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Policies,Clinical,UWHC Clinical,Department Specific,Surgical Services,Anesthesia

Anesthesia Daily/Monthly OR Cleaning, Stocking and Assisting for All Procedures, Including Satellite Area Procedures in Perioperative Areas (3.01)

Anesthesia Daily/Monthly OR Cleaning, Stocking and Assisting for All Procedures, Including Satellite Area Procedures in Perioperative Areas (3.01) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Anesthesia

3.01

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

SEPTEMBER 2017
PAGE 1
OF 8
POLICY #

3.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER
Surgical Services
TITLE
ANESTHESIA DAILY/MONTHLY OR CLEANING,
STOCKING AND ASSISTING FOR ALL PROCEDURES,
INCLUDING SATELLITE AREA PROCEDURES IN
PERIOPERATIVE AREAS


I. PURPOSE

To provide clean, disinfected, or sterile equipment for Anesthesia personnel in the Operating Room; ensure all
standard supplies and equipment are present; assist Anesthesia personnel as needed, gather/supply extra
equipment, extra drugs, specialized items not routinely stocked, etc.

II. POLICY

The Anesthesia Technicians, Anesthesia Materials Specialists and Patient Care Techs will institute cleaning
protocols as required by the type of procedure. Check-off lists will be completed for monthly outdates. Supervisor
or designee is responsible for assuring that monthly checks are completed.

III. PROCEDURE

Five different cleaning modes are used for anesthesia equipment; cleaning techniques are performed by
Anesthesia Technicians (AT), Anesthesia Materials Specialists (AMS) and Patient Care Techs (PCT).

IV. BETWEEN CASE CLEANING AND STOCKING PROCEDURE

A. Wear gloves, safety glasses, and appropriate PPE when cleaning all anesthesia machines, carts and
equipment. For additional protocol in cleaning isolation rooms, reference section VII.
B. Determine what is waste, what can be reprocessed, and what is set up for the next case. Dispose of
waste in proper receptacles.
1. Dispose of sharps into red sharps container.
2. Dispose of anything containing medications into black container.
3. Dispose of used supplies (circuit, airways, masks, etc.) into appropriate waste container (black or
red waste basket).
4. Place items to be reprocessed (i.e. laryngoscope, stylet, T. piece, etc.) in soiled Anesthesia
equipment polybag or basin, cover with a towel, and take to dirty reprocessing.
5. Dispose of all used excess liquids appropriately.
6. Throw away all used and outdated IV’s hanging from IV poles.
7. Throw away all used ranger tubing.
8. Throw away all used Alaris cassettes.
9. Throw away all used syringe pump tubing, unless it contains controlled substances.
10. Throw away anesthesia suction canister and suction tubing unless labeled “CLEAN”.


UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

SEPTEMBER 2017
PAGE 2
OF 8
POLICY #

3.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER
Surgical Services
TITLE
ANESTHESIA DAILY/MONTHLY OR CLEANING,
STOCKING AND ASSISTING FOR ALL PROCEDURES,
INCLUDING SATELLITE AREA PROCEDURES IN
PERIOPERATIVE AREAS


C. Anesthesia Supply Cart
1. Remove and/or discard all soiled items in appropriate containers.
2. Take out used drug trays. Replace emergency drug tray if used.
3. Wipe surfaces and supplies with hospital approved disinfectant solution from cleanest to dirtiest (look
for any blood/fluid spillage). Areas/items including, but not limited to:
i. Supply cart drawers
ii. Supply cart ledges
iii. Hand disinfectant bottle
iv. Marker

4. Check needle box and pharmacy waste box for fullness and blood spatter. Replace if ¾ full.
D. Anesthesia Machine
1. Look for any blood and/or fluid spillage.
2. Wipe with hospital approved disinfectant from cleanest to dirtiest:
i. Anesthesia machine monitors
ii. Clipboards
iii. Pens
iv. Nerve stimulator
v. Towel clamps
vi. Knobs
vii. Screens
viii. Tube clamps
ix. Phones
x. BP cuffs
xi. Patient cables
xii. Leads
xiii. Any other used/contaminated items or areas that anesthesia personnel could have
touched/contaminated during the procedure
3. Put all wiped items back in the proper place.
4. Change soda lime on the Anesthesia Machine [Approved by the UW Clinical Practices Committee on
March 17, 2009].
i. This only applies to AFCH and Outpatient OR’s. Within the Inpatient OR’s, changing of soda
lime is an anesthesia provider responsibility.
ii. As part of the pre-use anesthesia machine checkout, the anesthesia care provider will inspect the
soda lime and change if it is mostly blue.
iii. At the end of each case, the AMS will inspect the soda lime canister and dispose of any that are
blue half-way or more. If it is borderline as to whether it is 50% exhausted, use the

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

SEPTEMBER 2017
PAGE 3
OF 8
POLICY #

3.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER
Surgical Services
TITLE
ANESTHESIA DAILY/MONTHLY OR CLEANING,
STOCKING AND ASSISTING FOR ALL PROCEDURES,
INCLUDING SATELLITE AREA PROCEDURES IN
PERIOPERATIVE AREAS


installation date as additional information. The goal is to minimize the number of times
that soda lime canisters need to be changed during a case.
iv. It is important to inspect them shortly after use as the color will gradually revert to white.
v. The Aestiva () have double canisters, so the above does not apply. For these locations, the AMS
will inspect after each case and change the top canister if the bottom one is blue for one
inch.
vi. When installing a new one, the orange cover must be removed and thrown away. Do not put the
cover on the exhausted canister to avoid confusion.
vii. The AMS will only change the soda sorb if needed.
E. Remove your gloves, perform hand hygiene, and proceed to make a list of items missing from the
anesthesia machine drawers, supply cart drawers, and all other supplies of equipment stocked
specifically for anesthesia use (see detailed anesthesia supply cart/anesthesia machine drawer protocols
for assistance, located in each of the Anesthesia Work Rooms).
F. Take used drug trays out and place on the Pharmacy “Return Cart” (Inpatient OR) or back to the OR
Pharmacy (Outpatient and AFCH).
G. Take soiled anesthesia equipment basin and its contents, as well as any other soiled/used equipment
(i.e. scopes, etc.) to Anesthesia Reprocessing Room E7/325 (Inpatient OR), C3294 (AFCH OR),
Reprocessing Department (TAC) or F6/205A &/or D6/224(Outpatient OR) to be cleaned.
H. Put all extra wiped carts and extra supplies in the Anesthesia Work Room to be put away or stocked as
necessary.
I. From the Anesthesia Work Room, pick all items from your list of missing items and take back to the
OR room from which you came, and replace all items in the appropriate area.
J. Replace emergency drug tray if used (Inpatient OR/AFCH only).
K. Assist Anesthesia staff in gathering and/or preparing any additional supplies or specialized equipment
for special procedures.
L. When needed, assist in moving anesthesia equipment to opposite side of operating room (strictly
adhere to Procedure for Flipping Rooms and the reconnect procedure).
M. Items to Remember:
1. Take out any extra anesthesia equipment/supplies not being used (i.e. syringe pumps, A-line
brackets, Bair Hugger unit, blankets, ranger tubing, etc.)
2. Place one syringe infusion pump in all Inpatient OR rooms. Inpatient OR rooms 2,13, 19, 20, 21,
22 and IOMRI should have two.
3. Place Alaris pump with two muscles and cassettes in Inpatient OR rooms.
4. Place two Alaris pumps with eight muscles and cassettes in Inpatient OR rooms 19, 20, 21, 22,
and IOMRI.
5. Ensure Inpatient OR rooms 19-27 have extra cassettes in metal cabinet.
6. Place cardiac blanket in Inpatient OR rooms 2, 3, 16,19-22, and IOMRI, and Road Trip Carts

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

SEPTEMBER 2017
PAGE 4
OF 8
POLICY #

3.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER
Surgical Services
TITLE
ANESTHESIA DAILY/MONTHLY OR CLEANING,
STOCKING AND ASSISTING FOR ALL PROCEDURES,
INCLUDING SATELLITE AREA PROCEDURES IN
PERIOPERATIVE AREAS


(any room with 5 trans packs will automatically have a cardiac blanket).
7. Upper and lower body disposable Bair Hugger blankets are stocked in all rooms.
8. Replace new gas sampling tubing after each case in Inpatient OR, OP OR and AFCH OR.
9. Make sure all monitors are in working order.
10. Ensure the 500 ml and 1000 ml unopened white pressure infusion bags are on the hooks on the
Anesthesia supply carts (Inpatient OR only).
11. Ensure there is a pediatric and adult Ambu Bag with Peep valve and mask stocked on back of
supply cart IP OR and AFCH OR and O2 tank on side of cart. Only an adult Ambu Bag will be
stocked on the back of the supply cart in the TAC ORs. Pediatric Ambu Bag is available on the
Code Blue Cart.
12. Make sure both adult and pediatric Eschmann stylets are stocked. Only adult Eschmann stylets
will be stocked in the TAC ORs.
13. Make sure all machines and carts in the hallway are stocked.
N. If scheduled procedures are done for the day, proceed with daily terminal cleaning (see Section V.
Daily Terminal Cleaning and Stocking Procedure).

V. DAILY TERMINAL CLEANING AND STOCKING PROCEDURE

A. This protocol is used when all procedures have been completed in a particular operating room and the
room is not expected to be used until the following day.
B. Ensure the operating room is no longer needed for cases or emergency standby/set-up.
C. Wear gloves, safety glasses, and appropriate PPE when cleaning all anesthesia machines, carts and
equipment. For additional protocol in cleaning isolation rooms, reference section VII.
D. Place all soiled items in polybag to be removed from the room on the supply cart.
E. Wipe down anesthesia machine, all monitors, and accessories (i.e. cables, cords, cuffs, etc.) with
hospital approved disinfectant.
1. Always check for blood and fluid stains.
2. When necessary, use adhesive remover to clean off tape residue from machine and cables/leads.
3. Wipe front, back, sides, and underneath machine.
F. Turn off all anesthesia monitors and machines EXCEPT in the following Inpatient ORs (these
monitors and machines should ALWAYS be left on and the Anesthesia provider is responsible for
AM checks on machines that were left on all night
1. E Trauma
2. E Crani
3. General Set up
G. IV’s, Medley cassettes, syringe infusion, arterial line, and transducer set-ups that are indicated clean
and dated can be saved for 24 hours.

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

SEPTEMBER 2017
PAGE 5
OF 8
POLICY #

3.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER
Surgical Services
TITLE
ANESTHESIA DAILY/MONTHLY OR CLEANING,
STOCKING AND ASSISTING FOR ALL PROCEDURES,
INCLUDING SATELLITE AREA PROCEDURES IN
PERIOPERATIVE AREAS


H. Restock drawers of the anesthesia machine. Replace all used items and remove and restock outdated
items. See detailed drawer plan (located in each Anesthesia Work Room) for assistance.
I. Wipe supply cart (front, back, sides, and underneath) with hospital approved disinfectant.
J. Restock the supply cart entirely.
K. Place any books, articles, or important documents in lost and found in the AMS Work Room or the
Physicians Workroom in Outpatient area
L. Give any narcotics to the Pharmacist on duty or charge nurse immediately.

VI. MONTHLY CLEANING

A. Protocol used which cleans and disinfects all areas of the anesthesia machine, all monitors and their
accessories, supply cart, and all equipment belonging to Anesthesia including Rangers.
B. Wipe down the following with hospital approved disinfectant:
1. Anesthesia machine
i. All sides, back, and front
ii. Remove supplies from all of the drawers. Wipe out drawers and containers.
iii. Replace all supplies
2. Anesthesia supply carts (all sides, back, and front)
i. All sides, back, and front
ii. Remove items one drawer at a time. Wipe out drawer and all containers.
iii. Check items for outdates and replace all supplies in drawer.
iv. Remove all items from top shelves and syringe holder. Wipe thoroughly.
v. Check items for outdates and replace all items on shelves.
3. All hoses leading from machine
4. Gas tanks
5. Caster guards on all anesthesia machine wheels (take off, clean, and replace)
6. Monitors, wiping under and in between
7. Remove all tape residue.
8. Remove all ink marks.
9. All cords (gas hoses, cables, tubing); also straighten and untangle
C. Remove vaporizers and clean all surrounding areas.
D. Check gas tanks on anesthesia machine.
E. Check O2 tank on side of anesthesia supply cart to ensure it is full.
F. Initial and date which anesthesia machines and supply carts have been cleaned on check-off list.
G. Note any necessary maintenance needed and report to the Anesthesiology Clinical Engineer.
H. Drugs are checked monthly by pharmacy staff per pharmacy protocols.
I. Anesthesia Workroom outdates are checked and documented.

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

SEPTEMBER 2017
PAGE 6
OF 8
POLICY #

3.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER
Surgical Services
TITLE
ANESTHESIA DAILY/MONTHLY OR CLEANING,
STOCKING AND ASSISTING FOR ALL PROCEDURES,
INCLUDING SATELLITE AREA PROCEDURES IN
PERIOPERATIVE AREAS


VII. CLEANING PROCEDURE FOR ISOLATION CASES

A. Airborne and Droplet Isolation
Wear proper PPE if entry occurs prior to 1 hour of Hepa Filtering.
1. Wear gown, gloves, isolation mask, and eye protection. Refer to 4.1.8 Policy - Standard
Precautions and Isolation
2. Follow wiping guidelines of the terminal cleaning procedure for anesthesia machines/carts.
3. Replace soda sorb unit(s). Replace gas sample tubing (AGM), replace filter on inhalation side of
anesthesia machine. Replace H2O trap.
4. Oral and nasal airways are discarded. All reusable intubating items are taken to Anesthesia
Reprocessing Room (E7/355A - Inpatient OR) or Decontamination Room (AFCH #3295) or
Reprocessing Department (TAC) to be washed in hospital high level disinfectant and soaked in
glutaraldehyde based solution for twenty minutes and/or steam sterilized.
5. Remove all linens from anesthesia machine and cart.
6. Throw away all items unpackaged or opened (ET tubes, nasal airways, 4 x 4’s, IV infusion bags
etc.).
7. Remove all disposable PPE before leaving room (this includes gowns, gloves, mask you are
wearing.
8. After Housekeeping is done, return and restock.
B. Contact Isolation
1. Wear gown, gloves, isolation mask, and eye protection.
2. Follow wiping guidelines of the terminal cleaning procedure for anesthesia machines/carts.
3. Oral and nasal airways are discarded. All reusable intubating items are taken to Anesthesia
Reprocessing Room (E7/325 - Inpatient OR) or Decontamination Room (AFCH #3295) to be
washed in hospital high level disinfectant and soaked in glutaraldehyde based solution for twenty
minutes and/or steam sterilized.
4. Throw away all items unpackaged or opened (ET tubes, nasal airways, 4 x 4’s, IV infusion bags
etc.).
5. Remove all disposable PPE before leaving room (this includes gowns, gloves, mask you are
wearing.

VIII. REPROCESSING ITEMS

A. When cleaning items to be reprocessed, don all appropriate PPE. Spray each item with pretreatment
foam with a brush and/or washcloth if necessary. Attempt to keep items submerged to prevent
aerosolization from occurring. Rinse items to be placed in glutaraldehyde (Cidex) with tap water and
submerge in glutaraldehyde for 20 minutes.

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

SEPTEMBER 2017
PAGE 7
OF 8
POLICY #

3.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER
Surgical Services
TITLE
ANESTHESIA DAILY/MONTHLY OR CLEANING,
STOCKING AND ASSISTING FOR ALL PROCEDURES,
INCLUDING SATELLITE AREA PROCEDURES IN
PERIOPERATIVE AREAS


1. C-Mac Video Laryngoscopes, flexible intubation video endoscope and monitor
i. Remove disposable pieces and place in proper disposal container.
ii. Send non-disposable pieces in an enclosed container marked biohazard and take to
reprocessing for HLD.
iii. Wipe down monitors with hospital high level disinfectant soaked rag.

2. Laryngoscopes, Blades, Eschmanns, etc. (OP OR only)
i. Disassemble laryngoscope handle and wipe handle off with hospital high level
disinfectant and set aside.
ii. After disinfection, items must be handled with gloves on, peel packaged and labeled
“clean not sterile”.

3. Laryngeal Mask Airway (LMA) Re-usable Only (OP OR only)
i. Soak in hospital approved disinfectant.
ii. Wash all over with hospital approved disinfectant soaked rag.
iii. Check cuff for leak under water.
iv. Wash inside with proper brushes.
v. Rinse with tap water.
vi. Do the six different performance tests.
vii. Monitor use via tracking system.
viii. Package in sterilizing pouch.
ix. Steam sterilize on unwrapped cycle.
 Exposure time = 10 minutes
 Exhaust time = 1 minute
 Temperature = 135°C
 Record all cycles on the autoclave log

4. Glidescope and Monitor (Color Units Only)
i. Wipe monitor with damp, wet rag soaked with hospital approved disinfectant.
5. Site Rite (Inpatient OR) or Ultrasound (AFCH OR): Probe and Monitor
i. Clean probe with hospital approved disinfectant.
ii. Use small brush to remove Aquasonic Lube from small hole in probe.
iii. Wipe down cart and any accessories, cleanest to dirtiest. Return to Storage.
6. Jet Ventilator (Inpatient OR and AFCH)
i. Disconnect air and oxygen hoses from ceiling column and bring back to Anesthesia
Reprocessing Room for cleaning.
ii. Wipe down all equipment with hospital approved disinfectant, cleanest to dirtiest.

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

SEPTEMBER 2017
PAGE 8
OF 8
POLICY #

3.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER
Surgical Services
TITLE
ANESTHESIA DAILY/MONTHLY OR CLEANING,
STOCKING AND ASSISTING FOR ALL PROCEDURES,
INCLUDING SATELLITE AREA PROCEDURES IN
PERIOPERATIVE AREAS


iii. Return to proper storage location.
7. Sono Site and Titan Ultrasound Machines
i. Wipe probe and unit with damp wet rag soaked with hospital approved disinfectant.
ii. Stock with 18 gauge needles.
iii. Stock with probe covers.
iv. Plug in.

REVIEWED BY

A. Surgical Services Policy and Procedure Committee 6/2017
B. Connie Allen, Surgical Services Supervisor, 5/2017
C. Deb Zink, RN, Surgical Services Supervisor, 5/2017
D. Tricia Ejzak, Nursing Education Specialist, 6/2017
E. Katharine Holley, Nursing Education Specialist 6/2017

SIGNED BY

Anne Mork, MHCDS, MS, RN
Director, Surgical Services Department