Vascular Cuffs: Friend or Fomite
Part One Cleaning
“Cleanliness is not next to godliness. No one has ever gotten a religious experience out of removing
burned-on cheese from the grill of the toaster oven.”
― Erma Bombeck
An easy way to keep cuffs clean:
If the patient has open wounds, blisters, ulcers or sores, while gloved, place sterile 4X4’s
(gauze) over the actual wound(s) and then gently wrap the leg or ankle with kitchen grade
plastic wrap (example Saran® Wrap). Put the plastic wrap all the way around the limb so that
it adheres to itself. Then put the appropriate sized cuff over the limb to take the pressure or
reading. Be careful when removing the wrap and gauze not to contaminate anything. The
4X4’s and plastic wrap will not affect the testing.
Grody toes should have disposable cuffs applied and then disposed of post testing. Paper
disposable cuff covers can be easily contaminated by the exudate from open wounds or sores
and wick the organic material to the surface of the fabric cuff covers exposing them to
microorganisms; use the plastic wrap technique instead.
Glossary of Terms
Bioburden: Bioburden is normally defined as the number of bacteria living on a surface that has not
been sterilized.
VRE: vancomycin-resistant enterococci
MRSA: Methicillin-resistant Staphylococcus Aureus
C.diff: Clostridium difficile (organism related to tetanus)
Clean: “Cleaning is the removal of visible soil (e.g., organic and inorganic material) from objects and
surfaces and normally is accomplished manually or mechanically using water with detergents or
enzymatic products.” From Guideline for Disinfection and Sterilization in Healthcare Facilities 2008
CDC
Disinfected: “Disinfection describes a process that eliminates many or all pathogenic microorganisms,
except bacterial spores, on inanimate objects usually performed using wet pasteurization or
chemicals.” From Guideline for Disinfection and Sterilization in Healthcare Facilities 2008 CDC
Sterilized: “Sterilization describes a process that destroys or eliminates all forms of microbial life and
is carried out in health-care facilities by physical or chemical methods.” From Guideline for Disinfection
and Sterilization in Healthcare Facilities 2008 CDC
Fomite: A fomite is an inanimate object that can transmit an infectious agent from one person to
another. Example blood pressure cuff, stethoscope, gel.
Biofilm: “A biofilm is any group of microorganisms in which cells stick to each other on a surface.
These adherent cells are frequently embedded within a self-produced matrix of extracellular polymeric
substance (EPS). Biofilm EPS, which is also referred to as slime (although not everything described as
slime is a biofilm), is a polymeric conglomeration generally composed of extracellular DNA, proteins,
and polysaccharides. Biofilms may form on living or non-living surfaces and can be prevalent in
natural, industrial and hospital settings. The microbial cells growing in a biofilm are physiologically
distinct from planktonic cells of the same organism, which, by contrast, are single-cells that may float
or swim in a liquid medium.
Microbes form a biofilm in response to many factors, which may include cellular recognition of specific
or non-specific attachment sites on a surface, nutritional cues, or in some cases, by exposure of
planktonic cells to sub-inhibitory concentrations of antibiotics. When a cell switches to the biofilm
mode of growth, it undergoes a phenotypic shift in behavior in which large suites of genes are
differentially regulated”. Source Wikipedia
Why bother to clean when CDC said cuffs are low risk in the 2008 guidelines and subsequent
addendums?
Hospital Acquired Infections (HAI) or infections acquired in other medical facilities are a serious
problem in our healthcare system. The 2008 (and the 2011 Update) of the CDC Guideline for
Disinfection and Sterilization in Healthcare Facilities is outdated. It presumes that vascular or blood
pressure cuffs are noncritical items and are only placed on intact skin, and it doesn’t address the
cleaning, disinfection and sterilization of them when they are contaminated with VRE, MRSA, C.diff or
other organisms. It also doesn’t address cuffs used in vascular labs or the tourniquets in the OR. Since
these documents have been published there have been several excellent studies proving that these
Vascular Cuffs: Friend or Fomite
Part One Cleaning
cuffs including regular patient vital signs blood pressure cuffs become contaminated and need to be
cleaned and disinfected. Imagine if you would having to sleep in a bed where someone else just slept
and the sheets were not cleaned or would you remove a bandage from a patient’s leg and put it on
another patient’s leg? Of course you wouldn’t, but if the vascular cuff you are putting on a patient
went from being on a previous patient’s leg to this patient’s leg without cleaning or disinfection there
is a real risk that the cuff is a fomite. Necrotizing fasciitis can occur when the streptococcus finds entry
into a small cut or abrasion; the cut or abrasion could be small and seem inconsequential. Group A βhemolytic streptococcus can be present on a “clean” vascular cuff. What you can’t see can kill you.
Maintaining a supply of cuffs ready for patient use requires cleaning, disinfection and in some cases
sterilization of those cuffs. This article will deal with cleaning which is ultimately the most important of
the three processes, and the other two are dependent on adequate cleaning in order for disinfection or
sterilization to occur.
Vascular cuffs can become a mechanism for transmitting infectious disease between patients. Despite
the hassle in our already overburdened and rushed working place – it is imperative that we keep them
free of contamination. The most important thing you can do to prevent cross infection is to clean the
cuffs before disinfecting them between uses.
Cleaning reduces the bioburden in order for the disinfectant to make adequate contact with the cuff
material and in fact disinfect the cuff in the time period provided by the manufacturer of the chemical.
Testing has shown that cleaning a contaminated surface reduces the amount of microorganisms
remaining on the object and enables the disinfectant to completely disinfect the object in the projected
time. If there is a high bioburden then the time to disinfect raises almost exponentially so what takes
minutes normally can now take hours. Spaulding tested conditions and was able to demonstrate that it
took 30 minutes to kill 10 Bacillus atrophaeus spores and 3 hours to kill 100,000 Bacillus atrophaeus
spores. Large groups of microorganisms tend to clump together and this creates places where the
disinfectant does not contact the organism so disinfection cannot occur.
Cleaning removes any inorganic or organic material including biofilms that interfere with the
disinfection process. Air pockets or wrinkles that keep the cuff surface from being wetted by the
disinfectant do not get disinfected. Biofilms are nature’s way of protecting the layer of organisms on
the bottom by sacrificing the top layer. Applying disinfectant to the top of a biofilm may kill the
organisms on the surface but not affect the bottom layer in contact with the cuff material. Biofilms are
more apt to occur where there is a hot humid climate.
What is clean?
Cuffs that do not have obvious soiling whether inorganic or organic can appear clean but unfortunately
be contaminated with a large amount of microorganisms. Because microorganisms are too small to be
seen and they can be found on unbroken skin and vascular cuffs can become contaminated without
our knowledge. Because cuffs can be very contaminated with organisms like VRE, MRSA and C. difficile
without any visible evidence and it is more difficult to see contamination on a dry cuff, if in doubt
clean the cuff.
When to clean and where?
Recommended: cuff covers should be washed daily. Minimum: at least once a week you should wash
the covers on your vascular cuffs either in a washing machine or in a sink. Knowing that most
facilities do not have the time or cuffs than this is the bare minimum: if there is no obvious soiling you
can wipe down or spray the cuff with a disinfectant and let it stay visibly wet for 10 minutes to clean
the cuff. Because the cuff has not been cleaned prior to the application of the disinfectant there is a
chance that all of the organisms have not been either removed or killed. Then you can dry off the cuff
with a clean towel before use.
Cleaning vascular cuffs: the process
Vascular Cuffs: Friend or Fomite
Part One Cleaning
If possible all straight segmental cuffs should be washed daily or at minimum once a week. This can
be accomplished using a washing machine with warm water (cold water will work also), soap or a mild
detergent and gentle cycle. If there is no washing machine, the cuffs can be washed in a sink and
hung to dry.
Two components to cleaning: Friction and Fluids
Pre-washing: keep soiled cuffs in a bucket or container with soapy water to keep the “soil” from drying
on the cuff. Once the contamination has dried on the cuff it is more difficult to see the extent of the
material and also more difficult to remove.
1. Mechanical: scrubbing or rubbing
By scrubbing the fabric, the debris is roughed and dislodged from the fabric so that it can be flushed
away. Just as using a brush to scrub their fingers and hands removes any contaminant on a surgeon’s
hands during a surgical scrub. Using a soft tooth brush (or hand brush) is a useful tool to remove any
organic or inorganic material without damaging the cuff fabric. When fabric is damaged there are
more pockets of air in the torn fabric for microorganisms to “hide” in. The scrubbing of the fabric
removes the bulk of the organisms on the cuff. The fewer organisms or lower bioburden the easier the
disinfection is and the less likely that some areas will escape disinfection. The soap acts as a lubricant
and to promote separation of the contaminants from the fabric. Soap also acts as an emulsifying agent
that disperses one liquid into another immiscible liquid so that oils which attract dirt can be suspended
in water and flushed or rinsed away. Additionally there are polar molecules that interact with the oil
and grease and “dirt” and incorporate them inside these molecules so they can be flushed away.
Water temperature is not as important as the rubbing and scrubbing and having lots of liquid to rinse
the “soil” away. In fact high temperatures can denature the proteins and cause them to adhere more
closely to the cuff; you are cooking them onto the cuff.
If there is a lot of protein contamination such as blood, an enzyme detergent will help remove the
organic material. Enzol® is an example.
Only surfaces that are clean and in contact with the disinfectant long enough can be disinfected.
Spores (coat and cortex), mycobacterium (waxy cell wall) and gram-negative bacterium (outer
membrane) make it more difficult for disinfectant but they can be removed by washing.
Fluids:
Flushing or rinsing the cuffs will wash away the debris including any microorganisms that were release
from the fabric by the scrubbing/brushing and soap. There is better cleaning if the cuffs are exposed
to water under pressure, like in a washing machine or holding them under a faucet.
Air dry the cuffs by hanging them on a clothes line or some way that holds them open a bit (where the
bladder goes in) so that both the outer cuff and inner cuff dry completely. Do not disinfect until they
are completely dry.
Cleaning vascular cuffs with a washing machine
•
If cuffs are grossly contaminated with blood or body secretions including pus and
serosanguinous fluids keep the cuffs wet or moist to prevent the material from drying which
will make removal more difficult.
•
Remove the bladders from the cuffs. To protect yourself you can put on surgical gloves (nonsterile).
•
If the bladder was contaminated, it can be washed off with soapy water and then rinsed. DO
NOT GET WATER INSIDE THE BLADDER OR TUBING.
•
Add a laundry soap or mild detergent to either warm or cold water and put the cuff covers in.
Do not skimp on the amount of water. Higher temperatures may lead to coagulation of
proteinacious material forming a protective layer for microorganisms.
Vascular Cuffs: Friend or Fomite
Part One Cleaning
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•
•
•
Use a gentle cycle.
Remove cuffs from the washing machine and open the end of the cuff where the bladder goes
and hang the cuff up to dry.
Make sure both the outside and inside are dry including the Velcro before reinserting the
bladders.
You can disinfect the cuff covers before or after inserting the bladders. Disinfection will be
covered next month.
Cleaning vascular cuffs in a sink by hand
•
If cuffs are grossly contaminated with blood or body secretions including pus and
serosanguinous fluids keep the cuffs wet or moist to prevent the material from drying which
will make removal more difficult. If there is a lot of protein in the “dirt” you might choose to
use an enzyme detergent which will remove proteins better than soap.
•
Remove the bladders from the cuffs. To protect yourself you can put on surgical gloves (nonsterile).
•
If the bladder was contaminated, it can be washed off with soapy water and then rinsed. DO
NOT GET WATER INSIDE THE BLADDER OR TUBING.
•
Add soap or a mild detergent to a sink filled with warm water (easier on your hands than cold
water.) Higher temperatures may lead to coagulation of proteinacious material forming a
protective layer for microorganisms.
•
Using a soft tooth brush or hand brush scrub the cuffs especially where there is a biofilm or
obvious contamination to remove the matter. All Velcro should be well scrubbed to loosen and
remove any material and microorganisms as possible.
•
Rub the cuff material together and agitate the water to remove as much material as possible.
•
You can soak the cuffs for a few minutes to loosen the soiled material.
•
When there is no visible contaminates, remove from the soapy water and rinse thoroughly
with copious amounts of water, preferably under a faucet.
•
Roll the cuffs up to drain off as much water as possible (do not twist) and open the end of the
cuff where the bladder goes and hang the cuff up to dry.
•
Make sure both the outside and inside are dry including the Velcro before reinserting the
bladders.
•
You can disinfect the cuff covers before or after inserting the bladders. Disinfection will be
covered next month.
Better to err in favor of cleaning then to assume because the cuff looks dry and has no obvious soiling
that it is safe.
Just in case you think the vascular lab has an issue with cuffs, please read this article about OR
perioperative tourniquet cuffs. Just might scare you into becoming a clean freak.
http://www.healio.com/orthopedics/journals/ortho/%7B4bf73a64-75ad-4e06-abe0cd98c4b8779a%7D/microbial-colonization-of-tourniquets-used-in-orthopedic-surgery