Mission Accomplished: Sterilization & Disinfection

1. Mission Accomplished: Sterilization & Disinfection Robin Haag Sherry Chisholm 2011 Awardee Baltimore, Maryland

2. What I Attended ? • Anything and Everything related to sterilization and disinfection • No matter how repetitive • No matter how boring

3. Why this topic? • We “assume” others are doing the right thing • Corners get cut • Salary and titles do not equate with knowledge or expertise • Common sense is not common • TJC and CMS citations • We are ultimately responsible

4. Bill Rutala says…… • Current surface disinfection practices are not effective • 65% of high touch areas are not cleaned • Inadequate terminal cleaning puts the next patients at risk for acquiring MDROs • Improved methods are needed

5. Risk of Acquiring MRSA, VRE and C Dif from Prior Occupants • Admission to previously occupied MRSA or VRE room significantly increases odds of acquisition • Huang et al Arch Intern Med 2006; 166;1945. • Prior environmental contamination measured by environmental culture or VRE colonized patients increases risk • Drees et al Clin Infect Dis 2008; 46:678. • Prior room occupant with CDAD significantly increase risk • Shaughnessy et al. ICHE 2011; 32:201

6. Novel Methods of Room Decontamination • No touch methods • Supplement, do not replace standard cleaning/disinfection • Ultraviolet lights • Work best in direct line of sight • ~15 minutes for MDROs • ~50 minutes for c dif spores • Hydrogen Peroxide Systems • May take hours • Rooms need sealing • Proposed self disinfecting surfaces • Silver or silver ion impregnated • Copper • Sharklet pattern • Deflects organisms from adhering

7. New Approaches to Room Decontamination

8. UV Decontamination Advantages • Reliable biocidal activity • Surface and equipment decon • Room decon • ~15 min for vegetative bacteria • HVAC can stay on • Room need not be sealed • Low operating cost

9. UV Decontamination Disadvantages • No studies regarding HAI reduction • Not for daily cleaning • Terminal cleaning only • Initial capital equipment cost • Does not remove dust or stains • Need to determine UV parameters

10. Hydrogen Peroxide Decontamination Advantages • Reliable biocidal • Surface and equipment decontamination • Decreases C difficile • Residual free • Minimal health or safety concerns • Can use on complex equipment

11. Hydrogen Peroxide Decontamination Disadvantages • Can only be used for terminal cleaning • All patients and staff may not be in room • Process takes 3 – 5 hours • HVAC must be disabled • Room must be sealed with tape • Does not remove dust or stains • Need to determine HP concentration

12. C. difficile • Factors that facilitate transmission • Survives in environment for hours to days • Remains virulent in the environment • Low inoculating dose • Colonizes patients • Surface contamination • Frequently touched by HCWs • Direct transmission from contaminated hands • Relative resistance to antiseptics and disinfectants

13. Controlling the Spread of C dif • Practice • Contact precautions • Ensure thorough disinfection • Products • 5000 – 6000 ppm chlorine • Products with c dif claims • When • Areas with increased C dif rates • All patient rooms?

14. Surface Disinfection • Exposure time • Close attention by TJC and CMS • Following manufacturers’ directions • Dilution • Contact time: may require repeat applications • Appeals denied by for following findings of peer reviewed studies supporting shorter exposure times • Wipes • Wet time • Size of wipe

15. 2011 Multi-Society for Reprocessing Flexible Endoscopes • Changes since 2003 • High level disinfectants • Automated reprocessors • Endoscopes • Endoscopic accessories • HLD efficacy is unchanged • Principles remain valid • Outbreaks associated with: • ASCs • Unfamiliarity with endoscope channels, accessories and attachments

16. Endoscope Procedure Transmission: Non scope related • IV lines • Anesthesia administration • Medication administration • Multidose vials • Reuse of needles and syringes • IV tubing

17. Endoscope Procedure Transmission: Scope related • Failure to sterilize forceps between patients • Lapses in reprocessing channels used in irrigation

18. Unresolved Endoscope Issues • Interval of storage between reprocessing and scope use • Data suggests negligible contamination 7 – 14 days • Insufficient data to determine maximal duration • Need for microbiologic surveillance

19. Disinfection Boot Camp: Rose Seavey and Martha Young • Evidence based Guidelines • Focus on AAMI/ANSI Standards 2010 • NPSGs • AORN 2011 • CDC 2008

20. Environmental Concerns • 68 – 70° F in clean area • 60 – 65° F in decon area • 30 – 60% humidity in decon area • Not over 70% humidity in sterile storage • Separate housekeeping and decontamination cleaning supplies • Eye wash stations • 60 – 100° F • Test weekly for 3 minutes • Use AAMI Work flow diagrams • Dirty to clean

21. Decontamination Personnel Attire • Scrubs • Cover all facial hair • No artificial nails • Prefer no nail polish • No jewelry • Bouffant caps only • Heavy long gloves, not surgical • Face masks with full protection splash guards

22. Decontamination • Decrease bioburden • Prepare devices • Disassemble • Lubricate • Keep instruments moist • Brush and clean under water • Use disposable brushes or decontaminate once per shift • Prefer automatic washers • Water • Initial rinse can be tap water • Final rinse should be sterile, de-ionized, distilled • Sterilization • Do not use preset parameters for cycles • Maintain sterility in storage • Event related sterility

23. Potential Problems With Automated Cleaners • Wrong water temperature • Wrong detergent concentration • Problem with mechanical functioning • Human element • How machine is loaded

24. How Do You Know Your Automatic Washer is Working Right? • Verification of Cleaning • TOSI (Test Object Surgical Instruments) • Monitoring of the Cleaning Efficiency of Washer-Disinfectors • Surrogate device for surgical instruments soiled with blood • Test weekly, preferably daily • Maintain records

25. Count sheets should not be inside sets or containers Ink transfers Paper shreds Peel packs No more than 1 or 2 small light items Double packing not needed No folds in packs BIs preferred daily Do not exceed 25 lbs including container and wrapper Do process audits Load configuration Item density Your hand should fit between items Cooling in a high AC environment May lead to wet packs Immediate use sterilization Old “flash sterilization” Loaners Have in 3 days ahead of time Keep repair logs Sterilization Caveats

26. Storage • 75°F • 4 air exchanges per hour • Under 70% humidity • Don’t stack • Keep items covered • 8 – 10 inches above floor • Solid bottom shelf • 2 inches from outside wall • Prevents condensation • No corrugated boxes • No shipping boxes

27. Tracer Activity • Trace a set from patient in OR through reprocessing • Look for competencies • Certification within 2 years of hire • Review all paperwork for reprocessing parameters • Better that staff look like a deer in headlights with you, than with a TJC or CMS surveyor

28. Implants • Require a BI in each load • Quarantine loads until BI results are known • Early release of implant loads • Can only be released by the surgeon • A written policy is required • In an emergency a Class 5 indicator can be used

29. Sterilizer Qualification Testing • Testing a sterilizer after certain events • 3 consecutive cycles • Events may adversely impact process • Installation of new sterilizer • Relocation of sterilizer • Sterilizer malfunction • Process failures • Major repairs • Gasket replacement • Welding • After annual boiler maintenance • After a water main break

30. In Summary……Why this topic? • We “assume” others are doing the right thing • Corners get cut • Salary and titles do not equate with knowledge or expertise • Common sense is not common • TJC and CMS citations • We are ultimately responsible

31. Don’t Get Caught With Your Pants Down • Class 6 process challenge packs • Not a substitute for Class 5 integrating BIs • No matter what the sales rep told the reprocessing administrator • Sharing memos and recall notices • Credentialing • Inservice records