HYGIENE Medical Devices & Processes Basic Course Tuttlingen (Tuesday, January 16th 2018, 3.00-5.00pm) Dr. Thomas Fengler How to preserve hygiene & function KARL STORZ GmbH & Co. KG Global Quality Management & Regulatory Affairs Department CLEANICAL ®
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HYGIENE
Medical Devices & ProcessesBasic Course Tuttlingen
• Processing on the actual level of science and technology (state of play)
• Gapless traceable documentation with available tracking technology
• Quality assurance system including evaluation of occurring risks
MD are a longterm Investment
MD are sometimes fine and complexe
Function requires Hygiene
Hygiene is part of a quality cycle:
What does (Re-)Processing of Medical Devices imply?
traceability
sterilize
waste use
stock
clean &
disinfect dry
inspect waste
sterilize
wrap &
label
raw
material
A Process oriented Quality Concept
Responsibility for Results
• Operator responsibility pertains to all services of a hospital or
other health care facility, which includes the processing of
medical devices (MD), usually carried out in a Sterile
Processing Department (SPD) or Central Sterile Supply
Department (CSSD) or Reprocessing Unit for Medical Devices
(RUMED).
• There is an obligation to actively request/seek out information
in order to keep up with current developments.
• The delegation of responsibilities (e.g. to service providers)
does not affect the responsibility for the results. The onus of
control is on the operator, within his stipulated mandate to
provide care.
• The manufacturer provides the necessary information for use
(IFU) and after sales services supporting the customer.
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The Impact of Processing in Legal Terms
• The risks of reprocessing are considered to be „fullymanageable“.
• The incidence of nosocomial infections remains unclear, since they are difficult to trace back. Some of them (perhaps: 20-30%) could be prevented.
• „The hygiene- and sterilisation risk has to be kept to theinevitable residual risk, according to the state of science andtechnology.“ (from a verdict of German Federal Supreme Court [BGH])
• From a legal point of view, work in a CSSD is a task „of a higher degree“. This implies an obligation for the staff tofurther their education „to the limits of what can reasonably beexpected“ (quotations from relevant verdicts).
Task
(legal and standard conformous) processing of MD
Implementing
Laws, standards, guidelines, recommendations
Prior arts, state of technologies and sciences
Qualitiy Management establishment and practice
Evaluation of risks
Education and training
Goal
Safety of patients, staff and third parties
Aiming to lower residual risks
Job professionalism instead of „training on the job“
• Needlestick injuries (NSI) are generally understood to be pricks, cuts and scratch injuries of the skin by needles, cannulas, scalpels or similarinstruments
• Needlestick injuries are among the most frequently occurring in clinical routine work accidents
• They are often not reported, the alleged true figure is between 50% and 90%
• In Europe the following pathogens pertain the greatest risk:Hepatitis C virus (HCV)Hepatitis B virus (HBV) (if no sufficient vaccination is provided)Human Immunodeficiency Virus (HIV)
Storage / Transport
Safe Transport
„one touch“
Procedures must be adapted to the Task
Cleaning is Disinfection
ISO/FDIS 17664: 2017
3.1 cleaning
Removal of contaminants to the extent necessary for further
processing or for intended use.
Note: Cleaning consists of the removal, usually with detergent
and water, of adherent soil (e.g. blood, protein substances and
other debris) from the surfaces, crevices, serrations, joints, and
lumens of a medical device by a manual or automated process
that prepares the items for safe handling and/or further
processing.
3.3 disinfection
Process to reduce the number of viable microorganisms to a
level previously specified as being appropriate for a defined
purpose
• Contact time (t)
• Temperature (T)
• Mechanics (M)
• Chemistry (Ch)
– Type of active component
– Concentration
– pH-value
Sinner Circle
Removal or inactivation of any contamination
Main agent is water, as means of transport.
And for rinsing in between…
Influencing Parameters
Drinking water may not contain potentially infectious
microorganisms, from the water company/utility to the tap.
Water availability and its quality may be problematic.
- Pipes not properly installed or maintenance problems
- Dead zones
- Flow speed too low
- Cold water close to hot water (not insulated)
Water Supply & Availability
Water Quality for Processing
Automated or manual cleaning/disinfection – wherever:
Drinking water quality required for cleaning and disinfectionsolutions (including precleaning, change of water, cleaning, and rinsing processes in between).
If possible use desalinated water1
To determine thermal or chemical disinfection:
Final rinse with desalinated water1
Manual disinfection with desalinated sterile water!
1 conductivity value <15µs (EN 285)
(Pre-) Cleaning
Manual
soaking
brushing
flushing
ultrasonic (pre)cleaning
Cleaning (AIR)
Automated/mechanized
washer disinfector
Automated Instrument
Reprocessor
Load Carriers are varying for specific MD
Program specifications
Pump pressure
MD load
Water quantities
Water quality
Wetting
Distribution of water
Spray arms‘ distribution and rotation
Nozzles‘ distribution and diameters
Temperature
Time
Cleaning agent
Many Parameter enable Cleaning
Wet Loads after thermal Disinfection (AIR)
Cleaning AER
Automated/
mechanized
washer
disinfector
Automated
Endoscope
Reprocessor
Cleaning and biocidal action
are separate steps
Cleaning, rinsing, biocidal action (“disinfection”) and final rinsing
with sterile desalinated water have to be executed separately!
Dis-infection by biocidal Action
Disinfection
Inactivation of infectious agents
by biocidal action (instead of
reduction/removal by cleaning)
Target: infection impossible!
Automated reprocessing
- Thermal disinfection
(≥90°C)
- Chemical disinfection
(≤60°C)
Disinfection manually or Device-supported
manual „automated“
Concentration
Immersion time
Rinsing / neutralization
Recommended detergents
Water Quality and Formation of Biofilms
Biofilms are developing from use to use depending on formation
of specific microorganisms at boundary layers, mainly in
aqueous systems often adherent to solid phases.
Biofilms consist of slime (film) that might cover bacteria, algae,
fungi, protozoes (some of which produce the slime).
Therefore cleaning by brushing is crucial. Disinfectants might
loose their biocidal effects, since the bacteria are protected by
the biofilm.
1. Cleanliness, dryness, changes (e.g. corrosion)
2. Oiling (joints, ratchets)
3. Assembly
4. Functional inspection
5. Packaging
Maintenance & Sterile Barrier System
Sterilization
• Steam Sterilization 132-137°C, 4-18 minutes
(preferred method where applicable)
• Low-temperature Sterilization max. 60°C
(thermolabile MD like flexible endoscopes)
– H2O2
STERRAD 100S, NX, 100NX
(Advanced Sterilization Products - ASP)
VPro, VPro Max (STERIS Corporation)
– Formaldehyde (FA)
– Ethylene Oxide (EO/EtO)
– STERIS System 1/1E (PAA)
Information for Use (IFU) e.g. Rigid Scope
● This processing step is part of the validated process.
○ This additional processing step may be optionally performed to support cleaning.
The sterilization procedure has been approved in terms of material compatibility, but its effectiveness must still
be validated by the on-site operator.
x This processing step must not be performed as it may cause damage.
How to process this rigid scope?
Processing Information e.g. Rigid Scope
Rigid Telescope
• Cleaning
Manual or automated
max. temperature 95°C (110°C for drying)
recommended chemicals
• Disinfection
Manual or automated
thermal/chemical disinfection process
• Maintenance
Clean optical surfaces with 70% alcohol (Ethanol / Isopropyl)
• Sterilization
Steam sterilization (in an „autoclave“) at 134 – 137°C
Alternatives: H2O2 (STERRAD / STERIS V-PRO), ETO, FA
Information for Use (IFU) e.g. Forceps
How to process the forceps?
● This processing step is part of the validated process.
○ This additional processing step may be optionally performed to support cleaning.
The sterilization procedure has been approved in terms of material compatibility, but its effectiveness must still
be validated by the on-site operator.
x This processing step must not be performed as it may cause damage.