Guidelines for safety in the gastrointestinal endoscopy unit.

Executive summaryHistorically, safety in the gastrointestinal (GI) endoscopy unit has focused on infection control, particularly around the reprocessing of endoscopes. Two highly publicized outbreaks in which the transmission of infectious agents were related to GI endoscopy have highlighted the need to address potential gaps along the endoscopy care continuum that could impact patient safety.In 2009, the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage eliminated the distinction between a sterile operating room and a non-sterile procedure room. Hence, GI endoscopy units are now held to the same standards as sterile operating rooms by CMS1Federal Centers for Medicare and Medicaid Services Publication 100-07, State Operations Manual, Ambulatory Surgical Centers Condition for Coverage, 416.2-416.52. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf. Accessed January 2, 2014.Google Scholar without evidence demonstrating that safety or clinical outcomes in endoscopy are thereby improved. Although the American Society for Gastrointestinal Endoscopy (ASGE) has previously published guidelines on staffing, sedation, infection control, and endoscope reprocessing for endoscopic procedures (Multisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2011; Infection control during GI endoscopy; Minimum staffing requirements for the performance of GI endoscopy; Multisociety sedation curriculum for gastrointestinal endoscopy),2Petersen B.T. Chennat J. Cohen J. et al.ASGE Quality Assurance in Endoscopy CommitteeMultisociety guideline on reprocessing flexible gastrointestinal endoscopes.Gastrointest Endosc. 2011; 73: 1075-1084Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar, 3Banerjee S. Shen B. Nelson D.B. et al.ASGE Standards of Practice CommitteeInfection control during GI endoscopy.Gastrointest Endosc. 2008; 67: 781-790Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 4Jain R. Ikenberry S.O. Anderson M.A. et al.ASGE Standards of Practice CommitteeMinimum staffing requirements for the performance of GI endoscopy.Gastrointest Endosc. 2010; 72: 469-470Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 5Vargo J.J. DeLegge M.H. Feld A.D. et al.Multisociety sedation curriculum for gastrointestinal endoscopy.Gastrointest Endosc. 2012; 76: e1-e25Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar the purpose of this document is to present recommendations for endoscopy units in implementing and prioritizing safety efforts and to provide an endoscopy-specific guideline by which to evaluate endoscopy units. As a general principle, requirements for safety ought to be rooted in evidence that demonstrates a benefit in outcomes. When data are absent, these requirements may be derived from experts with experience in the safe delivery of care in the GI endoscopy setting. Additionally, consideration should be given to the promotion of efficient care and cost containment, with avoidance of requirements unsupported by evidence that then contribute to rising healthcare costs.Over the past 2 years, surveyors have called into question accepted practices at many accredited endoscopy units seeking reaccreditation. Many of these issues relate to the Ambulatory Surgical Center Conditions for Coverage set forth by CMS and the lack of distinction between the sterile operating room and the endoscopy setting. The following is a summary of issues that have been faced by endoscopy units throughout the country along with the ASGE position and accompanying rationale.Issues and rationale1.Issue: Structural requirements for 40-inch doors and room sizes >400 square feet required of sterile operating roomsPosition: Standard 36-inch doors, if they accommodate patient transport mechanisms, and room sizes 180 square feet are adequate and safe for endoscopy units because they do not use the same large equipment or number of staff as the operating room.6Health Guidelines Revision CommitteeGuidelines for the design and construction of health care facilities. The Facility Guidelines Institute, Washington DC2010Google Scholar2.Issue: Requirement for a written policy on traffic patterns in the endoscopy unitPosition: The unit should define low-risk exposure and high-risk exposure areas and activities within the endoscopy unit and describe the attire and personal protective equipment (PPE) that should be worn in each area. Endoscopy staff can move freely throughout the unit provided that there is appropriate use and changing of PPE.3.Issue: Requirement for endoscopy personnel to don full sterile operating room PPE, including new scrubs, hair covers, and bootiesPosition: It is recommended that staff directly engaged in GI endoscopy or in processes in which splash or contamination could occur wear gloves, face and/or eye shields, and impervious gowns. Units should develop policies that are consistent with Occupational Safety and Health Administration and state-mandated recommendations for wearing face and/or eye shields or masks.7Recommended practices for surgical attirePerioperative standards and recommended practices. Association of Perioperative Registered Nurses, Inc, Denver2011: 57-72Google Scholar Scrubs or other attire may be worn from home because endoscopy is not a sterile procedure. Likewise, there is no need for hair covers or booties. Staff must remove and appropriately discard used PPE before leaving the procedure area.4.Issue: Supervision of moderate sedationPosition: Moderate sedation may be administered safely under the supervision of a non-anesthesia physician who is credentialed and privileged to do so.5.Issue: Role of capnographyPosition: There is inadequate data to support the routine use of capnography when moderate sedation is the target.6.Issue: Requirement that 2 nurses (1 monitoring, 1 circulating) are present when moderate sedation is performedPosition: When moderate sedation is the target, a nurse should monitor the patient and can perform interruptible tasks. If more technical assistance is required, a second assistant (nurse, licensed practical nurse [LPN], or unlicensed assistive personnel [UAP]) should be available to join the care team.7.Issue: Staffing requirements when sedation and monitoring is provided by anesthesia personnelPosition: When sedation and monitoring are provided by anesthesia personnel, a single additional staff person (nurse, LPN, or UAP) is sufficient to assist with the technical aspects of the procedure.8.Issue: Technical capabilities of techniciansPosition: Unlicensed technicians who have received initial orientation and ongoing training and are deemed competent by their units, can assist with and participate in tissue acquisition during the endoscopic procedure, including but not limited to the opening and closing of forceps, snares, and other accessories.BackgroundThe overall risk of transmission of healthcare-associated infections during the performance of endoscopic procedures is estimated to be very low.8Nelson D.B. Infectious disease complications of GI endoscopy: Part II, exogenous infections.Gastrointest Endosc. 2003; 57: 695-711Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar Historically, according to the Centers for Disease Control and Prevention, most cases have occurred from a breach in proper cleaning and disinfection of endoscopic equipment. Despite the low risk of healthcare-associated infections from endoscopic procedures, outbreaks of certain hospital-based healthcare-associated infections, such as Clostridium difficile and methicillin-resistant Staphylococcus aureus, have brought healthcare-associated infections to the attention of hospital administrators and other stakeholders and have raised the public's concern over safety in hospitals. In addition, several highly publicized cases of hepatitis C infection in the outpatient endoscopy setting have heightened interest in ensuring safety in ambulatory endoscopy centers and office-based endoscopy units. The outbreak of hepatitis C among patients undergoing endoscopy at 2 facilities owned by a single physician in Nevada was attributed to improper injection techniques, whereas an infection control breach among patients who underwent colonoscopy at 2 U.S. Department of Veterans Affairs medical centers in Florida and Tennessee was attributed to installation of an improper irrigation valve on the endoscope and failure to change irrigation tubing between cases.9Labus B. Armour P. Middaugh J. et al.Southern Nevada Health District Outbreak Investigation Team. Outbreak of hepatitis C at outpatient surgical centers. Public Health Investigation Report. Southern Nevada Health District, Las Vegas2009Google Scholar, 10Centers for Disease Control and Prevention Web site. Healthcare-Associated Hepatitis B and C Outbreaks Reported to the Centers for Disease Control and Prevention in 2008-2011, 2012. Available at: http://www.cdc.gov/hepatitis/Outbreaks/HealthcareHepOutbreakTable.htm. Accessed January 2, 2014.Google Scholar Although the risk of infections from endoscopic procedures, regardless of the setting, remains low, these cases highlight the need to address potential gaps along the endoscopy care continuum that may impact patient safety outcomes.2Petersen B.T. Chennat J. Cohen J. et al.ASGE Quality Assurance in Endoscopy CommitteeMultisociety guideline on reprocessing flexible gastrointestinal endoscopes.Gastrointest Endosc. 2011; 73: 1075-1084Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar, 3Banerjee S. Shen B. Nelson D.B. et al.ASGE Standards of Practice CommitteeInfection control during GI endoscopy.Gastrointest Endosc. 2008; 67: 781-790Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 4Jain R. Ikenberry S.O. Anderson M.A. et al.ASGE Standards of Practice CommitteeMinimum staffing requirements for the performance of GI endoscopy.Gastrointest Endosc. 2010; 72: 469-470Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 5Vargo J.J. DeLegge M.H. Feld A.D. et al.Multisociety sedation curriculum for gastrointestinal endoscopy.Gastrointest Endosc. 2012; 76: e1-e25Abstract Full Text Full Text PDF PubMed Scopus (87) Google ScholarChanges to the CMS Ambulatory Surgical Center Conditions for Coverage that went into effect in 2009 eliminated the distinction between a sterile surgical room and a non-sterile procedure room, providing further impetus for this guideline. As a result of these conditions, non-sterile procedure environments, including endoscopy units, are now held to the same standards as sterile operating rooms even though requirements for facilities, infection control, staffing, and sedation applicable to the sterile operating room may not be relevant or necessary for endoscopy units. To date, the Association of periOperative Registered Nurses and other organizations have set standards for sterile operating environments.11Blanchard J. Braswell M. Association of periOperative Registered Nurses Recommended Practices for Surgical Attire.in: Perioperative Standards and Recommended Practices, 2010. Association of periOperative Registered Nurses, Denver2010Google Scholar This document is endorsed by organizations with specific expertise in the safe delivery of care in the non-sterile, GI endoscopy environment, which recognize the important distinction between the endoscopy and sterile operating room settings. Safety in the GI endoscopy unit begins with clear and effective leadership that fosters a culture of safety including team work, openness in communication, and efforts to minimize adverse events. Although issues of governance and culture are important, they are outside the scope of this document. Table 1 provides a summary of the key strategies to maintain safety in the GI endoscopy unit.Table 1Summary of the key strategies to maintain safety in the GI endoscopy unitEach unit should have a designated flow for the safe physical movement of dirty endoscopes and other equipment.Procedure rooms vary in size, with more complex procedures requiring greater space for more specialized equipment and, in some cases, additional staff.Before starting an endoscopic procedure, the patient, staff, and performing physician should verify the correct patient and procedure to be performed.A specific infection prevention plan must be implemented and directed by a qualified person.Gloves and an impervious gown should be worn by staff engaged in direct patient care during the procedure.The unit should have a terminal cleansing plan that includes methods and chemical agents for cleansing and disinfecting the procedural space at the end of the day.For patients undergoing routine endoscopy under moderate sedation, a single nurse is required in the room in addition to the performing physician.Complex procedures may require additional staff for efficiency but not necessarily for safety.At a minimum, patient monitoring should be performed before the procedure, after administration of sedatives, at regular intervals during the procedure, during initial recovery, and before discharge.For cases in which moderate sedation is the target, the individual responsible for patient monitoring may perform brief interruptible tasks.For cases in which moderate sedation is the target, there is currently inadequate data to support the routine use of capnography. Open table in a new tab FacilitiesFacilities are the foundation of a unit, the layout of which should provide a safe environment for patients and staff. Facilities should be designed to comply with local and state building codes as well as the National Fire Protection Association (NFPA) 101 Life Safety Code.12National Fire Protection AssociationNFPA 101: Life Safety Code 2012 edition. National Fire Protection Association, Quincy (Mass)2011Google Scholar The specific version of the Code will depend on currently accepted practice for CMS and state regulations.13Marasco J.A. Marasco R.F. Designing the ambulatory endoscopy center.Gastrointest Endosc Clin N Am. 2002; 12 (v. 6): 185-204Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 14Ganz R.A. Regulation and certification issues.Gastrointest Endosc Clin N Am. 2002; 12: 205-214Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Recommendations for facility standards are largely based on expert opinion and put into practice by accreditation bodies; however, no association with patient outcomes has been shown.Recommendations for architectural layoutEach unit should have a designated flow for the safe physical movement of dirty endoscopes that does not cross-contaminate clean endoscopes coming out of the cleaning process and their storage. Although circular flow is preferable, some units may be constrained by the existing footprint of the facility.Recommendations for the endoscopic procedure roomEndoscopic procedure rooms vary in size, with more complex procedures such as ERCP requiring greater space for more specialized equipment and possibly additional staff. For endoscopy, procedure rooms should not be held to the same standards as sterile operating rooms, which require space for anesthesia support and a greater number of staff members and bulkier equipment, none of which are essential for the performance of endoscopy. Standard endoscopic procedures require less space, with requirements varying from as little as 180 square feet to 300 square feet.6Health Guidelines Revision CommitteeGuidelines for the design and construction of health care facilities. The Facility Guidelines Institute, Washington DC2010Google ScholarThe following are issues within the endoscopic procedure room that are related to patient safety:1.Actual marking of the site is not required for endoscopic procedures because endoscopy does not involve lateral right-left distinction levels such as those found in spinal procedures or those done on multiple structures such as fingers or toes. Before starting an endoscopic procedure, the patient, staff, and performing physician should verify the correct patient and procedure to be performed.2.A reliable and adequate source for oxygen is required. Sources may include in-wall or free-standing oxygen. In some units, carbon dioxide may be used for insufflation of the GI lumen, but this is not a requirement.3.A suction source for the equipment and patient must be present either in-wall or portable. For tubing and portable suction, the manufacturer's guidelines must be followed.4.An uninterruptible source of power, supplied either by a generator or battery source is required. The purpose of a secondary power source is to allow completion of the current procedure in the event that the primary power source malfunctions. Procedures should not be started when the only source of power is the secondary source.5.Units must practice fire safety in adherence with the NFPA 101 Life Safety Code, which also dictates the number and type of electrical outlets tied to the generator.12National Fire Protection AssociationNFPA 101: Life Safety Code 2012 edition. National Fire Protection Association, Quincy (Mass)2011Google Scholar The NFPA 101 Life Safety Code recommends that not all outlets be tied to the generator in case the generator fails to disengage once power is restored.6.The unit's defibrillator and crash cart should be checked at the beginning of each day to ensure that all components are functional, fully stocked, and readily accessible.7.The routine monitoring of temperature and humidity within the endoscopic procedure area, although advocated by CMS to theoretically curtail growth of microorganisms and reduce fire hazard, has not been associated with safety outcomes in endoscopic units. In the absence of published guidelines on the optimal ranges for these parameters, routine monitoring of temperature and humidity is not currently warranted.1Federal Centers for Medicare and Medicaid Services Publication 100-07, State Operations Manual, Ambulatory Surgical Centers Condition for Coverage, 416.2-416.52. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf. Accessed January 2, 2014.Google Scholar8.Puncture-resistant containers for biohazardous materials and sharps should be located so that sharps are not passed over the patient.15Society of Gastroenterology Nurses and AssociatesManual of Gastrointestinal Procedures.6th ed. Society of Gastroenterology Nurses and Associates, Inc, Chicago2009Google Scholar9.If special therapeutic procedures are planned, specific room features may be required, such as leaded walls when flat-table fluoroscopy is utilized.16National Council on Radiation Protection and MeasurementsStructural shielding design for medical x-ray imaging facilities (NCRP Report No. 147). National Council on Radiation Protection and Measurements, Bethesda (MD)2004Google ScholarRecommendations for the endoscopic recovery area1.The recovery bays should provide privacy and sufficient space for monitoring and care. The minimum space per bay has not been established. Unit facilities must be able to provide the level of recovery appropriate to the level of sedation utilized.17ASGE Standards of Practice CommitteeSedation and anesthesia in GI endoscopy.Gastrointest Endosc. 2008; 68: 815-826Abstract Full Text Full Text PDF PubMed Scopus (326) Google ScholarRecommendation for storage of supplies1.Sterile supply items such as intravenous (IV) solutions should be protected from splash contamination during environmental cleaning (8-10 inches off the floor), damage from compression (stacking only ridged containers), and water damage (no storage under sinks).2.Units should have a process for periodically verifying that supplies marked with an expiration date have not expired. Compliance with this process should be documented.Infection controlASGE has published several guidelines detailing ways to minimize the risk of transmission of infection within the endoscopy unit.2Petersen B.T. Chennat J. Cohen J. et al.ASGE Quality Assurance in Endoscopy CommitteeMultisociety guideline on reprocessing flexible gastrointestinal endoscopes.Gastrointest Endosc. 2011; 73: 1075-1084Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar, 18ASGE policy on the use of single-dose and multiple-dose vials and solution containers. July 2012. American Society for Gastrointestinal Endoscopy Web site. Available at: http://www.asge.org/assets/0/47668/71294/f271942b-0529-4145-b317-9597d5009ecd.pdf. Accessed January 2, 2014.Google Scholar In addition to meticulous endoscope reprocessing, a specific infection prevention plan must be implemented to prevent the transmission of pathogens in the unit and to provide guidance should a breach occur. Active Infection Prevention Surveillance programs and ongoing educational and competency evaluation of staff regarding activities within the preprocedure, intraprocedure, and postprocedure phases are necessary to ensure overall safety of patients and healthcare workers. Infection prevention plans for a specific unit must be directed by a qualified person. Although state regulations may vary, CMS allows the unit to designate the specific training and competency of the individual.The infection prevention plan must be documented in writing and should include a set of policies and procedures appropriate for and targeted to the specific procedures performed in addition to likely sources of nosocomial infection in the unit. The plan should include a process for the ongoing assessment of compliance with the program and methods for correction.Standard precautions, the minimum infection prevention practices applicable to all patient care regardless of the suspected or confirmed infection status of the patient, are the foundation of a sound infection prevention strategy. These include:1.Hand hygiene2.PPE3.Safe medication administration practices4.Safe handling of potentially contaminated equipment or surfaces in the patient environment.19Centers for Disease Control and Prevention. Guide to infection prevention for outpatient settings: minimum expectations for safe care. May, 2011. CDC Web site. Available at: http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html. Accessed January 2, 2014.Google ScholarRecommendations for hand hygieneProper hand washing is considered to be the cornerstone of preventing the transmission of pathogens.1.Hand hygiene should be performed before patient contact (even if gloves are to be worn); after patient contact and before exiting the patient care area; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before performing invasive procedures (ie, placement or access of intravascular lines); and after glove removal.20Rutala WA, Weber DJ; Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, 2008. CDC Web site. Available at: http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed January 2, 2014.Google Scholar2.The use of soap and water is required when hands are visibly soiled and after caring for patients with known or suspected infectious causes of diarrhea such as C difficile. Otherwise, the use of alcohol-based hand agents is adequate.21Boyce J.M. Pittet D. Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee and HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings.MMWR. 2002; 51: 1-44Google ScholarRecommendations for PPEThe unit should have written policies and procedures regarding PPE that defines activities in which PPE should be worn and the appropriate type.22Decker M.D. The OSHA bloodborne hazard standard.Infect Control Hosp Epidemiol. 1992; 13: 407-417Crossref PubMed Scopus (20) Google Scholar For sterile environments, the use of PPE is commonly dictated by the traffic pattern and location of care, defined as unrestricted, semi-restricted, and restricted areas.23Association of periOperative Registered NursesRecommended practices for traffic patterns in the perioperative practice setting.AORN J. 2006; 83: 681-686Abstract Full Text Full Text PDF PubMed Google Scholar In contrast, in the non-sterile endoscopy environment, the use of PPE is dependent on the degree to which staff have the potential to come into direct contact with patients and their bodily fluids during specific activities, rather than the location of care. The risk of exposure can be categorized into low-risk exposure and high-risk exposure, which are defined as follows:1.Low-risk exposure: Any personnel not in direct contact with a contaminated endoscope, device or bodily fluid or with the potential for splash contamination. For example, personnel entering the procedure area for a brief period of time who are not involved in direct patient care are considered at low-risk exposure.2.High-risk exposure: Any personnel working in direct contact with a contaminated endoscope, device, or bodily fluid or any personnel in direct patient care with the potential to come into contact with a contaminated endoscope, device, or bodily fluid.Low-risk exposure activities require no PPE. Personnel whose exposure status may change during an endoscopy procedure should have immediate access to PPE should the need arise. High-risk exposure activities require the use of gloves and impervious gowns. Because of the potential for splash exposure to the face, individual units should develop policies based on Occupational Safety and Health Administration and state-mandated recommendations for wearing face and/or eye shields or masks.22Decker M.D. The OSHA bloodborne hazard standard.Infect Control Hosp Epidemiol. 1992; 13: 407-417Crossref PubMed Scopus (20) Google Scholar Hair and shoe covers and gown classifications above Association for the Advancement of Medical Instrumentation level 1 are often included in PPE recommendations.24Anonymous. Association for the Advancement of Medical Instrumentation AAMI PB70:2012: liquid barrier performance and classification of protective apparel and drapes in health care facilities. Available at: http://www.aami.org/publications/AAMINews/Sep2012/PB70_AAMI_protective%20barrier_standard.html. Accessed January 2, 2014.Google Scholar These items generally are mandated for the sterile operating room environment, but there is no evidence to support their requirement or benefit in the non-sterile endoscopy environment.1.Staff must remove and appropriately discard used PPE before leaving the procedure room. PPE should not be reused or worn to care for more than 1 patient.2.Scrub attire may be worn from home, because endoscopic procedures are performed in a non-sterile environment.3.Individuals may elect to wear regular clothing covered by an impervious gown. There is no requirement to change clothing once the individual arrives at work.4.If clothing under the procedure room attire is contaminated with a significant amount of blood or body fluids, the items should be placed in a bag, identified as a potential biohazard, then sent for cleaning to a laundry facility capable of properly cleaning and disinfecting clothing used in healthcare settings.Recommendations for safe medication administration practicesSafe medication administration practices promote safety in medication administration and have become a highly scrutinized activity within healthcare,25Garner J.S. Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals.Infect Control Hosp Epidemiol. 1996; 17: 53-80Crossref PubMed Google Scholar in part because of evidence of pathogen transmission resulting from the improper use or reuse of syringes, multiple-dose drug vials, and IV equipment. The Centers for Disease Control and Prevention and ASGE have issued guidelines outlining safe injection practices.3Banerjee S. Shen B. Nelson D.B. et al.ASGE Standards of Practice CommitteeInfection control during GI endoscopy.Gastrointest Endosc. 2008; 67: 781-790Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 19Centers for Disease Control and Prevention. Guide to infection prevention for outpatient settings: minimum expectations for safe care. May, 2011. CDC Web site. Available at: http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html. Accessed January 2, 2014.Google Scholar, 26Siegel JD, Rhinehart E, Jackson M, et al. Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Available at: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Accessed January 2, 2014.Google Scholar Units should adhere to the following:1.Preparing medications for multiple patients should be done in an area away from direct patient care or procedure rooms.2.Units should appropriately label all medications, including those used for sedation, unless the medication is for immediate use (prepared and administered immediately without leaving the provider's hand).26Siegel JD, Rhinehart E, Jackson M, et al. Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Available at: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Accessed January 2, 2014.Google Scholar3.Medications marked either on the container or noted in the package insert as “single patient use” should be used for a single patient only and any remaining drug should be discarded.4.Units should use new fluid administration sets (eg, IV tubing) for each p