UTSW Internal Medicine Website

At UTSW hospitals, informed consent forms are available by going to the Clinical Portal - Hospital Forms (all the forms are on the link).

At Parkland, the forms are found at the following link http://intranet.pmh.org/Home/PP-Index/consent.asp

See related document  Quick Reference – Informed Consents 08/19/2011 for further details.

Any bedside procedure is associated with some risk of inoculation of pathogens in a patient, and risk of cross-contamination within a patient and between patients or between patient and environment in the patient’s vicinity. Infection prevention measures need to be utilized during all procedures to prevent cross-contamination and to prevent development of healthcare-associated infection in a patient. The infection prevention technique used is generally one of the three broad categories – clean, aseptic or sterile. The specific technique/ level of precautions are dependent on the type of procedure, body site, whether the procedure is being performed in an emergency (code) situation and local hospital epidemiology conditions.

Clean Technique: This technique is used for non-invasive procedures like a routine blood draw, or overtly dirty procedures like colonoscopy. Standard precautions, i.e., hand hygiene, respiratory etiquette, and use of personal protective equipment (clean gloves, clean gown, mask, face shield or protective eyewear) must be used for all patients at all times. The level of precautions used when this technique is employed does not go beyond standard precautions, except for use of alcohol to disinfect skin prior to puncture.

Aseptic Technique: This technique goes beyond standard precautions and is used for invasive procedures of short duration such as urinary catheter placement. The provider who performs the procedure in a sterile field wears sterile gloves, but the area covered by this field is smaller compared to that for a sterile technique. It is not necessary to wear a sterile gown for this procedure. Clean gown may be worn as part of standard precautions when risk of splashing of body fluids high. Even though the infection prevention measures are not as stringent as those used for sterile technique, non-sterile items should not come into contact with the sterile field or the catheter being inserted at any time during the procedure.

Sterile Technique: This technique is the most rigorous of the three levels of precautions, and used for invasive procedures with high risk of introducing pathogens into patient. All items touching the patient during the procedure must be sterile; sterile gown is optional for some procedures. As for aseptic technique, non-sterile items should not be exposed to the sterile field or the catheter being inserted at any time during the procedure.

Specific techniques for procedures

Practices to Ensure Safe Procedure 07/11/2011

Visualise every step in advance, to make sure supplies are available

1. Space and work flow?
2. Clean, aseptic, or sterile technique?
3. Routine, aseptic or surgical hand hygiene?
4. Instruments and supplies?
5. Personal protective equipment? In addition to the personal protective equipment needed for the procedure, pay attention to the isolation requirements if the patient is placed in isolation precautions. The types of Isolation are - Contact (Contact-D additionally at Parkland for patients with Clostridium difficile infection), Droplet and Airborne isolation precautions.
6. Trash: sharps, infectious waste, radioactive waste, pathology or routine waste?
7. Should the procedure be done in a dedicated room or space?
8. Who will ensure that all visible dirt is removed form the space ahead of time, and surfaces disinfected if necessary?
9. Workflow: can staff move from hand washing to hand drying to separate clean and sterile areas without passing or touching contaminated areas?
10. Where will used instruments and specimens be placed?
11. All team members should be clear on who should be using clean, aseptic or sterile technique and what elements are intended. Example: a physician places a thoracic drain with sterile technique, the nurse assisting uses clean technique, and the person who empties the drain in subsequent days uses aseptic technique
12. Plan what medical devices and supplies are needed
13. Plan where each item should be placed
14. Plan where and how each item should be discarded or sterilised
15. Prepare in advance for the type of hand hygiene that is necessary
16. Arrange the supplies including hand drying towels, as appropriate
17. Discuss what other items are expected and needed
18. These may include aprons, shoe covers for bloody procedures, masks, hair coverings, face shields or goggles
19. Plan appropriate leak proof, puncture proof containers for the transfer and disposal of sharps, infectious waste, and specimens
20. Sharps containers should be moved to the point of use so sharps can be discarded by the original team and not left for later staff to find and discard
21. Assign observers who note contamination
22. To prevent contamination, keep clean, dirty, and sterile items separate. Only put sterile items in a sterile field. Change gloves and wash hands if going from a contaminated act to an aseptic or sterile act. The sterile field is considered sterile except for the 2.5 cm border

The following YouTube links demonstrate excellent technique.

Wearing surgical bouffant:

Wearing surgical mask:

All you need to know about surgical masks vs. respirator masks:

Wearing sterile gown and gloves:

How to know your correct sterile glove size

Try on a few different sizes (usually three) with the help of an experienced nurse – the gloves should be snug – not too tight, not too loose. No loose space at fingertips.

The goal of the time out is to ensure prior to the start of the procedure that you are doing the correct procedure, for the correct patient at the correct location. This is not a step in the process that should be done by one person alone. The time out needs to be done for all invasive procedures, even those done at the bedside.

See Universal Protocol Admin 6-30

Immediately before starting an invasive procedure, in the location in which the procedure will be done, the LP (Licensed Practitioner), Resident, Fellow, or Faculty will initiate the “Time Out” and receive acknowledgement from all team members.

Key Elements:

1. During the time out – all activities are suspended
2. Using the consent form as the source document, all team members must agree to the following:
   1. Correct patient – using two patient identifiers (Name and DOB)
   2. Correct procedure – using the consent
   3. Correct site/side – using the consent
3. Staff members should stay in the room until the procedure verified during the time out has been initiated.
4. Document in the EMR that the time out was done and verified the Correct Patient, Correct Procedure and Correct Site.

If there is any organic dirt on the skin, clean that first using soap and water before applying chlorhexidine.

Start from the site of puncture – scrub back and forth using friction for 60 seconds – once this is done, apply chlorhexidine using friction in concentric circles and go around the site of puncture and outward. The goal is to get enough chlorhexidine to penetrate the top 5 cell layers, and to make sure not to reintroduce pathogens into the site of puncture as you disinfect the skin.

Who We Are: The Patient Safety and Risk Department is part of the Clinical Quality Management Division which includes Infection Control, Performance Improvement including Core Measures, Continual Readiness, Clinical Information Services and Utilization Management.

What We Do: Patient Safety and Risk’s goal is to prevent harm to patients. But when things do go wrong, we are here to help. We help by figuring out what happened, support the staff involved and facilitate communication with the patient and/or family.

When to Call:

• Any time there is an adverse event meeting Joint Commission Sentinel Event Criteria or NQF “Never Event” criteria. Some examples include:
  • An unexpected death
  • Wrong procedure/surgery on the wrong patient
  • Wrong procedure/surgery on the wrong site (left vs right)
  • Patient allegation of assault (sexual or physical)
  • Fall resulting in serious injury
  • Unintended retained foreign object
• Any time assistance is needed with disclosure to patients and families.
• Any questions related to PSN (Patient Safety Net – electronic incident reporting system)
• Any time you have questions or concerns related to Patient Safety or Risk Management.

Disclosure Resources available on the Parkland Intranet

http://intranet.pmh.org/quality_/disclosure_resources.asp

Risk 24 hour pager – Smart Web – On Call Search – Risk Management

Patient Safety & Risk Project Management Coordinator – 214-590-1780
To speak to an PS&R analyst (Business Hours, Monday – Friday)