What Can Go Wrong in Cleaning, Disinfection & Sterilization?

1. What Can Go Wrong in Cleaning, Disinfection & Sterilization? TSICP October 2006 Barbara Moody, RN, CIC Director Infection Control Denton Regional Medical Center

2. and how would you know?

3. Objectives • Describe at least one infection associated with each: improper cleaning, disinfection & sterilization • Identify > 3 indicators that could implicate inadequate processing. • List 3 methods for investigating possible processing failures.

4. Background • 118,000 citations for HAI due to disinfectant failure • 299,000 citations for Infections due to disinfectant failure • Septic shock in healthy host due to Ochrobactrum antropi from contamination during reconstitution • Hepatitis B spread to 6 from improper sterilization • Mycobacterium abscessus outbreak post-acu- puncture; towels & hot pack covers possible source 2006 • Poor sterilization instruments results in Infection outbreak, Paris • 40 years of Disinfectant failure: M.abscessus Infection caused by contam. Benzalkonium Chloride (skin antiseptic before intra-articular injections)

5. Basic principles • Hosp. Environment visibly clean, free from dust, soil • Equipment used for >1 pt must be cleaned, disinfected or sterilized between patients • Established procedures must be used for clean & soiled linen, food hygiene & pest control • All staff must be educated & trained in prevention of HAI (& competency updated)

6. Baseline Info *Things you know Definitions: • Antisepsis: (Skin only) • Cleaning; pre-cleaning • Spaulding classification system • Disinfection: Low-med-High levels (environment only) concentration – dilution -MSDS • High level disinfection: (HLD: testing,duration of use - documentation • Sterilization: Steam, EO, Plasma • Biological indicators • Documentation

7. …WMD WeaponsofMicrobe Destruction… The • Weapons: Manual cleaning; automated processors, disinfectants, Sterilants • Microbes: fungi, bacteria, viruses, spores, prions • Destruction methods: Chemicals, Steam Gas (EO), H202 Plasma, Irradiation

8. Environmental Cleaning Yes Virginia, the Environment does matter in the prevention of infection ! MRSA outbreakcontinued & increased x 21 mos. until doubled cleaning hours, assigned cleaning of equipment & environment = end of outbreak MRSA ICU outbreakafter disinfectant changed: U Wisc. ID residents, Epidemiologist demonstrated room cleaning to Housekeeping. Hskpg. Returned demonstra- tion = Outbreak ended.( techniques not disinfectant )

9. Legal aspects:Headlines re failure of disinfection, sterilization, etc • $200 million suit – Toronto: non-sterile equipment used on patients • End Hospital Secrecy & Save Lives! • Improper sterilization cited in 400 Va biopsy exams!

10. Disinfectant contamination • Intrinsic contamination possible Phenolic solutions Benzalkonium chloride Other “Quats” • Extrinsic contamination frequent Most detergent/disinfectants Quats – especially Alcohol – bacillus spores

11. Environment – Non-critical • No contact with mucous membranes or non-intact skin • Contaminated with microbes: (fungi, bacteria, lipid viruses) • Examples: door knobs, surfaces, counters, shelves, bedpans, beds, rails, ekg leads, walls, bathrooms

12. Environmental Cleaning agents(low level) Chemical Disinfectant Strength • Ethyl, Isopropyl alcohol 70-90% • Chlorine bleach 1:500 (100 ppm) • Phenolic (1:120/1:256) Mfr directions • Iodophor “ “ • “Quats” quaternary ammon.cpd “ “ ~ Need disinfectant / detergent solution ~ Contact time a minimum of 1 minute * *Rutala W. 2005,6 Disinfection/Sterilization conference

13. When to check cleaning ? (Cluster of HAI patient infections) • Patients in same room as previous case(s) • Pathogen easily spread in environment (dry): MRSA, VRE, C.difficile • Check: ~ product - New product? ~ procedure - Change in procedure? ~ staff training - New Staff? - Initial training - Competency ~ actual practice- Observe • ~ population - Shift or increase

14. Examples of Improper / inadequate cleaning • Under-dilution disinfectant: -Too concentrated COMMON - Outbreak pseudomonas – SICU • Over-dilution disinfectant = rare OCCASIONAL: Automated disinfectant dispensing equipment • Inadequate application/ contaminated sol. FREQUENT: Spray bottles for application, quick spray, dry wipe, insufficient contact time. Bucket system, re=dipping used cloth in solution

15. Problems Pre- Cleaning instruments • Wrong product • Misunderstanding label or type product “wrong assumptions” • Failure to rinse organic matter promptly • Incorrect dilution (Over -, under -) • Inadequate soak time • Failure of disinfectant to reach all crevices

16. Storage Contamination • Packaging incorrect, inadequate, integrity compromised: penetrated by heat, moisture, dust • External shipping cartons contaminated remove before contents stored internally • Storage racks must have solid bottom shelf (potential for mop water contamination)

17. What to look for: Show me (or tell me) How do you dilute X ? ?automatic, have demonstration ?manual? Need handy measuring devices How should the solution look ? What color is the solution supposed to be? How applied? When cloths / mops changed?

18. Device-associated infections • Automated reprocessors • Bronchoscopes • Depth electrodes • Electrosurgical units • Endoscopes • Laryngoscope blades • Transducers • Rectal/vaginal probes

19. Device assoc.infections cont’d • Electronic thermometers • EKG leads • Tonometers • Cardioplegic solution/ice machine • Surgical instruments • Powered instruments • BP Cuffs

20. Powered instrument Issues • Difficult to clean, penetration w/ organic matter likely • Mfrs directions re switch position key • Changing sterilization parameters ~ Contact Mfr. annually re changed recommendations esp. duration steriliz.

21. Endoscopes: The IC issues • Narrow lumen • Complex inside parts* • Easily damaged • Manual pre-cleaning essential • Frequent repairs necessary • Surface integrity essential • Special connectors to AER a MUST !

22. Endoscopes: issues cont’d • Mechanical failure • Faulty design • Poor manufacturing quality • Adverse effects of materials • Improper maintenance • User error • Compromised sterility

23. Endoscopes & Bronchoscopes • GI endoscopy infections • > 300 published cases - 70% Salmonella, Pseudomonas - C.difficile • Scope: colonization • Bronchoscopy infections - >90 published cases - M.tb, atypical mycobacterium, pseudomonas Spach et al; Ann Int. Med 1993: Weber D J Gastrointest Dis.2002

24. What’s wrong with …………… • Nurse cleaning GI endoscope in sink in Endo- patient procedure room: Long cotton tipped swabs 1. Phisohex 2. povidone-Iodine 3. Septisol • Rinsed, blew powered air into it • Dried it on a towel next to the sink • Placed it in a large, long drawer

25. Assessing Endoscope Processing • “Show me….” Show me the steps in processing a scope • Look at everything. Ask, ask, ask, ask • Every solution & test strips need both date opened & expiration date • Check / Ask re every device, cleaning brushes etc. whether reusable or single use. • Review log & testing data, especially dates during regular staff’s vacations

26. Rinsing after HLD Endoscopes: • Rinse immediately after patient use • After HLD soak, water flush, alcohol flush

27. Endoscope contamination • Inadequate channel cleaning • Lack of proper connectors for channels • Improper methods:(Time exposure, some channels non-perfused, over-diluted solution) • Failure to follow recommended disinfection procedures • Flaws in design of endoscopes & AER’s • Lack of proper training, competency , etc.

28. Disinfection of Endoscope • User: Rinse inside & outside immediately after use • Mechanically clean with water & enzyme • Must HLD/sterilize-immerse scopes, fill channels • Rinse (final) sterile, filtered or tap followed by alcohol • Dry with forced air • Store: hang to prevent pooling. (off floor) • NEVER store in original case!!

29. Findings that “prick’ up your “EPI-EARS • Unusual gram-negatives in Bronch washes (>2 same one) or duplicate other sites (Urines, surgical wounds, etc) • >1 atypical mycobacteria (same species) from same sites

30. Initial Steps to Investigate #1: Notify lab to SAVE THE ISOLATES! (give a time frame…several weeks, lab to discuss w/IC before discarding)

31. Check your usual incidence of_________ • Check to see how many of X____ the facility has had in the past 1-2 years: Frequency Sites Source of culture (aspirated, surgical excision, etc)

32. #3 Investigation • Formulate an initial hypothesis: Key factor is whether the patients are clinically ill or pseudo-infection possible

33. Single vs Clusters SSI • Single SSI cases, different pathogens: frequently patient source, possible aseptic breach Clusters of single pathogen often common source: contaminated source or aseptic breach

34. Sterilization problems • Inadequate pre-cleaning • Improper sterilization parameters • Personnel not trained sufficiently to recognize seriousness of > parameter failure • Packaging inadequate • Inadequate sterilizer maintenance • Regulations do not assess the efficacy of a cleaning prcess • No easy or objective method to measure cleanliness of a internal parts of a device

35. Sterilization problems • Failure to meet parameters • Biological failure; next test ok • Biological failure; episodic, intermittent • Bowie Dick test uneven, not clear failure

36. Assessing sterilizing practice ~“Show me…..” (HIGHLY EFFECTIVE METHOD) ~ Review graphs, charts & monitoring records ~ Check pre-sterilizing cleaning processes ~ Examine additives to washer/disinfectors • Instrument “milk” preparation, use, shelf life, etc ~

37. Sterilizer practice assessment cont’d ~ Assess sterilizer loading, drying, emptying ~ Assess proximity soiled instruments to clean ~ Check inst. cleaning tools (brushes, hoses, etc) ~ Clean & Dirty areas separated by walls/closed doors ~ Procedures readily available (tray/container loading, power instrument handling, etc) ~ Check packaging: appropriate for type sterilizer?

38. Maintenance issue Sterilizer cleaning: • Check procedure, frequency • Responsibility? • Agent used ? • Documentation? Preventive Maintenance Log • Look for repeated problems • Check the repairs listed • Repair person credentials

39. “Peel Pack Pitfalls” Peel Pack standards: • Remove air; Seal must be intact • No marker ink on paper side (plastic ok) • Check loading of peel packs..no plastic to plastic • Double peel packs: --Not required; but easier to open, present sterile --Never fold inner peel pack or edges

40. Other Packaging issues • Package too small for contents • Crowded instruments in a container • Failure to put indicator inside • Use of non-standard packaging (washcloth, paper bag, plastic baggies) • Use of non-standard seals (rubber bands, scotch tape, bandage tape, safety pins)

41. Preventing Infection in the OR Know what is clean – Know what is sterile – Know what is contaminated…… AND NEVER THE TWAIN SHALL MEET! (keep them all separated!*) *Crow, S. Aseptic Practice