Oct 31, 2020
1
Marcia Patrick MSN RN CICmarciapatrickipgmailcom
Understand the basic elements of infection prevention and control to ensure patient and worker safety
Identify gaps in the practice setting that put patients and health care workers at risk
2
Hand Hygiene
MedicationInjection Safety
Standard amp Transmission-Based Precautions
Role of the Environment
Linen Laundry Trash and Sharps Disposal
Refrigerator Monitoring
Cleaning Disinfection Sterilization3
4
CDC Guideline for Hand Hygiene in Healthcare Settings 2002
httpwwwcdcgovhandhygiene
5
Antiseptic ndash antimicrobial substances (eg alcohol CHG triclosan) applied to the skin to reduce microbial flora
Alcohol-based hand rub ndash alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms
Antimicrobial soap ndash detergent containing antiseptic agent
Waterless antiseptic agent ndash an antiseptic agent that does not require use of exogenous water
Before and after each contact with patient or their environment
Before and after using the restroom
Before handling clean supplies linen medications
Before invasive procedures
After contact with soiled or contaminated surfaces supplies equipment linen the floor
After contact with blood or body fluids
When hands visibly soiled
6
Why We Use Hand Sanitizers
7
Hands after abdominal exam onPatient with nasal swab + MRSA
Hands after use of ABHR
Surgical Hand Antisepsis
8
State of the science waterless surgical scrub solutions LABELED AS SURGICAL HAND PREP
1 Alcohol-based surgical hand-scrub Prewash hands and forearms with non-antimicrobial
soap dry then apply per manufacturers instructions
2 Antiseptic surgical hand-scrubChlorhexidine amp PVI are most common
Can be done by IP or use secret shopper
Many forms and guidelines available
bull SHEA- Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene httpwwwsheaonlineorgPortals0PDFsStrategies-to-Prevent-HAIs-through-HHpdf (draft as of 114)
bull Joint Commission Measuring Hand Hygiene Adherence Overcoming the Challengesrdquo wwwjointcommissionorg
bull App for handhelds iScrub
httpvincicsuiowaeduindexphpResearchIScrub
9
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Understand the basic elements of infection prevention and control to ensure patient and worker safety
Identify gaps in the practice setting that put patients and health care workers at risk
2
Hand Hygiene
MedicationInjection Safety
Standard amp Transmission-Based Precautions
Role of the Environment
Linen Laundry Trash and Sharps Disposal
Refrigerator Monitoring
Cleaning Disinfection Sterilization3
4
CDC Guideline for Hand Hygiene in Healthcare Settings 2002
httpwwwcdcgovhandhygiene
5
Antiseptic ndash antimicrobial substances (eg alcohol CHG triclosan) applied to the skin to reduce microbial flora
Alcohol-based hand rub ndash alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms
Antimicrobial soap ndash detergent containing antiseptic agent
Waterless antiseptic agent ndash an antiseptic agent that does not require use of exogenous water
Before and after each contact with patient or their environment
Before and after using the restroom
Before handling clean supplies linen medications
Before invasive procedures
After contact with soiled or contaminated surfaces supplies equipment linen the floor
After contact with blood or body fluids
When hands visibly soiled
6
Why We Use Hand Sanitizers
7
Hands after abdominal exam onPatient with nasal swab + MRSA
Hands after use of ABHR
Surgical Hand Antisepsis
8
State of the science waterless surgical scrub solutions LABELED AS SURGICAL HAND PREP
1 Alcohol-based surgical hand-scrub Prewash hands and forearms with non-antimicrobial
soap dry then apply per manufacturers instructions
2 Antiseptic surgical hand-scrubChlorhexidine amp PVI are most common
Can be done by IP or use secret shopper
Many forms and guidelines available
bull SHEA- Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene httpwwwsheaonlineorgPortals0PDFsStrategies-to-Prevent-HAIs-through-HHpdf (draft as of 114)
bull Joint Commission Measuring Hand Hygiene Adherence Overcoming the Challengesrdquo wwwjointcommissionorg
bull App for handhelds iScrub
httpvincicsuiowaeduindexphpResearchIScrub
9
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Hand Hygiene
MedicationInjection Safety
Standard amp Transmission-Based Precautions
Role of the Environment
Linen Laundry Trash and Sharps Disposal
Refrigerator Monitoring
Cleaning Disinfection Sterilization3
4
CDC Guideline for Hand Hygiene in Healthcare Settings 2002
httpwwwcdcgovhandhygiene
5
Antiseptic ndash antimicrobial substances (eg alcohol CHG triclosan) applied to the skin to reduce microbial flora
Alcohol-based hand rub ndash alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms
Antimicrobial soap ndash detergent containing antiseptic agent
Waterless antiseptic agent ndash an antiseptic agent that does not require use of exogenous water
Before and after each contact with patient or their environment
Before and after using the restroom
Before handling clean supplies linen medications
Before invasive procedures
After contact with soiled or contaminated surfaces supplies equipment linen the floor
After contact with blood or body fluids
When hands visibly soiled
6
Why We Use Hand Sanitizers
7
Hands after abdominal exam onPatient with nasal swab + MRSA
Hands after use of ABHR
Surgical Hand Antisepsis
8
State of the science waterless surgical scrub solutions LABELED AS SURGICAL HAND PREP
1 Alcohol-based surgical hand-scrub Prewash hands and forearms with non-antimicrobial
soap dry then apply per manufacturers instructions
2 Antiseptic surgical hand-scrubChlorhexidine amp PVI are most common
Can be done by IP or use secret shopper
Many forms and guidelines available
bull SHEA- Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene httpwwwsheaonlineorgPortals0PDFsStrategies-to-Prevent-HAIs-through-HHpdf (draft as of 114)
bull Joint Commission Measuring Hand Hygiene Adherence Overcoming the Challengesrdquo wwwjointcommissionorg
bull App for handhelds iScrub
httpvincicsuiowaeduindexphpResearchIScrub
9
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
4
CDC Guideline for Hand Hygiene in Healthcare Settings 2002
httpwwwcdcgovhandhygiene
5
Antiseptic ndash antimicrobial substances (eg alcohol CHG triclosan) applied to the skin to reduce microbial flora
Alcohol-based hand rub ndash alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms
Antimicrobial soap ndash detergent containing antiseptic agent
Waterless antiseptic agent ndash an antiseptic agent that does not require use of exogenous water
Before and after each contact with patient or their environment
Before and after using the restroom
Before handling clean supplies linen medications
Before invasive procedures
After contact with soiled or contaminated surfaces supplies equipment linen the floor
After contact with blood or body fluids
When hands visibly soiled
6
Why We Use Hand Sanitizers
7
Hands after abdominal exam onPatient with nasal swab + MRSA
Hands after use of ABHR
Surgical Hand Antisepsis
8
State of the science waterless surgical scrub solutions LABELED AS SURGICAL HAND PREP
1 Alcohol-based surgical hand-scrub Prewash hands and forearms with non-antimicrobial
soap dry then apply per manufacturers instructions
2 Antiseptic surgical hand-scrubChlorhexidine amp PVI are most common
Can be done by IP or use secret shopper
Many forms and guidelines available
bull SHEA- Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene httpwwwsheaonlineorgPortals0PDFsStrategies-to-Prevent-HAIs-through-HHpdf (draft as of 114)
bull Joint Commission Measuring Hand Hygiene Adherence Overcoming the Challengesrdquo wwwjointcommissionorg
bull App for handhelds iScrub
httpvincicsuiowaeduindexphpResearchIScrub
9
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
5
Antiseptic ndash antimicrobial substances (eg alcohol CHG triclosan) applied to the skin to reduce microbial flora
Alcohol-based hand rub ndash alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms
Antimicrobial soap ndash detergent containing antiseptic agent
Waterless antiseptic agent ndash an antiseptic agent that does not require use of exogenous water
Before and after each contact with patient or their environment
Before and after using the restroom
Before handling clean supplies linen medications
Before invasive procedures
After contact with soiled or contaminated surfaces supplies equipment linen the floor
After contact with blood or body fluids
When hands visibly soiled
6
Why We Use Hand Sanitizers
7
Hands after abdominal exam onPatient with nasal swab + MRSA
Hands after use of ABHR
Surgical Hand Antisepsis
8
State of the science waterless surgical scrub solutions LABELED AS SURGICAL HAND PREP
1 Alcohol-based surgical hand-scrub Prewash hands and forearms with non-antimicrobial
soap dry then apply per manufacturers instructions
2 Antiseptic surgical hand-scrubChlorhexidine amp PVI are most common
Can be done by IP or use secret shopper
Many forms and guidelines available
bull SHEA- Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene httpwwwsheaonlineorgPortals0PDFsStrategies-to-Prevent-HAIs-through-HHpdf (draft as of 114)
bull Joint Commission Measuring Hand Hygiene Adherence Overcoming the Challengesrdquo wwwjointcommissionorg
bull App for handhelds iScrub
httpvincicsuiowaeduindexphpResearchIScrub
9
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Before and after each contact with patient or their environment
Before and after using the restroom
Before handling clean supplies linen medications
Before invasive procedures
After contact with soiled or contaminated surfaces supplies equipment linen the floor
After contact with blood or body fluids
When hands visibly soiled
6
Why We Use Hand Sanitizers
7
Hands after abdominal exam onPatient with nasal swab + MRSA
Hands after use of ABHR
Surgical Hand Antisepsis
8
State of the science waterless surgical scrub solutions LABELED AS SURGICAL HAND PREP
1 Alcohol-based surgical hand-scrub Prewash hands and forearms with non-antimicrobial
soap dry then apply per manufacturers instructions
2 Antiseptic surgical hand-scrubChlorhexidine amp PVI are most common
Can be done by IP or use secret shopper
Many forms and guidelines available
bull SHEA- Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene httpwwwsheaonlineorgPortals0PDFsStrategies-to-Prevent-HAIs-through-HHpdf (draft as of 114)
bull Joint Commission Measuring Hand Hygiene Adherence Overcoming the Challengesrdquo wwwjointcommissionorg
bull App for handhelds iScrub
httpvincicsuiowaeduindexphpResearchIScrub
9
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Why We Use Hand Sanitizers
7
Hands after abdominal exam onPatient with nasal swab + MRSA
Hands after use of ABHR
Surgical Hand Antisepsis
8
State of the science waterless surgical scrub solutions LABELED AS SURGICAL HAND PREP
1 Alcohol-based surgical hand-scrub Prewash hands and forearms with non-antimicrobial
soap dry then apply per manufacturers instructions
2 Antiseptic surgical hand-scrubChlorhexidine amp PVI are most common
Can be done by IP or use secret shopper
Many forms and guidelines available
bull SHEA- Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene httpwwwsheaonlineorgPortals0PDFsStrategies-to-Prevent-HAIs-through-HHpdf (draft as of 114)
bull Joint Commission Measuring Hand Hygiene Adherence Overcoming the Challengesrdquo wwwjointcommissionorg
bull App for handhelds iScrub
httpvincicsuiowaeduindexphpResearchIScrub
9
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Surgical Hand Antisepsis
8
State of the science waterless surgical scrub solutions LABELED AS SURGICAL HAND PREP
1 Alcohol-based surgical hand-scrub Prewash hands and forearms with non-antimicrobial
soap dry then apply per manufacturers instructions
2 Antiseptic surgical hand-scrubChlorhexidine amp PVI are most common
Can be done by IP or use secret shopper
Many forms and guidelines available
bull SHEA- Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene httpwwwsheaonlineorgPortals0PDFsStrategies-to-Prevent-HAIs-through-HHpdf (draft as of 114)
bull Joint Commission Measuring Hand Hygiene Adherence Overcoming the Challengesrdquo wwwjointcommissionorg
bull App for handhelds iScrub
httpvincicsuiowaeduindexphpResearchIScrub
9
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Can be done by IP or use secret shopper
Many forms and guidelines available
bull SHEA- Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene httpwwwsheaonlineorgPortals0PDFsStrategies-to-Prevent-HAIs-through-HHpdf (draft as of 114)
bull Joint Commission Measuring Hand Hygiene Adherence Overcoming the Challengesrdquo wwwjointcommissionorg
bull App for handhelds iScrub
httpvincicsuiowaeduindexphpResearchIScrub
9
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
10
HCWs more likely to harbor gram negative pathogens on their fingertips
Outbreak of Pseudomonas aeruginosa in NICU attributed to artificial fingernails
Artificial fingernails epidemiologically implicated in several other outbreaks
Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg those in intensive-care units or operating rooms) (IA)
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings
Study 40 of nurses harbored gram-negative bacilli (eg E cloacae Klebsiella and Acinetobacter) on skin under rings amp certain nurses carried the same organism under their rings for several months
In a more recent study involving gt60 intensive care unit nurses multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S aureus and that the concentration of organisms recovered correlated with the number of rings worn
Rings are not appropriate in the OR
Earringsnecklaces must be covered in OR11
(CDC Guideline for Hand Hygiene in Healthcare Settings 2002)
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
AORN Standards and Recommended Practices and CDC- facilitycontract laundering of OR attire
SHEA Healthcare Personnel Attire in Non-Operating-Room Settings
httpwwwshea-onlineorgViewArticleId249Health-care-Personnel-Attire-in-Non-Operating-Room-Settings-SHEA-Expert-Guidanceaspx
12
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Perform hand hygiene appropriately amp at key times
Soap and water (friction all surfaces turn off with paper towel)
Hand sanitizer (friction all surfaces with adequate amount)
13
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Investigations were resource-intensive and disruptive Notification testing and counseling of hundreds of patients
Delayed recognition and missed opportunities Prolonged transmission
Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)
Contractors (NYC and OK)
Entirely preventable Standard precautions + aseptic technique
15
MMWR 2003 52901-6 CID 2004 381592ndash8
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Perform hand hygiene before accessing preparing meds
Disinfect (scrub) all vial tops amp IV portshubs locks with alcohol for 15 seconds before accessing (includes needleless systems)
Let dry 15 seconds
Never leave a needle or other device inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid
Use 5 micron filter needle for ampules
16
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
A new sterile needle amp syringe used for each injection ampeach entry into vial
Do not use bags or bottles of intravenous solution as a
common source of supply for more than one patient
Leftover parenteral medications should never be pooled for later administration
Single-use medication vials (eg propofol) should never
be used for more than one patient
Assign multi-dose vials to a single patient whenever
possible17
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Use only in holder
Do not withdraw med from cartridge into syringe
Risk of contamination
Risk of med errors
Unacceptable practice to use as single or MDV
18
August 9 2012
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Discard medications upon expiration date or any time there are concerns regarding sterility
Date multidose vials on first entry amp discard at 28 days or the mfrrsquos expiration date whichever is first
Discard unopened vials at mfrrsquos expiration date
Discard single dose vialampule immediately after use
Discard prepared syringes at end of procedure-do not save for next case (includes anesthesia)
19
httpwwwcdcgovinjectionsafetyprovidersprovider_faqs_multivialshtml
USP 797
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
SINGLE PATIENT USE
Sanitize hands before any contact with IV tubing or bag handling or change
Keep IV bags in plastic overwrap until ready for use (if out date amp discard in 30 days or per manufacturer)
Begin administration within one hour of spiking IV bagbottle (USP 797) or a soon as possible (APIC)-otherwise discard bag
Follow IV manufacturer guidance on discarding IV solutions kept in a warmer
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
NEVER set an unlabeled syringe down or leave it unattended
NEVER administer a medication from an unlabeled syringe that you did not draw up amp have control of from time drawn up to time given
NEVER draw up an oral or topical liquid into an injection syringe
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
WWWTP
22
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Discard irrigation solutions after each patient
Most now labeled ldquosingle patient userdquo
Warming irrigation solutions
T max lt113degF lower (104deg) if IV fluids included (record temp daily)
NEVER warm in microwave
Medication-containing irrigations obtain from Pharmacy - single patient use
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
MANY issues in anesthesia infection control risks
Both ASA and AANA have written Infection Control Documents that support CDC and APIC positions
Search on web to find
If providers not cooperative ask them to provide you with documentation supporting their practice and absent that they must follow their professional guidelines
Yoursquoll need admin support
24
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Intubation
Whatrsquos wrong with this picture25
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Changed
Cleaned
Single use roll
26
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
27
2007 Guideline for Isolation Precautions Preventing
Transmission of Infectious Agents in Healthcare Settings
httpwwwcdcgovncidoddhqppdfisolation2007pdf
Reduces the risk of transmission of
microorganisms from both recognized and
unrecognized sources
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
28
You protect
the patientYou protect
yourself
Supplies
Environment
Procedures
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
29
Airborne Transmission Can hang in air up to 2 hours
Droplet Transmission Heavier drops quickly 3-6 feet range
Contact Transmission Direct body-surface-to-body surface physical transfer of
microorganisms Indirect transfer of microorganisms by a contaminated
intermediate object
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
30
Standard Precautions apply to all patient care regardless of diagnosis or presumed infectious status
Blood and all other body fluids including stool
Non-intact skin and mucous membranes
OPIM semen vaginal secretions amniotic cerebrospinal pericardial pleural peritoneal synovial fluids
DOES NOT apply to tears sweat urine or feces BUThellip
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
If itrsquos wet and not yours wear gloves
If itrsquos likely to spray or splash on your clothes wear a gown (single use)
If itrsquos likely to spray or splash your face wear eye and face protection
This is a federal law under OSHA not a guideline applies to all care givers
31
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Also includes Safe Injection Practices Respiratory Hygiene- cover coughs offer
masks tissues hand sanitizer during coldflu season
Use of masks for spinal injectionsCover in orientation annual updates
32
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Airborne- TB measles chickenpox disseminated shingles (defer surgery)
Droplet- URI flu pertussis mumps etc
Contact- large draining wounds large rashes MDROs etc
33
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Not ldquorequiredrdquo especially in outpatient settings base policy on risk assessment risk of transmission between patients and to staff Standard and Airborne (TB) Precautions must be followed
Consider for draining wounds multidrug-resistant organism colonizationinfection non intact skin (extensive skin rashes) diarrheal illness (C difficile)
34
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
If itrsquos wet and not yours and itrsquos likely to get on your clothing wear a gown
Should be appropriate to the level of exposure expected (I amp D requires gown)
Single patient use NEVER hang to reuse
35
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Hair Covers
Hair and jewelry (if worn) to be completely covered when in semirestricted and restricted areas of the surgical suite (AORN)
Chest beard amp sideburns must be covered
Shoe CoversBoots
Wear when blood or body fluid exposure anticipated
36
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Protects you and the patient
During invasive procedures wear a mask to protect the patient from your respiratory droplets - This includes lumbar punctures
All personnel entering restricted areas of the OR suite must wear a mask when open sterile items and equipment are present
Masks are single patient use
37
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Contain the route(s) of transmission Respiratory Mask patient for respiratory pathogens
coughing
Contact Cover wounds clean patient gown clean sheet
Donrsquot put chart in bed with the patient Place under gurney
Can use plastic bag and turn out onto counter
Transporter- good hand hygiene others as needed
38
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Basic infection preventioncontrol principles
Require a bundle of strategies
Consistently performed at appropriate times
To prevent direct or indirect transmission of pathogens and contamination
39
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Objectives
Identify environmental modes of transmission
Describe preventive measures to reduce the risk of microbial transmission
Describe environmental monitoring and environmental cleaning needs
40
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Air
Water
Space
Furnishings
Equipment
Supplies
Maintenancecleaning
41
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
bull Office occupancy- no special ventilation airflow air exchanges etcbull Soiled Utility Rooms- negative gt 10 ACH (old standard gt 6 ACH)bull ASC usually no capacity for Airborne Infection Isolation Rooms (AIIR) for TB varicella measlesbull Class A ORprocedure room = + pressure min ACH of 15 (min outdoor air exchange of 3)bull Class B and C ORs = + pressure min total ACHof 20 (min outdoor air exchange of 4)2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
42
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
2014 Guidelines for Design amp Construction of Health Care Facilities (The American Institute of Architects)
Class A OR Class B OR Class C OR
Minor surgical
procedures performed
under topical local or
regional anesthesia
without pre-op
sedation (Excluded
are IV spinal and
epidural procedures
which are Class B or
Class C surgeries)
Minor or major surgical
procedures performed
in conjunction with oral
parenteral or IV
sedation or performed
with patient under
analgesic or
dissociative drugs
Major surgical
procedures that require
general or regional
block anesthesia and
or support of vital
bodily functions
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Enemy 1 MOLD
ATTIC MOLD CEILING MOLD BLACK MOLD IN DUCT
MOLD CINDER BLOCK MOLD ON AIR DUCT MOLD IN BATHROOM
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Vents should be clean-no dust present on the grill
How often are the grills cleaned inside and out
Is the ventilation on 24 hours a day or is it off during the night Weekends
How often is preventive maintenance done on the ventilation system and how often are the ventilation filters changed
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Water leaks can lead to mold
Any material not dry 48-72 hours remove
Use moisture meters
Vinyl wallpaper can hide mold
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Adequate volume pressure temperature quality
Back flow air break (prevents back flow of water)
No aerators
Donrsquot use handwashing sink to dump biofluids use clinical sink
Adequate number of sinks located to facilitate handwashing
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Water features can be a reservoir of water bugs contaminate environment hands
Totally enclosed fish tanks and water walls OK professionally maintained not by staff
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above
Furnishings should be cleanable including waiting room furniture Vinyl preferred for chair coverings
Wood furniture amp cabinet finishes deteriorate with cleaning- porous
Infection Prevention amp Environmental Services should have input into decisions about furniture purchases
Carpet does not belong in health care It cannot be disinfected looks poorly after a short time difficult to clean
Carpet Cloth sofa
Must be washablewipeable with germicide
Covers must be intact- no cuts tears holes
Includes positioners
MattressesTears cracks holes
not cleanable
All toys must be washable or given to child
Crayons in 4-pack amp coloring sheets
Bin for clean toys child picks one
Bin for used toys child places on leaving
Toys washed with dish soap amp water dried
Used for receipt cleaning disinfection sterilization of surgical instruments and scopes
Area for soiled receiving
Unidirectional flow of instruments without crossovers
Clear delineation of functional areas
Specimen refrigerators may be stored in soiled utility room
Used for clean and sterile storage
Separate clean from sterile
No soiled items trash etc
Positive air pressure
ABHR
55
Separate machines for food reagents specimens and medications donrsquot mix
Record temps of both compartments daily at the same time twice if there are vaccines
Refrigerator ranges Food 34degF - 41degF (1-5degC)
Meds 36degF - 46degF (2-8degC)
Specimens amp Reagents 36degF - 46degF (2-8degC)
If the temp is out of range reset the temp and wait 15-30 minutes If itrsquos STILL out of range move items to a working refrigerator and call for service
Donrsquot record an out-of-range temp and do nothing
Penny in a cup in the freezer is no longer an acceptable monitor need a min-max thermometer or central monitoring
Clean monthly and as needed
Separate refrigerators and ice machines from sterile and clean supplies due to potential water contamination if flooding occurs in medical facilities that fall under DOH jurisdiction Other accrediting agencies look for this also
Not OK to put food or medication refrigerators in clean supply or linen storage
What do you do if facility has limited or no space
Used for ice bags beverages for patients and staff etc
Two types bin and chute
Chutes have less chance of contamination less cleaning needed
For bins store scoop dry in container near machine and a box of non-sterile gloves Sanitize hands first
ALWAYS glove and use scoop
Sanitize scoop every 12-24 hours
Document preventive maintenance and cleaning
Never store
scoop in bin
Who does it Contract or staff Both
What are HCW responsibilities vs housekeeping staff OR PACU change areas halls waiting areas bathrooms equipment
When is cleaning expected to take place OR turnover PACU discharge between patients end of day Every item accounted for who cleans it
Where are cleaning supplies kept Are they the correct supplies needed Environmental disinfectant gloves glass cleaner stainless steel
polisher etc
How is cleaning performed Are there written procedures and are they followed
How is compliance monitored
Monitoring cleaning usinga fluorescent marker canmake a big impact
www Breviscom- Glo-germ Glitterbug Clue Spray
Antiseptic chemical that inhibits the growth of or destroys organisms on living tissue (skin) Not suitable for environmental cleaning
Disinfectant chemical that kills or destroys organisms (ex spores) on inanimate objects and NEVER used on skin
Use EPA registered product
Manufacturerrsquos instructions
How is it dispensed
Wipes are efficient
Sprays donrsquot cover surface amp can aerosolize chemical
Squirt bottles
Manufacturerrsquos label
PPE required-gloves minimum
Expiration dates
Disinfectants are labeled tuberculocidal notbecause TB is a risk on contaminated floors amp surfaces but because TB is a tough bug to kill If the product is effective against TB it is effective against a wide range of organisms including Hepatitis B Virus
However any EPA registered germicide that has a HBVHIV claim is adequate for use when blood is present
ldquoTuberculocidalrdquo Germicides
httpwwwepagovoppad001list_d_hepatitisbhivpdf
bull Prions
bull Bacterial Spores
- Geobacillus stearothermophilus
bull Mycobacteria
- M tuberculosis
bull Viruses (HBV HIV HCV)
bull Fungi
bull Vegetative Bacteria
- Pseudomonas MRSA Staph aureus etc
HARDEST
EASIEST
Concentration of disinfectant
Amount amp type of contamination
How is surface cleaned manual steam
Cleanliness of the surface
Contact time
Physical amp chemical factors in environment (water hardness type of surface etc)
Factors Affecting Disinfection
Alcohols (ethyl isopropyl)
Halogens (chlorine iodophors)
Phenols- Phenolics can be toxic
Quaternary ammonium compounds (quats) a four-chain ammonia often with detergent fragrance most frequently used
Combination products (alcoholquat)
EPA approves germicides
Liquid Chemical Germicides
Bleach has no cleaning properties two-step process is necessary
May harm stainless steel furnishings
Employee exposure mixing
Will kill C difficile spores
Mix 110 to 1100 solution
Mix fresh daily or use wipes
Good detergent properties
Fast acting broad spectrum
Non-toxic surface compatible
Unaffected by type of soil water
Residual action long shelf life
Easy to use stable mild odor
Cheap
Ideal Disinfectant
Read labels carefully
Must be approved by EPA to kill Hep B HIV
Look under sinks (store nothing that can be harmed by water- paper patient care items etc)
Check expiration dates- shelf and mixed
Disinfectants
Donrsquot cut corners-take time Use right product or process Use appropriate PPE for task Follow manufacturerrsquos instructions for usedilution Clean thoroughly before disinfection Prevent contamination
Donrsquot re-dip cloth in disinfectant Pop-up wipes- one wipe for one surface Change mop heads each OR suite Separate dirty from clean including in janitorial closet Donrsquot top off disinfectant solution
It is the physical removal of visible dust soil other foreign material amp visible organic material from a surface
Cleaning removes most organisms-up to 99 but does not kill them-friction required
Prepares surface for disinfection
Most healthcare disinfectants have cleaning agents in them which makes them a one-step cleaning process (alcohol and bleach are not cleaners bleach WIPES have detergent)
If the surface does not have visible soil or organic matter then a thorough wipe using friction will clean and disinfect the surface
If body substance present clean discard wipe then clean again with another wipe and let air dry- this will disinfect the area
To meet federal regulations follow the manufacturerrsquos instructions often 10 minutes
Some of the pop-up wipes have shorter wet contact times
Those with high-alcohol content may need repeated applications to keep surface wet for the indicated length of time
EPA kill HBV HIV or a tuberculocidal
110 to 1100 bleach solution freshly mixed (never mix with anything but water)
PPE (gloves at a minimum) must be worn
Training- initial and annual required
Bloodborne Pathogens Standard
httpwwwepagovoppad001list_d_hepatitisbhivpdf
Bucket and cloth application have lots of cleaning cloths available-never redip and never top off disinfectant solution
Pop-up wipes fine ONE wipe ONE surface wear gloves
Pop-ups may be too small for large surfaces beds
Keep bucket and containers clean
Keep lids on wipes closed
Is enough time allowed (TAT goal)
How many staff clean a suite
Who is responsible for what surfaces and equipment
Is there a pause to make sure room properly cleaned before admitting next case
Have staff been trained
What monitoring is done and by whom whom and with what frequency
General purpose cleaner vs disinfectant
Floors are always considered dirty
Anything that falls on the floor goes in trash or soiled linen hamper as appropriate
Disinfect if blood body fluids stool spilled
Keep mop bucket clean-donrsquot re-dip mop
Microfiber much better at cleaning
Anything that comes in contact with a patient must be able to be disinfected
Anything that comes in contact with a patient must be disinfected before it touches another patient
This includes stethoscopes BP cuffs pulse ox probes EKG leads gurneys wheelchairs etc
Critical to clean whatever has been touched during the procedure by the patient or healthcare worker
Evaluate equipment prior to purchase What chemicals can be used to cleandisinfect Are there areas that are not cleanable Does it come in contact with sterile tissue mucous
membranes or non-intact skin Donrsquot take vendorrsquos word-get it in writing from the
company If instructions are not adequate donrsquot purchase If no other choice require manufacturer to provide
you with adequate disinfection guidelines in writing
Transport and store to protect from contamination
Wrapped or sealed carts from laundry
Clean linen carts may or may not be covered-riskier to have staff duck under flap that touches headshoulders than to leave flap up
Write this in your policy
Check stateother regulations
Soiled laundry placed in leak-proof bags
All can go in same bag unless contractor requires otherwise
Standard Precautions (gloves for soiled laundry)
No sorting rinsing prewashing in facility
Laundry accredited or meets HLAC standards
Non-commercial machines cannot meet standards
Water temp wash formula etc
Visit contract laundry to ensure safe processing
httpwwwhlacnetorgstandardsphp
Sharps pose a risk of exposure to bloodborne pathogens
OSHA requires if there is a safer device you must use it
Frontline workers must have input into selection
Donrsquot base only on cost
OSHA can fine facility- up to $70000 for a ldquowillful and serious violationrdquo
Bad publicity
bull Sharps disposed of in puncture-resistant sharps containers placed at point of use
bull Containers are replaced when fill line is reached
bull NIOSHOSHA Mounted 52-56rdquo from floor to slot for standing use
bull Biohazard labeledbull Located at point of usebull Store filled containers in secure location
httpwwwcdcgovnioshdocs97-111
The environment poses risks and challenges
Reduce risks as much as possible
Cleaning amp disinfection is critical
Control dust during construction
Remediate leaks and floods immediately
The level of disinfectionsterilization depends on the use of the instrument
Critical devices enter sterile body sites or the blood stream Must be STERILE
Semi-critical devices touch mucus membranes non-intact skin Minimum HIGH-LEVEL DISINFECTION
Non-critical devices touch normal intact skin LOW LEVEL DISINFECTION
87
Cleaning removal of all soil from objectssurfaces
Decontamination removal of all pathogenic microorganisms from objects to ensure they are safe to handle
Disinfection elimination of many or all pathogenic organisms with the exception of bacterial spores
Sterilization complete elimination destruction of all microbial life
CDC Guideline for Disinfection and Sterilization in Healthcare Settings 2008
Cleaning of the object
Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to disinfectant sterilant
Nature of the object
Temperature and relative humidity
Improper packaging or overloading the sterilizer chamber can form air pockets that prohibit items from being sterilized
Instruments scopes surfaces must be physically clean before they can be disinfected or sterilized
Presoak- enzymatic detergent helps remove proteins and soil keeps item moist
Manual cleaning- elbow Wear PPE scrub under surface of solution use a brush
Ultrasonic- difficult to clean fragile items
Based upon intended use
Degree of disinfection required
Spauldingrsquos classification
Capability to meet all requirements to use the disinfection agent safely appropriately
Turn-around-time (TAT)AAMI ST79 2010 7261 p 60
A process (usually liquid chemicals or wet pasteurization) that eliminates
Many or all pathogenic microorganisms on inanimate objects
Except large numbers of bacterial spores
Short exposure times (lt30 minutes)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Any instrument that will touch mucous membranes or non-intact skin Flexible endoscopes
Ultrasound probes vaginal and anal used with sheath
Brushes used to clean instruments for HLD
Laryngoscope blades
Vaginal specula amp related equipment
Diaphragm fitting rings
Follow label directions for soak time temperature use life shelf life product restrictions
No OPA for urology scopes per label on OPA
Some solutions require activation if not activated not soaking in HLD
Many HLD products are similar Compare
Different brands of same chemical may have different soak time and temp requirements
NEVER use HLD for environmental cleaning
Use for temperature-sensitive devices
Glutaraldehyde (gt 20) Many brands
Ortho-phthalaldehyde ndash OPA (055) Many brands
2 Activated Hydrogen Peroxide (Resert XL)
Peracetic acid-PA (02) Steris 1e (sterilant)
Brand names used for illustration only no endorsement is implied
Glutaraldehyde and Ortho-phthalaldehyde ndashOPA Various formulations and brands Ready to use or requires activation (mixing) 14 28 and 72 day formulations (maximum use days)
Must use test strips to assess concentration prior to each use Minimum Effective Concentration (MEC) specific to each
product
Product must be rinsed thoroughly x 3 Sterile or potable water (dependent upon intended
use of instrument)
Maintain log Must be neutralized for disposal - EPA (Glycine)
bull Perform some or all of the functions leak testing cleaning
disinfection alcohol rinse and air drying of scopes
bull MUST ensure all lumens are properly connected
bull MEC check before each use
bull Temperature set for HLD being used
bull Preventive maintenance service documented
Chemical dilution occurs during routine use
Test strips for monitoring the MEC specific to each product test prior to each use log
Do not use test strips beyond expiration date
QC test amp document when opening a new bottle refer to manufacturerrsquos protocol
Test strips are brand amp product-specific
AORN Perioperative Standards amp Recommended Practices 2014
Tray
Equipment
Date
Processed
Solution
Expiration
Date
Test Strip
Expiration
Date
MEC Test
Result
(+ Pass or
- Fail)
Solution
Temperature
Solution
Soak Time
Initials
Test Strip Example
-Fail
+ Pass
IMPORTANTSolution must be discarded by expiration date even when MEC test passes
Training of ALL staff responsible for cleaning instruments scopes equipment (vacationsillness)
Post the cleaning procedure in work area
Ensure proper equipment PPE supplies available
Competency evaluation initially and at least annually for each scope
Maintain training records
Periodic visual monitoring of practice
Consider microbiological monitoring if indicatedAAMI ST79 2010 42 p 37httpwwwuncedudeptsspicedisEndoscopehtml
101
Leak testing and scope inspection
Processing per manufacturer
Chemical
Automated endoscope washer-disinfector
Use alcohol for final rinse blow air
Hang to dry per manufacturer (vented cabinet designed for hanging and storage of scopes)
Do not store in the case
Thermal (Heat)
Moist (Tabletop or large Gravity amp High Speed Vacuum)
Dry
Chemical
ETO (ethylene oxide ldquogasrdquo)
Other chemicals- H2O2 gas plasma (Sterrad) Steris
Ozone- commercial use
Radiation- commercial use
Example of a tabletop steam autoclave
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
Low cost quick turnover no toxic chemicals accommodates large loads
Steam enters the chamber by gravity amp displaces air (so steam can penetrate load)
Takes longer for steam to reach required temperature
May not penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59-60
Low cost quick turnover no toxic chemicals accommodates large loads
Air is removed (so steam can penetrate load) by a pump before steam at an elevated temperature is rapidly introduced then rapidly removed at end to facilitate drying
Will penetrate complex instruments
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 59
105
Ethylene oxide (EtOEO)
Used for heat amp moisture sensitive devices
Lengthy aeration time must follow each cycle to allow removal of harmful residuals before opening chamber doors
EtOEO is associated with human tumors
Alarms ventilation and training of staff promote safe use of this agent
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008 p 61
106
FDA Approved
107
Use the correct wrappercasket for the type of sterilization to be performed items to be packaged
Wrapperscaskets must have a 510k that specifies what it can be used for (ETO steam etc)
Same for peel packs
Donrsquot put peel packs inside trays
AORN Standards amp Recommended Practices 2014
109
Definition
AAMI ldquoprocess designed for the steam sterilization of patient care items for immediate userdquo
AORN ldquoshould be used only when there is insufficient time to sterilize the item by the preferred wrapped or container methodrdquo
Not recommended outside of the hospital or ambulatory surgical center where it can be used in a controlled manner
Should never be used as a substitute for sufficient inventory
AAMI ST79 2010 88 p 86
Considerations
Risk of burns from hot instruments
Recontamination of instruments during transport
Keep logs of all immediate using (process surveillance)
Monitor number of times used what procedures and why ndash use as dept PI
Monitor staff training and performance
AORN Standards and Recommended Practices 2014
Acceptable
AAMI amp AORN guidelines for implants
Single instruments only (not trays)
Urgently needed
Cleaned well
Used close to point of sterilization
Adequately covered or protected from contamination
Use mechanical chemical and biological indicators
AORN Standards and Recommended Practices 2014
Please indicate which best describes your practice
1 Only use IUSS for dropped items for which there was no replacement
2 Routinely use IUSS to process trays
3 Do not use IUSS at all
Cycle time temperature amp pressure is displayed on the sterilizer gauges with each instrument load
Printout or graph documents these
Tabletop units should have printout
If these fail load is no good
The CI is a process indicator that signals the item has been exposed to sterilization process (temperature time etc)
A CI is affixed to outside of package amp used with every load
An indicator is also placed inside the pack to verify steam penetration
Peel-packs have a single indicator
If these fail load is no good
Closest to being the ideal monitor amp measure of effectiveness by challenging the sterilization process against a resistant spore (Bacillus sp)
Run BI at least weekly daily if sterilizer is used infrequently
Also use a BI for every implant amp EtO run
Rapid indicator for implants must be negative before using item
Policy for positive tests- who to notify identify instruments used recall
Manufacturers cite ldquosingle use onlyrdquo on many of their products (eg cardiac caths orthopedic bitsblades DVT sleeves etc)
Re-use of these products can result in significant financial savings
Concern with the risk of infection and injury when the devices are re-used
Must consider regulatory medical ethical legal amp economic issues before proceeding forward
3rd party reprocessing acceptable when premarket requirements are met (FDA 510(k)
httpwwwfdagovMedicalDevicesDeviceRegulationandGuidanceReprocessingofSingle-UseDevicesdefaulthtm
Store at least
8-10rdquo from the floor
18rdquo from the ceiling
2rdquo from outside walls
Solid bottom shelf
Closed cabinets
Controlled temp humidity
Avoid overfilled drawers
NO RUBBER BANDS
AORN Standards amp Recommended Practices 2014
Written policy
bullMust be delivered to the CS decon for cleaning and sterilization (with instructions or check Internet)
bullAllow adequate time for processing
bullKeep a log use for QAPI
bullRecord loaner equipment contents vendorlender name patient or case number surgeon date and time
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developingreviewingrevising related policies
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
AORN - Association of periOperative Registered Nurses
httpwwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation
- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section
httpwwwapicorg
INFORMATION FOR SPECIFIC AMBULATORY AREAS
Both need to have germs from previous patients removed but usually donrsquot require sterility
High-level disinfect or sterilize Bag in zip lock bag if sterilized wrapped Laryngoscope handles ideally will be HLD or sterilized
between patients remove batteries Rutala Blade sterilized in Sterrad handle steam
sterilized then both placed in zip lock after batteries amp bulb replaced and device tested before return to unit
Decontamination and care of equipment Insertion of central catheters- central line ldquobundlerdquo
Single use vs reusable patient care items
Disposable cover for probes (vaginal rectal etc)
Cleaning and high level disinfection of probes ndashManufacturerrsquos instructions
Use of closed flush and waste containment systems for angiography
Environmental cleaning especially in procedure areas
Cleanable positioners- clean between patients
Instruments that penetrate soft tissue or bone (eg extraction forceps scalpel blades bone chisels periodontal scalers and surgical burs) should besterilized after each use or discarded (Critical items)
After each use sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (eg amalgam condensers hand pieces air-water syringes) but that might contact oral tissues and are heat-tolerant although classified as semicritical
Clean and at a minimum high-level disinfect heat-sensitive semicritical items
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
Noncritical clinical contact surfaces such as uncovered operatory surfaces (eg countertops switches light handles) should be barrier-protected or disinfected between patients with an intermediate disinfectant (ie EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (ie EPA-registered hospital disinfectant with HIV and HBV claim)
So called ldquoBead Sterilizersrdquo are not approved by the FDA for sterilization and should not be used
Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care that are likely to become contaminated with blood or body substances or that are difficult to clean
Change these coverings when they are visibly soiled when they become damaged and on a routine basis (eg between patients)
Disinfect protected surfaces at the end of the day or if visibly soiled
Tonometer tips can spread
Herpes simplex virus
Adenovirus (keratoconjunctivitis)
CDC Guideline for Disinfection amp Sterilization in Healthcare Settings 2008
CDCAOA Wipe tips clean then disinfect by soaking for 5-10 minutes in either 5000 ppm chlorine or 70 ethyl alcohol
CDC 3 H2O2 and 70 IPA are not effective against adeno and other viruses causing EKC and should not be used
Soaking is the key wiping alone is not sufficient
Schiotz devices damaged by chlorine
Rinse thoroughly with tap water and air dry 1 part household bleach to 9 parts water freshly mixed
American Academy of Ophthalmology Infection Prevention in Eye Care Services amp Operating
Areas 2009
TASS- Toxic Anterior Segment Syndrome Severe inflammation of eye- blindness Poor cleaning and disinfection of eye instruments Introduction of foreign matter into the eye Detergent residues preservatives Contaminated salt solution Endotoxins from overgrowth of GNB in ultrasonic cleaners Impurities in steam Degradation of brass in gas plasma sterilizers
Follow device manufacturerrsquos instructions
Single use cleaning brushes
Pour rinse solution over instruments
Sterile deionized or distilled water for final rinse
Avoid use of immediate use sterilization (flashing)-not an acceptable substitute for adequate instrumentation
Perform a variety of services
Tools that penetrate tissues should be sterilized or high-level disinfected per Spaulding criteria
Follow monitoring requirements for each
Water environments risky for water-borne pathogens such as P aeruginosa and others
Disinfect surfaces between patients
Wear gloves for procedures sanitize hands before and after monitor
Wash linens in hot water with bleach hot dryer
Not exempt from safe patient care practices
Not exempt from Bloodborne Pathogens for staff
Written policies and procedures
Document employee orientation and at least annual education on infection prevention
Proper disinfection and sterilization practices support patient and staff safety in the use of invasive and non-invasive medical devices
The method of disinfection and sterilization used depends on the intended use of the medical device and of what itrsquos made
Meticulous cleaning should precede high-level disinfection and sterilization
Staff should know the current recommended guidelines and utilize them when developing reviewingrevising related policies
Guidelines
AORN - Association of periOperative Registered Nurses wwwaornorg
(AAMI) Association for the Advancement of Medical Instrumentation- httpwwwaamiorgpublicationsstandardsst79html
CDC Guidelines for Environmental Infection Control in Health-Care Facilities
httpwwwcdcgovmmwrpreviewmmwrhtmlrr5210a1htm
CDC Guideline for Sterilization amp Disinfection in Healthcare Settings 2008
httpwwwcdcgovhicpacpdfguidelinesDisinfection_Nov_2008pdf
APIC web site Practice Guidance section wwwapicorg
Self-assessment of cleaning disinfection and sterilization as presented
1 My facility is in substantial compliance
2 My facility is in partial compliance
3 My facility has a way to go to reach compliance
4 OMG
wwwdisinfectionandsterilizationorgEstablished by William A Rutala PhD
MPH
1 Are used when the hands are visibly soiled
False
2 Damage skin
- False
3 Kills 999 of transient pathogens on the hands within 15 seconds of application
- True
4 Not recommended as a surgical scrub
False
1 After using the bathroom
2 Before accessing clean supplies
3 Prior to preparing medication
4 Before and after intubation
5 All of the above
All True
1 Patients or HCWs with colonization can transmit the organism
bull True
2 Donrsquot need to use contact precautions in the ASC
False
1 The top of the vial is sterile when the cap is removed so it doesnrsquot need to be wiped with alcohol False
2 IV tubing ports do not need to be wipe with alcohol prior to accessingbull False
Organisms from the environment can cause infections
True
142
Patients with untreated pulmonary TB can have surgery in an ASC
False
a It must be thoroughly cleaned to be chemically disinfected
b The wet contact time on the label must be observed
c It may be necessary to reapply disinfectant to achieve wet contact time
d All of the above