Transcript The W-M-D of Disinfection/Sterilization Killiing Germs may
What Can Go Wrong in Cleaning, Disinfection & Sterilization?
TSICP October 2006
Barbara Moody, RN, CIC Director Infection Control Denton Regional Medical Center
and how would you know?
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.
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 )
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)
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
…WMD
The
W
eapons of
M
icrobe
D
estruction…
Weapons: Manual cleaning; automated processors, disinfectants, Sterilants Microbes: fungi, bacteria, viruses, spores, prions Destruction methods: Chemicals, Steam Gas (EO), H202 Plasma, Irradiation
Environmental Cleaning
Yes Virginia, the Environment does matter in the prevention of infection !
MRSA outbreak continued & increased x 21 mos. until doubled cleaning hours, assigned cleaning of equipment & environment = end of outbreak MRSA ICU outbreak after disinfectant changed: U Wisc.
ID residents, Epidemiologist demonstrated room cleaning to Housekeeping. Hskpg. Returned demonstra tion = Outbreak ended. ( techniques not disinfectant )
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!
Disinfectant contamination
Intrinsic contamination possible Phenolic solutions Benzalkonium chloride Other “Quats” Extrinsic contamination frequent Most detergent/disinfectants Quats – especially Alcohol – bacillus spores
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
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
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
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
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
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)
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?
Device-associated infections
Automated reprocessors
Bronchoscopes
Depth electrodes
Electrosurgical units
Endoscopes
Laryngoscope blades
Transducers
Rectal/vaginal probes
Device assoc.infections cont’d
Electronic thermometers
EKG leads
Tonometers
Cardioplegic solution/ice machine
Surgical instruments
Powered instruments
BP Cuffs
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.
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 !
Endoscopes: issues cont’d
Mechanical failure
Faulty design
Poor manufacturing quality
Adverse effects of materials
Improper maintenance
User error
Compromised sterility
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
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
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
Rinsing after HLD
Endoscopes:
Rinse immediately after patient use
After HLD soak, water flush, alcohol flush
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.
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!!
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
Initial Steps to Investigate
#1: Notify lab to SAVE THE ISOLATES!
(give a time frame…several weeks, lab to discuss w/IC before discarding)
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)
#3 Investigation
Formulate an initial hypothesis: Key factor is whether the patients are clinically ill or pseudo-infection possible
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
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
Sterilization problems
Failure to meet parameters
Biological failure; next test ok
Biological failure; episodic, intermittent
Bowie Dick test uneven, not clear failure
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 ~
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?
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
“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
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)
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