Mission Accomplished:
Sterilization &
Disinfection
Robin Haag
Sherry Chisholm 2011 Awardee
Baltimore, Maryland
What I Attended ?
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Anything and Everything related to
sterilization and disinfection
 No
matter how repetitive
 No matter how boring
Why this topic?
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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
Bill Rutala says……
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Current surface
disinfection practices
are not effective
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65% of high touch areas
are not cleaned
Inadequate terminal
cleaning puts the next
patients at risk for
acquiring MDROs
Improved methods are
needed
Risk of Acquiring MRSA, VRE and
C Dif from Prior Occupants

Admission to previously occupied MRSA or VRE room
significantly increases odds of acquisition
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Prior environmental contamination measured by
environmental culture or VRE colonized patients
increases risk
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Huang et al Arch Intern Med 2006; 166;1945.
Drees et al Clin Infect Dis 2008; 46:678.
Prior room occupant with CDAD significantly increase
risk
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Shaughnessy et al. ICHE 2011; 32:201
Novel Methods of Room
Decontamination
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No touch methods
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Ultraviolet lights
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Work best in direct line of sight
~15 minutes for MDROs
~50 minutes for c dif spores
Hydrogen Peroxide Systems
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Supplement, do not replace standard cleaning/disinfection
May take hours
Rooms need sealing
Proposed self disinfecting surfaces
 Silver or silver ion impregnated
 Copper
 Sharklet pattern
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Deflects organisms from adhering
New Approaches to Room
Decontamination
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
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
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Hydrogen Peroxide
Decontamination Advantages
Reliable biocidal
 Surface and equipment decontamination
 Decreases C difficile
 Residual free
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 Minimal

health or safety concerns
Can use on complex equipment
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

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
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Frequently touched by HCWs
 Direct
transmission from contaminated hands
 Relative resistance to antiseptics and disinfectants
Controlling the Spread of C dif
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Practice
 Contact
precautions
 Ensure thorough disinfection
 Products
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5000 – 6000 ppm chlorine
Products with c dif claims
 When
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Areas with increased C dif rates
All patient rooms?
Surface Disinfection
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Exposure time
 Close
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attention by TJC and CMS
Following manufacturers’ directions
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Dilution
Contact time: may require repeat applications
Appeals denied by for following findings of peer reviewed
studies supporting shorter exposure times
 Wipes
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Wet time
Size of wipe
2011 Multi-Society for
Reprocessing Flexible Endoscopes
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Changes since 2003
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HLD efficacy is unchanged
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High level disinfectants
Automated reprocessors
Endoscopes
Endoscopic accessories
Principles remain valid
Outbreaks associated with:
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ASCs
Unfamiliarity with endoscope channels, accessories and
attachments
Endoscope Procedure
Transmission: Non scope related
IV lines
 Anesthesia administration
 Medication administration
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 Multidose
vials
 Reuse of needles and syringes
 IV tubing
Endoscope Procedure
Transmission: Scope related
Failure to sterilize forceps between
patients
 Lapses in reprocessing channels used in
irrigation
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Unresolved Endoscope Issues
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Interval of storage between reprocessing
and scope use
suggests negligible contamination 7 –
14 days
 Insufficient data to determine maximal
duration
 Data
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Need for microbiologic surveillance
Disinfection Boot Camp:
Rose Seavey and Martha Young
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Evidence based
Guidelines
Focus on AAMI/ANSI
Standards 2010
NPSGs
AORN 2011
CDC 2008
Environmental Concerns
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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
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60 – 100° F
Test weekly for 3 minutes
Use AAMI Work flow diagrams
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Dirty to clean
Decontamination Personnel Attire
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Scrubs
Cover all facial hair
No artificial nails
 Prefer
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no nail polish
No jewelry
Bouffant caps only
Heavy long gloves, not surgical
Face masks with full protection splash guards
Decontamination
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Decrease bioburden
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Water
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Prepare devices
Disassemble
Lubricate
Keep instruments moist
Brush and clean under water
Use disposable brushes or decontaminate once per shift
Prefer automatic washers
Initial rinse can be tap water
Final rinse should be sterile, de-ionized, distilled
Sterilization
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Do not use preset parameters for cycles
Maintain sterility in storage
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Event related sterility
Potential Problems With Automated
Cleaners
Wrong water temperature
 Wrong detergent concentration
 Problem with mechanical functioning
 Human element
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 How
machine is loaded
How Do You Know Your
Automatic Washer is Working
Right?
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Verification of Cleaning
 TOSI
(Test Object Surgical Instruments)
Monitoring of the Cleaning Efficiency of WasherDisinfectors
 Surrogate device for surgical instruments soiled
with blood
 Test weekly, preferably daily
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 Maintain
records
Sterilization Caveats
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Count sheets should not be
inside sets or containers
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Load configuration
 Item density
 Your hand should fit between
items
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Ink transfers
 Paper shreds
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Peel packs
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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
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Cooling in a high AC
environment
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Immediate use sterilization
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Old “flash sterilization”
Loaners
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May lead to wet packs
Have in 3 days ahead of time
Keep repair logs
Storage
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75°F
4 air exchanges per hour
Under 70% humidity
Don’t stack
Keep items covered
8 – 10 inches above floor
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2 inches from outside wall
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Solid bottom shelf
Prevents condensation
No corrugated boxes
No shipping boxes
Tracer Activity
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Trace a set from patient
in OR through
reprocessing
Look for competencies
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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
Implants
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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
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In an emergency a Class 5 indicator can be
used
Sterilizer Qualification Testing
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Testing a sterilizer after certain events
3
consecutive cycles
 Events may adversely impact process
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Installation of new sterilizer
Relocation of sterilizer
Sterilizer malfunction
Process failures
Major repairs
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Gasket replacement
Welding
After annual boiler maintenance
After a water main break
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
Don’t Get Caught With Your Pants
Down

Class 6 process
challenge packs
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Not a substitute for Class 5
integrating BIs
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No matter what the sales
rep told the reprocessing
administrator
Sharing memos and
recall notices
Credentialing
Inservice records