IMPLEMENTING A TEAM APPROACH TO PREVENTING TASS. Understanding implications and following best practices. by Cynthia Hubbard, RN, BS

IMPLEMENTING A TEAM APPROACH TO PREVENTING TASS Understanding implications and following best practices by Cynthia Hubbard, RN, BS Objectives 1. Identify the causes of Toxic Anterior Segment Syndrome (TASS). 2. Identify recommended practices for reprocessing intraocular instruments. 3. Develop an interdepartmental strategy to prevent TASS. 4. List the quality monitoring documentation that can help prevent TASS. Test Questions True or False. Circle the correct answer. 1. Toxic Anterior Segment Syndrome (TASS) is an early postoperative complication of cataract surgery caused by an infection. 2. Due to the multiple potential sources of toxins it is often time-consuming, expensive, frustrating and difficult to isolate a particular cause directly after a TASS outbreak. 68 MANAGING INFECTION CONTROL

3. Ophthalmic viscosurgical device solutions (OVDs) should not be allowed to dry on the instruments in the OR. 4. All materials used in intraocular surgery or instrument management must be chemical, residue and lint-free. 5. AAMI suggests designating an individual to be responsible for collecting and documenting current recommendations for processing intraocular instruments. 6. All ophthalmic instrument manufacturers recommend use of a detergent for cleaning their products. 7. Bacterial endotoxin contamination of ultrasonic cleaners is highly probable if they are not properly emptied, cleaned, disinfected, rinsed, and dried at least daily and preferably after each use. 8. If tap water is approved by the detergent and instrument manufacturers for rinsing, always use sterile distilled or sterile deionized water for the final rinse to prevent TASS. 9. Exotoxins, released as a result of cell destruction during the cleaning and sterilizing, have not been linked to TASS. 10. Preventive maintenance of equipment like sterilizers, ultrasonic cleaners, water filtration systems, and boilers is not useful to help prevent TASS. Introduction Toxic Anterior Segment Syndrome (TASS), a.k.a. toxic endothelial cell destruction, is a non-infectious inflammation after an uncomplicated and uneventful eye surgery. TASS is an early postoperative complication of anterior chamber surgery. The anterior segment is located between the lens and the cornea the area targeted in cataract surgeries. 1 A cataract is a clouding of the eye s lens that affects vision. Most cataracts are related to aging and by age 80, more than half of all Americans either have a cataract or have had cataract surgery. 2 Archaeological findings attest to primitive operations performed by the early Chinese, Romans and Greeks. Deliberate blows to the head or insertion of metal needles into the eye were used to dislodge cataracts so that light could again penetrate into the eye. 3 Many thanks to the team at 3M Health Care for working with Managing Infection Control to provide the following accredited course. IAHCSMM has awarded one (1) contact point for completion of this continuing education lesson toward IAHCSMM recertification. The CBSPD has preapproved this inservice for one (1) contact hour for a period of five (5) years from the date of publication, and to be used only once in a recertification period. This inservice is 3M Health Care Provider approved by the California Board of Registered Nurses, CEP 5770 for one (1) contact hour. This form is valid up to five (5) years from the date of publication. Instructions for submitting results are on page 84. Managing Infection Control and 3M Health Care will be working collaboratively to provide continuing education courses in monthly editions of Managing Infection Control. 70 MANAGING INFECTION CONTROL

While these methods were crude by today s standards, the ancients were on the right track. The only effective treatment for cataracts is surgery to remove the clouded lens. Today s surgeons can also replace it with a clear lens implant. Surgery is recommended when cataracts begin to interfere with a person s ability to perform normal daily activities. The frequency of cataract surgery is expected to increase as baby boomers age. 4 The Centers for Disease Control and Prevention (CDC) reports that more than 3.1 million cataract procedures were performed in the United States during outpatient surgery in 2006. 5 Cataract surgery is successful in 90 percent to 95 percent of all cases. How often, then, does TASS occur? Data on the incidence of TASS are lacking, but a North American database collects voluntary data to track outbreaks that appear to be more widespread since 2005. The Association of perioperative Nurses (AORN s) 2009 edition of Perioperative Standards and Recommended Practices notes that in 2005 more than 300 cases of TASS associated with endotoxin-contaminated balanced salt solutions were reported to the U.S. FDA, leading to recall of the product. 6 More than 100 North American clinics reported TASS over a 4-month period in 2006. 7 In 2008 it was reported that clusters ranging from a few cases to up to 20 cases occur several times each year in the United States. 1 Sometimes surgery centers must close until the cause(s) are identified and appropriate changes are made. This has happened in both the United States and Canada. 8.9 Table 1: Categories and Examples of Substances Implicated in TASS Outbreaks1 Categories Extraocular Substances inadvertently entering the anterior chamber during or after surgery: Products introduced into the anterior chamber during the surgical procedure: Irritants on the surfaces or inside lumens of surgical instruments used for anterior chamber procedures: Examples Topical antiseptics; Talc from surgical gloves; Ophthalmic ointments. Anesthetics like lidocaine 2%; Preservatives like benzalkonium chloride; Inappropriately reconstituted intraocular preparations; Mitomycin-C; Intraocular lenses (IOLs); Contaminated irrigating solutions. Denatured viscosurgical devices; Enzymatic detergents; Bacterial endotoxin residue from ultrasonic cleaners; Impurities of autoclave steam; Oxidized metal deposits and residues. The most effective way to prevent TASS is to increase awareness of its multi-faceted causes in all members of the healthcare team. Causes of TASS Investigations have shown that TASS is caused by substances that are foreign to the anterior chamber and cause toxic, rather than infectious, reactions. Three general categories of substances show up in the literature review of TASS cases. They include extraocular substances that inadvertently get into the anterior chamber during or after surgery, products introduced into the anterior chamber during the surgical procedure, and irritants on the surfaces of surgical instruments used for the procedure. Table 1 provides examples of these toxins. 1 Developing TASS Awareness and Implementing a Facility-wide Prevention Strategy The most effective way to prevent TASS is to increase awareness of its multi-faceted causes in all members of the healthcare team. Recommended practices, guidelines, and notifications related to reprocessing and preventing TASS outbreaks exist and are published by these professional associations and U.S. Government agencies: American Society for Cataract Refractive Surgery (www.ascrs.org); American Society of Ophthalmic Registered Nurses (www.asorn.org); Association for the Advancement of Medical Instrumentation (www.aami.org); Association of perioperative Registered Nurses (www.aorn.org); International Association of Healthcare Central Service Materiel Management (www.iahcsmm.org); Centers for Disease Control and Prevention (www.cdc.gov); Food and Drug Administration (www.fda.gov). 72 MANAGING INFECTION CONTROL

This article organizes and summarizes recommended practices and suggestions to facilitate interdepartmental discussions and assist in updating policies and procedures. TASS cases can be reduced through facility-wide awareness and education. Infection Control Early recognition of the symptoms of TASS is directly tied to the prognosis and recovery. Delays in treatment can result in vision loss or the need for additional surgery. Symptoms of TASS that differentiate it from an infectious process include: 1. A reduction in visual acuity due to corneal edema and accumulation of white cells in the anterior chamber of the eye occurring within 12-24 hours after surgery. 2. By contrast, symptoms of an infectious process generally appear 48-72 hours post-operatively. 3. TASS is not bacterial and cultures will be negative. 4. Patients with TASS may be pain-free or have only mild pain. 5. Pupils are dilated and intraocular pressure may increase suddenly. 6. If initially treated as an infection, the symptoms of TASS do not respond to antibiotics. 1 The most common treatment for TASS is use of topical steroids to decrease inflammation, given in an intense hourly regime, for several days. Sometimes oral steroids are also prescribed. 10 Milder cases resolve within a few days to one to three weeks, but after five weeks, more dire consequences are likely. Recovery prognosis ranges from good to very poor as the inflammatory response to the toxins has the potential to cause serious damage to intraocular tissues. In severe cases TASS leads to a torn or detached retina, a form of glaucoma, a permanently dilated pupil and vision loss. 11,15 Surgery What are the responsibilities of surgery personnel to prevent TASS? Verify expiration dates and product packaging integrity for all irrigating solutions, drugs and intraocular devices prior to their use for surgical procedures. Several references cite an increased risk of TASS when instruments (including cannulas) are reused quickly between cases and the proper time is not available for thorough cleaning and rinsing prior to sterilization. 8,9,12,15 Develop a plan to provide adequate instruments so that flash sterilization is not routinely practiced. Both AORN and American Society for Cataract Refractive Sugery (ASCRS) caution against flash sterilization, as it shouldn t be used to save time or be a substitute for having sufficient inventory to handle the day s caseload. 6,13 During the surgical procedure intraocular instruments should be managed with these best practices: 1. Do not allow ophthalmic viscosurgical device solutions (OVDs) to dry on instruments; these solutions harden within minutes, making cleaning extremely difficult. 6,12 2. Wipe instruments in use with a damp, lint-free cloth and flush and/or immerse them in sterile water in the operating room (OR) immediately after use. 6,12 3. Keep the organic material on instruments moist to prevent biofilm formation. Biofilm adheres to the surfaces of instruments and is very difficult to remove. 6 4. Flush phacoemulsifier handpieces, irrigators, aspirators, and their accessories before disconnecting the handpiece from the unit to prevent occluded tips that have been implicated as a potential cause of TASS. 6,12 5. Use disposable cannulas and tubing whenever possible. 6,12 6. Devices labeled single use should be used only once or reprocessed in accordance with FDAvalidated methods. 6,12 7. Use only preservative-free epinephrine. 6,12 Monitor all materials placed into the eye during surgery (anesthetics, OVDs, antibiotics or other medications) as they have been associated with TASS. 14 8. ASCRS recommended practice states that all instruments opened for the procedure should be transported from the OR in a closed container to the decontamination area where immediate cleaning (separate from other nonophthalmologic instruments) must take place. 12 Sterile Processing The Association for the Advancement of Medical Instrumentation Comprehensive guide to steam sterilization and sterility assurance in healthcare facilities, ANSI/ AAMI ST79:2006/A1:2008 notes in Annex N that many of the reprocessing issues related to TASS outbreaks have occurred due to improper processing methods and 74 MANAGING INFECTION CONTROL

procedures that are not in alignment with recommended practices. Intraocular instruments are complex, delicate, and many can not be processed by automated methods. This means that manual cleaning is the preferred processing method. 13 1. Receiving Intraocular Instruments in Decontamination: a. Once dedicated closed containers of intraocular instruments are received in the decontamination area do not co-mingle them with other types. 12 2. Cleaning and Rinsing Recommendations: a. Always consult the instrument manufacturers for written cleaning procedures and acceptable cleaning products. 12 b. Immediate cleaning, separate from other nonophthalmologic instruments, must take place so that viscoelastic solutions do not harden on or in the lumens of instruments. 6,12 c, Clean intraocular lens injectors/inserters carefully as residues in the injector can be inserted into the next patient s eye chamber and cause TASS. 6 d. Single-use syringes and brushes are recommended to clean ophthalmic instruments; they should be discarded after each use. 12 e. If you use reusable cleaning tools, understand that they may harbor various contaminants that can be reintroduced during cleaning of subsequent instruments. All reusable cleaning tools must, themselves, be cleaned and high-level disinfected or sterilized, preferably after each use or, at a minimum, daily. 12 f. Some ophthalmic instrument manufacturers may not recommend use of any detergent for cleaning their products; do not assume that the products you use for other instruments are recommended for ophthalmic instruments. 6,15 g. Use enzyme-formula cleaners only in accordance with the instrument and chemical manufacturers directions. Some enzymatic detergents contain subtilisin, an exotoxin that is not inactivated by autoclaving and causes inflammation, edema and potential corneal damage. 11 h. Following cleaning, instruments must be thoroughly rinsed with copious volumes of water to remove all chemicals from all surfaces. CDC notes that failure to adequately clean instruments results in higher bioburden, protein load, and salt concentration that interferes with sterilization. 16 Consider any rinse volumes recommended by the detergent or instrument manufacturers to be minimum rinse volumes. 12 i. Rinsing procedures should flow/flush water over/ through the instruments and discard it into a sink or separate basin so that the fluid is never reused during the rinsing process. 6 j. If tap water is approved for rinsing by the detergent and instrument manufacturers always use sterile distilled or sterile deionized water for the final rinse. 12 In 2008 a Spanish hospital implicated tap water final rinses as the cause of their five-patient TASS outbreak. 17 k. Agitation in a basin of water is not adequate for a final rinse. 12 l. Instruments with lumens should be fully flushed with sterile water and dried with filtered forced or compressed air that is free of oil and water. 6,12 m. AORN recommends that manually-cleaned instruments be wiped with alcohol to disinfect and render them safe to handle. 6 3. Using an Ultrasonic Cleaner: Concerns with using ultrasonic cleaners for intraocular instruments stem from the high probability of bacterial endotoxin contamination discovered in some TASS outbreaks. 6,8 If you decide to continue to use an ultrasonic cleaner follow these best practices: a. Use only ultrasonic cleaners designated for cleaning medical instruments. 12 b. Use only EPA-registered disinfectants, facilityapproved for instruments, and suitable for use in ultrasonic cleaners; their use must also be approved by the instrument manufacturer. 12 c. Properly empty, clean, disinfect, rinse, and dry the ultrasonic with a lint-free cloth, preferably after each use or at least daily. If not contraindicated by the manufacturer, an alcohol rinse is also recommended. 12 d. Check the manufacturer s reprocessing instructions before putting intraocular instruments into an ultrasonic cleaner, as some may not be compatible with the process. 12 e. Remove gross soil from instruments prior to using an ultrasonic cleaner. 12 f. Refill the ultrasonic just prior to use so that the water does not sit for long periods of time; do not put nonophthalmologic instruments into the ultrasonic at the same time it is used for eye instruments. 12 g, Endotoxins, released by certain gram negative bacteria when these cells are destroyed, must be thoroughly removed by rinsing after the cleaning cycle. 6,12 h. Instruments with lumens should be fully flushed with sterile water and dried with filtered forced or compressed air that is free of oil and water. 2 i. AORN recommends that instruments should be wiped with alcohol after ultrasonic cleaning to disinfect and render them safe to reassemble. 6 76 MANAGING INFECTION CONTROL

j. Validation of the functioning, degassing and preventive maintenance of ultrasonic cleaners is required. 12 4. Instrument Inspection and Assembly: a. Review use of water-soluble instrument lubrication as it may not be appropriate for intraocular instruments. Any milk bath residuals in the cannula lumens may be toxic when injected into the anterior chamber. Milk bath can grow gram-negative bacteria when left unchanged for an extended time. Upon sterilization the heat-stable endotoxins may cause TASS. 10 b. After cleaning and disinfection, instruments that have contacted viscoelastic material should be inspected under good lighting and magnification. 6 OVDs remaining in reusable cannulas may become denatured during sterilization and may be injected into the next patient s eye. 10 c. Instruments that have oxidized metal deposits and residues have been implicated in TASS outbreaks. 8 Inspection with magnification can assist in identifying instruments with rust or corrosion; remove them from inventory as they cannot be safely sterilized or used in this condition. d. All materials used in intraocular surgery or instrument management must be chemical, residue and lint-free. 6,12 5. Sterilization concerns: When it comes to anterior chamber surgery it s not enough to merely kill bacteria. The endotoxins released when the bacteria are lysed must be broken down or they can cause irritation. Residues from sterilization processes have been implicated in TASS. 1,15,18 When quick turn-around of sub-optimal instrument inventories occurs, inadequate time for proper cleaning and sterilization may result. 6,15 a. Glutaraldehyde is not recommended for sterilizing intraocular instruments due to highly toxic residues that can result from inadequate rinsing. 12 In 2006 a Turkish hospital reported a TASS outbreak related to cold sterilization with 2% glutaraldehyde in the OR. The affected corneas did not heal and subsequent surgical procedures were required for six patients. 19 b, Low temperature sterilization must be approved by the ophthalmic instrument manufacturer. 12,13 In 2000, gas plasma sterilization degraded brass-containing instruments implicated in a TASS outbreak. 12 c. Monitoring of sterilizer function should be completed in accordance with the sterilizer manufacturer s instructions and published recommended practice guidelines, and be appropriately documented. 6,12,13,16 d, Flash sterilization is not recommended 6,12,15 but still occurs as a substitute for maintaining sufficient inventories; budget for appropriate instruments so that flashing or short cycle sterilization is not required for turnaround of eye cases. 12,15 Supply Chain (Purchasing/Value Analysis/ Materials Management) As previously mentioned, contaminated ophthalmic solutions have been linked to TASS. Even brand-name suppliers are outsourcing production these days and do not have direct control over manufacturing processes. The root of a contaminated solution may be several steps down the industrial supply chain. 15 The Federal Register of 9-23-2008 announced enforcement action starting in Nov. 2008 against unapproved ophthalmic balanced salt solutions due to increasing numbers of adverse events reported to the FDA. 20 Check this notice to ensure that the products you are using are FDA approved. If current products have yielded good results, there may be reluctance to substitute new brands. A new product evaluation checklist for ophthalmic products/ solutions and drugs might include a note to check proposed manufacturers recall/product alert histories. Purchase quality products from quality companies; be alert to recalls; and check the solution specifications with OR prior to changing brands. Ophthalmic pharmaceuticals deserve special attention. Generic medications must be scrutinized for different preservatives or other chemicals from the brandname counterparts, because any dissimilar compounds could cause inflammation. 10 Expiration dates must be verified on all incoming ophthalmic products, per quality control procedures. 78 MANAGING INFECTION CONTROL

By investigating suspected TASS cases Risk Managers help the organization uncover mitigating circumstances by reviewing all aspects of the issue. They work with the team to identify deviations from recommended practices; implement procedural changes; document them, and monitor the results of procedural changes. Risk managers also may provide training to hospital staff to help reduce future incidents. Voluntary reporting of any TASS cases to the database on www.ascrs.org helps to track this complex phenomenon. Commercial products implicated in a TASS outbreak are reported to the FDA; go to www.fda.gov/medwatch/report.htm. TASS also may be a reportable incident to your state health department. Facilities Engineering Awareness of TASS by the healthcare engineers is important. TASS is linked to foreign materials like heavy metals, chemical contaminates and impurities in the water and steam which can be deposited on instruments during processing in automated equipment. ANSI/AAMI ST79:2006/A1:2008, Annex N, provides a summary of the approach to preventive maintenance that may be helpful in preventing TASS: 1. Complete proper maintenance of equipment like sterilizers, ultrasonic cleaners, water filtration systems, and boilers. 2. Consult equipment manufacturers operations manuals for maintenance activities and monitoring frequency. 3. Use only qualified personnel to complete preventive maintenance. 4. Document all maintenance activities. 13 Engineering can greatly assist areas which have sterilizers by providing notification of boiler chemical treatment. This allows them to run several empty cycles to flush out chemicals and contaminants from steam lines prior to sterilizing medical devices. Risk Management Risk Management seeks to prevent liability through a process of education, feedback, and early response. 21 Risk Managers investigate incidents to determine if there is any liability exposure on the part of the hospital/organization. Their role in monitoring manufacturer s recalls and FDA communications via public health alerts is helpful to other team members. Risk Managers help increase awareness by disseminating information received on products and devices associated with TASS outbreaks. Education Education, competency validation and periodic performance reviews are required for anyone handling intraocular instruments; document this as you would for other training. 12,13,16 When new devices/procedures are introduced, educate and document competency. The ASCRS recommends that all staff involved with handling eye instrumentation be educated about TASS upon hiring and included in updates. 12 The Recommended practices for cleaning and sterilizing intraocular surgical instruments, developed by the ASCRS/ASORN task force on TASS is available at no cost at www.ascrs.org/tass/ upload/tass_guidelines.pdf. Quality Monitoring A continuous quality monitoring program has long been recommended by AAMI. 13 While specifics are left up to the organization, all phases of instrument reprocessing must be monitored. Cases of TASS should prompt immediate re-evaluation of cleaning and sterilizing procedures. 12 Facilities that have not experienced the intensity and expense of investigating suspected TASS usually lack a surveillance system for it. Don t be caught in this dilemma; once procedures are up-to-date for all departments consider developing a TASS surveillance tool for your organization. Documentation of policies/procedures related to surgical instrument reprocessing is already required or recommended by many agencies. 6,12,13,16 Here are a few key points that can help prevent TASS: 1. Since a variety of eye instruments require cleaning based on the manufacturers recommendations keep updated documentation readily accessible. 12,13,16 2. AAMI suggests designating an individual to be responsible for collecting and documenting current recommendations for processing intraocular instruments. 13 3. Reprocessing staff should understand the specifics of intraocular instrument processing; document competency and annual skills reviews. 12,13,16 80 MANAGING INFECTION CONTROL

4. Document sterilizer monitoring in accordance with recommended practices. 6,12,13,16 A Korean hospital concluded that ineffective sterilization of eye instruments caused 15 patients to develop TASS in 2005. 22 5. Monitor steam quality; the sterile processing department (SPD) and OR must be aware of annual boiler maintenance chemical treatment so that steam lines can be properly flushed prior to re-using the sterilizers. 12 A Florida hospital implicated steam impurities (sulfates, copper, zinc, nickel and silica) in their improperly maintained autoclaves in the outpatient surgical center as the cause of a TASS outbreak in 2002. 18 6. AORN recommends that records should be maintained of all cleaning methods, detergent solutions and lot numbers of cleaning solutions. These records can be used to help investigate any suspected or confirmed cases of TASS. 6 Summary Because so many different factors are implicated in TASS it is vital that each person understand the implications of their role and follow best practices. The experience gained by investigators in TASS outbreaks challenges some previously accepted cleaning practices. Identifying toxins as a cause for patient injury during cataract surgery brings new focus to the need for meticulous removal of organics, cleaning products and other potential toxins. Obtain the manufacturers latest recommendations for intraocular instrument re-processing, and then develop best practices. Everyone responsible for handling ophthalmic instruments must be aware of TASS-related issues. It is not enough for the surgeon and OR team to be informed about TASS; all associated personnel must be aware of this emerging issue to help prevent it. Documenting training and skills competency annually reinforces the importance of each person s role in preventing TASS outbreaks. Glossary of Terms Balanced salt solution: A sterile isotonic irrigating solution made to a physiological ph and salt concentration, used during intraocular surgery to temporarily replace intraocular fluids. 20 Bioburden: The degree of microbial load; the number of viable organisms contaminating an object. 6 Biofilm: A thin coating containing biologically active organisms with the ability to grow in water and water solutions. They coat the surface of structures such as cannulas and instruments and, by becoming entrapped with the organic matter, protect themselves from destruction by antimicrobial agents. 6 Cataract: A clouding of the lens in the eye that affects vision. A cataract can occur in either or both eyes, but cannot spread from one eye to the other. 2 Endotoxin: A toxin produced by certain bacteria and released upon destruction of the bacterial cell. 6 Exotoxin: A soluble protein excreted by microorganisms like bacteria, fungi, algae and protozoa. Both gram negative and gram positive bacteria produce exotoxins. They are highly potent and can cause major damage to the host. Exotoxins may be released during lysis of the cell. 23 Phacoemulsification or phaco: The preferred method of performing cataract surgery, it s also called small incision cataract surgery. It uses a machine with an ultrasonic hand piece equipped with a titanium or steel tip. A small incision is made on the side of the cornea. A tiny probe is inserted into the eye that emits ultrasound waves to soften and break up the lens so that it can be removed by suction. 2 Viscoelastic: gels injected into the anterior chamber during ophthalmic surgery to maintain the depth of the chamber, protect the corneal endothelium, and stabilize the vitreous. 6 References 1. Al-Ghoul AR, Charukamnoetkanok P, Dhaliwal DK. Toxic Anterior Segment Syndrome updated Feb.14, 2008. http://emedicine. medscape.com/article/1190343-overview 2. http://www.nei.nih.gov/health/cataract/cataract_facts.asp 3. Elliott, J. The Romans carried out cataract ops. http://newsvote.bbc. co.uk/mpapps /pagetools/print/news.bbc.co.uk/2/hi/health/7194352.stm 4. www.mayoclinic.com/health/cataracts/ds00050/dsection= treatments-and-drugs 5. CDC Online Newsroom Press Release January 28, 2009. http:// www.cdc.gov/media/preswswrel/2009/r090128.htm 6. Perioperative Standards and Recommended Practices, 2009 edition. Denver, CO: AORN, Inc; 2009:611-670. 7. Holland SP, Morck, DW, Lee TL. Update on toxic anterior segment syndrome. ttp://unboundmedicine.com/medline/ebm/record/ 17159439 8. MMWR Morb Mortal Wkly Rep. 2007:56(25):629 630. 9. http://www.cbc.ca/health/story/2006/11/30/tass-montreal.html 10. Davis B, Mamalis, N. Averting TASS. http://www.crstodayarchieve. com/03_archive/0203/041.html 11. Parikh CH, Edelhauser HF. Ocular surgical pharmacology: corneal endothelial safety and toxicity. Current Opinion in Ophthalmology 2003; 14:178-185. 12. American Society of Cataract and Refractory Surgery. Recommended practices for cleaning and sterilizing intraocular surgical instruments. J Cataract Refract Surg 2007; 33:1095-1100. 13. Comprehensive guide to steam sterilization and sterility assurance in healthcare facilities, Association for the Advancement of Medical Instrumentation, ANSI/AAMI ST79:2006/A1:2008. 14. American Society of Cataract and Refractive Surgery & American Society of Ophthalmic Administrators, Memorandum to: ASCRS Members URGENT COMMUNICATION, April 2005. 15. http://www.escrs.org/publications/eurotimes/07june/ Amorphousanatomyof.pdf 16. Centers for Disease Control. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. 17. Sarobe Carricas M, Segrelles Bellmunt G, Jimenez Lasanta L. Toxic anterior segment syndrome (TASS) studying an outbreak. http:// unboundmedicine.com/medline/ ebm/ record/19232219 18. Hellinger WC, Hasan SA, Bacalis LP, et al. Outbreak of toxic anterior segment syndrome following cataract surgery associated with impurities 82 MANAGING INFECTION CONTROL

in autoclave steam moisture. Infect. Control Hosp Epidemiol 2006:27:294-8. 19. Unal M, Yucel I, Oner A. Outbreak of toxic anterior segment syndrome associated with glutaraldehyde after cataract surgery. http:// unboundmedicine. com/medline/ebm/record/ 17010870 20. Federal Register. Tuesday, September 23, 2008/Notices.73:185: 54829-31. 21. http://www.upstate.edu/uha/risk/glossary.php 22. Choi JS, Shyn KH. Development of toxic anterior segment syndrome immediately after uneventful phaco surgery. http:// unboundmedicine.com/medline/ebm/ record/19096238 23. Wikipedia.https://ssl.search.live.com/ health/article.asp Sterile Process and Distribution CEU Information CEU Applicant Name Address City State Zip Code The CBSPD (Certification Board for Sterile Processing and Distribution) has pre-approved this inservice for one (1) contact hour for a period of five (5) years from the date of publication. Successful completion of the lesson and post test must be documented by facility management and those records maintained by the individuals until recertification is required. DO NOT SEND LESSON OR TEST TO CBSPD. For additional information regarding Certification contact: CBSPD, Inc. 148 Main St., Lebanon, NJ 08833 or call 908-236-0530 or visit the Web site at www. sterileprocessing.org. IAHCSMM has awarded one (1) Contact Point for completion of this continuing education lesson toward IAHCSMM recertification. Cynthia Hubbard, RN, BS, is a published author and independent nurse consultant. She has worked in the healthcare industry for more than 30 years, including positions in ER nursing, occupational health nursing, materials management, and sterile processing management at Saint Mary Hospital, Mayo Clinic in Rochester, Minn. Ms. Hubbard was a design consultant on national and international construction projects related to sterile processing, materials and waste management for 14 years with the Lerch Bates Hospital Group of Littleton, Colo. After moving to Washington State in 2003 Cynthia served as the sterile processing manager at Sacred Heart Medical Center in Spokane during their surgical building addition. She is a fellow member and served on the ASHCSP Board of Directors and received their Educator of the Year Award. Nursing CE Application Form This inservice is approved by the California Board of Registered Nurses, CEP 5770 for one (1) contact hour. This form is valid up to five years from the date of publication. 1. Make a photocopy of this form. 2. Print your name, address and daytime phone number and position/title. 3. Add the last 4 digits of your social security number or your nursing license number. 4. Date the application and sign. 5. Answer the true/false CE questions. KEEP A COPY FOR YOUR RECORDS. 6. Submit this form and the answer sheet to: Workhorse Publishing Managing Infection Control PO Box 25310, Scottsdale, AZ 85255-9998 7. For questions or follow-up, contact craig@manageinfection.com. 8. Participants who score at least 70% will receive a certificate of completion within 30 days of Managing Infection Control s receipt of the application. Application Please print or type. Name Mailing Address City, State, Country, Zip Daytime phone ( ) Position/Title Social Security or Nursing License Number Date application submitted ANSWERS 1. B 2. A 3. A 4. A 5. A 6. B 7. A 8. A 9. B 10. B Signature Offer expires July 2014 On a scale of 1-5, 5 being Excellent and 1 being Poor, please rate this program for the following: 1) Overall content 2) Met written objectives 3) Usability of content Reprint with permission from Workhorse Publishing L.L.C. Copyright 2009/Workhorse Publishing L.L.C./All Rights Reseved. <07/09> 70-2010-7315-5 84 MANAGING INFECTION CONTROL