Upload
cricket
View
52
Download
0
Embed Size (px)
DESCRIPTION
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. - PowerPoint PPT Presentation
Citation preview
What Can Go Wrong in What Can Go Wrong in Cleaning, Disinfection & Cleaning, Disinfection &
Sterilization?Sterilization?
TSICP October 2006
Barbara Moody, RN, CICDirector Infection Control
Denton Regional Medical Center
and how would you know?and how would you know?
ObjectivesObjectives 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.
BackgroundBackground
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 Basic principles Hosp. Environment visibly clean, free from
dust, soilEquipment used for >1 pt must be cleaned,
disinfected or sterilized between patientsEstablished 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 Baseline Info *Things you *Things you
knowknow 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 WMD W Weaponseapons ofof MMicrobe icrobe DDestruction…estruction…
The Weapons: Manual cleaning; automated
processors, disinfectants, Sterilants Microbes: fungi, bacteria, viruses, spores,
prions Destruction methods: Chemicals, Steam
Gas (EO), H202 Plasma, Irradiation
Environmental Cleaning 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 Legal aspects:Headlines re failure of disinfection, sterilization, etcdisinfection, 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 contaminationDisinfectant contamination
Intrinsic contamination possible Phenolic solutions Benzalkonium chloride Other “Quats”
Extrinsic contamination frequent Most detergent/disinfectants Quats – especially Alcohol – bacillus spores
Environment – Non-criticalEnvironment – 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 agentsEnvironmental Cleaning agents(low level)(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 ?When to check cleaning ? ( (Cluster of HAI patient infectionsCluster 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 Examples ofof Improper / inadequate cleaning Improper / inadequate cleaningUnder-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 instrumentsProblems Pre- Cleaning instruments
Wrong productMisunderstanding label or type product
“wrong assumptions”Failure to rinse organic matter promptlyIncorrect dilution (Over -, under -)Inadequate soak timeFailure of disinfectant to reach all crevices
Storage Contamination 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)
WhatWhat to look for: 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 infectionsDevice-associated infections
Automated reprocessorsBronchoscopesDepth electrodesElectrosurgical unitsEndoscopesLaryngoscope bladesTransducersRectal/vaginal probes
Device assoc.infections cont’dDevice assoc.infections cont’d
Electronic thermometersEKG leadsTonometersCardioplegic solution/ice machineSurgical instrumentsPowered instrumentsBP Cuffs
Powered instrument IssuesPowered 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 issuesEndoscopes: The IC issues
Narrow lumenComplex inside parts*Easily damagedManual pre-cleaning essentialFrequent repairs necessarySurface integrity essentialSpecial connectors to AER a MUST !
Endoscopes: issues cont’dEndoscopes: issues cont’d
Mechanical failureFaulty designPoor manufacturing qualityAdverse effects of materialsImproper maintenance User error Compromised sterility
Endoscopes & BronchoscopesEndoscopes & 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 ……………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 ProcessingAssessing 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 HLDRinsing after HLD
Endoscopes: Rinse immediately after patient use After HLD soak, water flush, alcohol flush
Endoscope contaminationEndoscope contamination
Inadequate channel cleaningLack of proper connectors for
channelsImproper 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 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 Findings that “prick’ up your “EPI-EARS“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 InvestigateInitial 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 Check your usual incidence of_________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#3 Investigation
Formulate an initial hypothesis:
Key factor is whether the
patients are clinically ill
or
pseudo-infection possible
Single vs Clusters SSISingle vs Clusters SSISingle SSI cases, different pathogens: frequently patient source, possible aseptic breach
Clusters of single pathogen often common
source: contaminated source or aseptic breach
Sterilization problemsSterilization 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 problemsSterilization problems
Failure to meet parametersBiological failure; next test okBiological failure; episodic,
intermittentBowie Dick test uneven, not clear
failure
Assessing sterilizing practiceAssessing 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’dSterilizer 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 issueMaintenance 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 Pitfalls”
Peel Pack standards:Remove air; Seal must be intactNo 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 issuesOther Packaging issues
Package too small for contentsCrowded instruments in a containerFailure to put indicator insideUse 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 Preventing Infection in the OROR
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