
MR TERRANOVA: So I can start and just say… So construction is a pretty big risk. Because some of it is going to be environmental, again, depending on where you are, and humidity and all those things. Fungus can grow. And as we’ve seen from the cleansers, some cleansers aren’t fungicidal. Some aren’t viricidal. You have to be careful going about doing this. So one of the resources we were looking at talked about putting in a risk assessment prior to starting the project. What are the environmental risks? What are the risks that you’re going to face, doing your construction or doing your remodel in your center, given your location? Because that’s always gonna be a component of this. So you should plan it out and approve your process before you’ve commenced the work. And then obviously adjust as needed. So fungus has been a big known infection control risk from construction around the globe. Legionella, listeria, and aspergillus are common construction associated health acquired infections. So be aware of those. And combat those health infections appropriately. You need to look at air quality. Negative pressure. Minimizing dust. Using drop seats. Sealing the areas, especially if you’re going to be partially operating while the theater is going to be renovated. Changing air filters more frequently really important. Flushing the plumbing is gonna be critical. Flushing water lines, looking for discolored water, looking for appropriate temperature. Microorganisms, testing for microorganisms. And then obviously, again, if you’re going to be partially in operation, making sure that patients have minimal exposure to any areas that are under construction. And then upon completion, you want to have sort of a full terminal cleaning. You want to wipe down all hard surfaces. You want to not just from an infection control standpoint… From a biomed standpoint… You want to recheck all of your equipment. All of your equipment that’s been decommed for a while, you need to make sure it is biomed tested and approved and still calibrated appropriately, and disinfected and cleaned up and resterilizing supplies that may have been in the area is critical. So that’s my quick one. Because I’m sure Dianne is gonna give you some more info. The other thing that I think is important: We found a good resource from Australia that was a government tool for utilizing construction. We’ve provided that to Cybersight. It’s attributed to the government in Australia. If you need that, I think it would be a good starting point. Obviously again it may be geography specific. So you may need to adjust based on where you are. But it’s a nice tool and a good policy for a starting point.
MS PACHECO: Yeah. May I also add as well: If you’re moving the sterilizers, if you’re having to do any repairs on your sterilizers, anything during this renovations or anything… These sterilizers, they can’t just be put into use. We’re back up and running on Monday. Let’s sterilize our instruments on Monday. You need to test those sterilizers before you put them back into use.
MS BOURQUE: Three times.
MS PACHECO: Three times. Thank you. You need to do biological bug testing, if you’re using indicator strips, three times. These sterilizers need to be tested before you put them back into use. You can’t just start back up again.
MR TERRANOVA: That’s also an important note even without renovation or prolonged closure. If you buy new equipment or put a piece of equipment into storage and it was recalibrated before it went into storage, and now you need to use it, maybe equipment was broken or out for maintenance and you’re bringing that equipment back into use… Just because it was good before doesn’t mean it’s good again. You need to retest it, the biomeds need to get involved. So recalibration is a key all the time. In prolonged use and in disuse. It’s very important that those sort of routines are respected.
MS PACHECO: Log it. Document what you’re doing. Document that you’ve done this testing so you can go back and reassure.
MS BOURQUE: And retrain staff if you need to. Get them back into training. We’ve seen ASCs that move into locations. They have an ASC building… New construction. It’s a big deal, and you want to roll it out effectively. Have a checklist. Go through the checklist. Make sure you don’t miss anything. Yeah. It’s a big deal.
MS PACHECO: Short cycles. Suggestion for sterilizing instruments in long cases. Utilizing short cycles. Dr. Goldstein?
DR GOLDSTEIN: If I could share… Because I want to say a little something about this. Thank you.
MS PACHECO: Lawrence, I know we’ve reached the 10:30 mark. I hope it’s okay. We’ve got some great questions here that we would like to go through. So we’re just gonna keep on trucking away.
DR GOLDSTEIN: I want to talk about short cycle, because it is pretty unique to the ophthalmology world. I’ve learned there is short cycle sterilization, which is not immediate use sterilization. I want to make sure we understand the distinction between the two. What I think we need to be very cognizant of, that short cycle is good for very specific instruments. And they have to be validated for that short cycle. It is not necessarily recognized by all regulatory agencies. Involved with infection control and sterilization. In the United States, it is recognized by CMS, which is the Center for Medicare and Medicare Services. But it’s not necessarily recognized by other infection control bodies, such as AME and so forth. What I want to caution everybody about, as you can see up on the screen… I saw that the poll indicated that there’s a lot of immediate use sterilization out there. And that to me… Actually throws a lot of caution in the wind. Immediate use is defined as the shortest possible time between items’ removal from the sterilizer and its aseptic transfer to the field. And an item that’s intended for immediate use should never be stored for future use. So one of the suggestions that’s come out as well… You know, we don’t have enough equipment to run our day. We’re just gonna use immediate use sterilization between cases. Because we can’t do short cycle. And we don’t have enough time. That’s an extreme risk in the accreditation world. When we work with Cybersight and ask a facility when we accredit them, we ask: Do you use immediate use sterilization and what do you use it for? If you use it in 70% of cases, that’s not appropriate. That’s got to stop immediately. What I tell people is: You need to slow down between cases. You can only book the number of cases that you can sterilize the instruments for. We’re going to look at immediate use sterilization very carefully. What processes occur and the equipment needs to be appropriately manufactured for that use. So you can’t use IUSS. And you can’t store items that aren’t used immediately. There are, however, some indications where you can use it. We’ll look for that. Obviously in an emergency, if an instrument is dropped off the field, by all means, go ahead and use IUSS. Return that item to the field, and then it needs to be sterilized appropriately. With manufacturers’ instructions for use. It is everyone’s responsibility to ensure that we do not use shortcut methods to provide care in our facilities. So I would say that is probably the takeaway. Short cycle is appropriate. Everything has to be validated accordingly. Because it’s all about the drying time.
MS PACHECO: Excellent. Thank you so much. Gonio lens. So… Dianne, either you or myself… Either way… I know when it comes to lenses that we’re using, gonio lenses, when we’re doing laser procedures — I know we do so many procedures back to back to back. And cleaning these lenses has always been a question. But really it all comes down to manufacturers’ instructions. They’re telling you what you need to do to clean these lenses. Typically it’s some sort of germicidal wipe that you’re using. I know a lot of people tend to try to use alcohol wipes. It’s really just a matter of whether the manufacturer says that’s effective or not. So typically what I see for most lenses is germicidal wipes. But just be very, very cautious if
— these things are toxic to the cornea. So rinse, rinse, rinse, rinse, rinse. And make sure whether you’re using alcohol, germicidal wipes, or whatever the manufacturer is telling you to — usually it’s a multistep process. The first thing they’re telling you to do is wash these lenses with very gentle soap. Exactly, just regular… Any type of soft soap that you can use. First just to get the goo off. To get the gonio gel off. And then it goes into — it’s a two-step process — what you can do to clean it, to rid it of germs. That’s usually germicidal wipes, typically. But you want to go through the manufacturers’ instructions for that and see what they’re recommending. And also those instructions are not just for cleaning and making sure you have proper cleaning. It’s also extending the life of them. If you’re using something that’s not meant to be cleaning them, you’re gonna break down, often, some of these lenses. You can ruin them. We spend a lot of money on our instruments. You want to make sure we take care of them, the way the manufacturer told us to. But if you’re using these germicidal wipes, be sure that you’re rinsing, rinsing, rinsing, and it’s not going back on someone’s eye. Allergies in iodine. I get this question so often in the operating room, when patients come in with allergies, and the difference between IVP and iodine… Can you use alcohol? Dr. Goldstein, what is your idea?
DR GOLDSTEIN: I’ll share one more time.
MS PACHECO: You got it. There you go, sir.
DR GOLDSTEIN: Let’s see. I think the most important question is whether there really is a Betadine allergy. That gets lost. The easiest thing to do is chart Betadine allergy. It gets promulgated or sent out to the whole facility and everyone just shies away. You can’t use Betadine. You can’t touch Betadine. Actually, Betadine allergy… It usually comes from people who have had IV contrast dye, maybe the iodine within that. Really true allergy to Betadine is extremely rare. The problem is… There really are not great alternatives to Betadine in the ophthalmology world. Pretty much almost everything else is caustic to the eye. So there have been a lot of… Different formulas out there of what to do. So what is recommended is that we determine whether there’s a true allergy. If there’s some slight irritation on the skin, that’s not an allergy. And it’s safe to go ahead and use Betadine. Because that’s the preferred choice. There are a lot of recipes out there using baby shampoo to cleanse the eye, the lids, the eyelids, before surgery. It’s well tolerated. Can be diluted out of the eye. In conjunction with antibiotic drops. That’s used. Most of these other items are really quite caustic to the eye and should not be used. 3% PCMX, which is actually a scrub item that’s been used recently to cleanse the eye… That is being used. With some success. But there really is no good data out there, and no great alternative. The key is: Don’t make it up. Look at what is potentially caustic to the eye and don’t use that. Cleanse around the eye as best as you can. Use antibiotic drops. But really determine if it’s a true allergy. It’s not a true allergy, go ahead and use the Betadine.
MS PACHECO: Excellent. We’ve gone through all of your questions. Thank you, everyone, for sticking with us. I did look at some of the Q and A questions. I think we hit most of them. It is getting quite late, so I appreciate everyone sticking with us. One question I did see come up, last question I wanted to touch upon… I’m afraid I don’t have much experience with it. It’s UV lights for cleaning in the operating theater. I don’t know, Dianne, if you’ve seen this, or Tom. As far as UV lights, and how well they do, I don’t have much experience with that. So I’m wondering if you have any thoughts on that.
MS BOURQUE: I don’t really either, to be honest with you. I know that… That was a technology that we used to tell. We used to see in hospitals all the time. That it can be helpful. But no, I don’t know that it’s evidence-based. Yeah. I don’t know that it’s an evidence-based…
MR TERRANOVA: To my knowledge too, there was a big push towards UV with COVID. It was that UV light was killing COVID. To the extent that I have seen it… I have seen it in conjunction with all of these other infection control practices. I’ve seen it where folks were using the OR, they did their terminal cleaning, and then did UV light to sort of… A belt and suspenders approach to killing COVID.
MS BOURQUE: It’s kind of an old methodology. They used to employ it in hospitals all the time. It was an adjunct. But I don’t know that it’s anything that’s evidence-based for, like, in addition to your terminal cleaning processes. Yeah.
MS PACHECO: Good. Thank you all so much. We had such great resources that we shared with you all today. So many forms. Templates, infection control plans. Please, please, please reach out. AAAA is so helpful in their resources. There is some information here on the screen, if you want to get ahold of any one of us. You can certainly email AAAA. We’re always happy to help. You can always email me. I’m willing to share anything that I may have with you. Again, we’re all in this together. And Cybersight as well. So please feel free if you have any nursing questions that you would like to ask, you can always go on to Cybersight and send in something that you wish to have a consult with and it will come to me, and I will help out in any way I can. Thank you all for our panel. Thank you for our wealth of knowledge. This was wonderful, and I appreciate everybody joining us today. Everybody take care and be well.
MR TERRANOVA: Thank you so much.
MS BOURQUE: Bye-bye. Have a great day.
June 13, 2022