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Based on review of facility documents, direct observation, and staff interviews (EMP), it was determined that facility failed to ensure the appropriate use of personal protective equipment (PPE) and hand hygiene practice for two of four surgical procedures.

Findings include:

Review of the "UPMC Physician Services Division Bloodborne Pathogen Exposure Control Plan," no date, revealed "Appendix C" in which procedures were identified requiring routine use of hand hygiene, gloves and mask/eye covering. Review "Appendix C" revealed, "PROCEDURES
insertion peripheral venous catheters
insertion invasive CVP catheters
insertion arteriole catheters
insertion epidural catheters; spinal catheters for regional catheters for regional anesthesia insertion catheters for caudal anesthesia
insertion naso/oral gastric tubes
insertion endo tubes."

Review of Policy # 305, "Assisting with Endotracheal Intubation, Extubation and Repositioning," reviewed/revised January 2014 revealed, "GENERAL GUIDELINES: ... EQUIPMENT FOR INTUBATION ... 24. Gloves and face/eye shield ..."

Review of Policy # 2.02, "Maintenance of Surgical Asepsis," reviewed/revised September 2013 revealed, "II. POLICY: ... An aseptic technique should be implemented during any invasive procedure that bypasses the body's natural defenses. ..."

Review of Policy # 855, "Intravenous Therapy," reviewed/revised June 2004 revealed, "I. PROCEDURE: ... Procedure for IV Insertion: ... C. Wash hands and use intact gloves."

Review of facility documents revealed an education packet titled, "Infection Prevention and Anesthesia," no date. Review of the education further revealed, "Excerpts from Patient Care Policy & Procedure # 855, Intravenous Therapy. ... Procedure for IV Insertion: ... C. Wash hands and use intact gloves."

1. Observations in Operating Room (OR) #6 on April 7, 2015, between 10:00 AM and 10:20 AM revealed after the patient was placed on the operative table, an IV was placed by EMP11 using no gloves and the patient was intubated by EMP12 wearing one, and then no gloves.

On April 7, 2015, at 10:21 AM, EMP8 confirmed the two staff (EMP11 and EMP12) should have worn gloves for both procedures stating, "Yes. Gloves should have been worn."


2. Observations in the Short Procedure Room #4 on April 7, 2015, between 10:00 AM and 10: 45 AM revealed after the patient was placed on the operative table, a peripheral intravenous catheter (IV) was placed by EMP24, wearing gloves, the port was cleansed with an alcohol swab and intravenous (IV) medications were introduced. EMP12 was observed wearing gloves during the observation of EMP24. EMP12 did not perform hand hygiene after the gloves were removed and was observed twice approaching EMP24 to offer assistance with positioning of the patient's arms and endotracheal tube (ET) without wearing gloves. EMP24 removed the gloves after inserting the IV and giving IV medications but did not perform hand hygiene and donned a fresh pair of gloves to intubate the patient. EMP24 was observed throughout the procedure changing into fresh gloves during various aspects of the anesthesia processes, however, during three separate observed glove changes, EMP24 failed to perform hand hygiene in between glove changes per facility policy.

3. Observations in the Short Procedure Room #4 on April 7, 2015 at approximately 10:38 AM, revealed EMP25 was observed removing the gloves and without performing hand hygiene went to the computer and documented the procedural note. EMP25 was also observed at 10:45 AM donning a fresh pair of gloves without performing hand hygiene. The gloves were removed and EMP25 left the procedure room. EMP25 was observed removing the PPE and then performed hand hygiene at the wash station outside the procedure room.

On April 7, 2015, at 11:00 AM EMP9 confirmed that hand hygiene should have been performed in between glove changes by EMP12, EMP24 and that EMP25 should have performed hand hygiene after removing the gloves, before documenting the procedure on the computer. EMP9 also noted that EMP12 should have worn gloves when assisting EMP24 with anesthesia. EMP9 and EMP19 noted awareness of the hand hygiene issues in the OR, Short procedure Unit and the ED with physicians, especially Anesthesia. EMP9 stated, " We actually have been targeting these providers and trying to get Anesthesia and the OR Physicians on board with the hand hygiene. We did an inservice in February with them and noted an increase in compliance but we know we have to do more. "