Sterilization and Disinfection – Common issues often overlooked in eye hospitals

Asim Kumar Sil, DO, DNB (Ophthalmology), M Sc (London)Medical Director

Vivekananda Mission Ashram Netra Niramay Niketan

Chaitanyapur (Haldia), West Bengalwww.vmaindia.net

Quantity rests on Quality

• India is one of the best performing countries in Eye Care in the World.

• “Quality” issue is gradually gaining importance in eye care and now the current challenge is matching volume with quality.

• “Safety” is the foundation of quality. In an eye hospital safety largely depends on Sterilization and Disinfection.

Definition: Sterilization

• Sterilization describes a process that destroys or eliminates all forms of living micro organisms including spores and is carried out by physical or chemical methods. Autoclaving (steam under pressure), dry heat, EtO gas, and liquid chemicals are the principal sterilizing agents used in hospitals.

Disinfection

• Disinfection is the process of reducing the number of microorganisms from the surface where sterilization is not possible.

• A few disinfectants will kill spores with prolonged exposure times (3–12 hours); these are called chemical sterilants. At similar concentrations but with shorter exposure periods (e.g., 20 minutes for 2% glutaraldehyde), these same disinfectants will kill all microorganisms except large numbers of bacterial spores.

Cleaning

• Single most factor that affect the efficacy of both disinfection and sterilization is prior cleaning of the object.

• 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.

• Thorough cleaning is essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.

Theatre lay out and interior

• Three barriers are recommended between external air and the Operating Room.

• Preferably there should be higher pressure inside the OR to prevent entry of external air.

• To be careful enough about closing the doors to prevent contamination of inside air.

• There should not be any window in the theatre.• Any surface that may gather dust should be

avoided. Ceiling fans are not recommended.

Floor and wall construction

• Nonporous material with minimal joint is recommended for Walls and floors

• Surface should be smooth for better disinfection.

• Corners should be rounded• Thorough wiping of walls and floor with

disinfectants is currently preferred to regular fumigation.

Wall & Floor

Furniture

• Only essential equipments and furniture should be kept in the OT.

• It should not look like a store room.

• No wooden furniture should be allowed to prevent growth of organisms.

Sterile unsterile separation

• There should be a system of separation of sterile and unsterile materials.

• The lay out should have separate sterile and unsterile corridors.

Air care• Preferred practice is having

an Air Handling Unit (AHU) with air blown through HEPA filter. The cost of installation is of course high.

• At least a split AC should be there,

• Window AC is not desired. • Regular cleaning of filters

should be done. • OT should never be

overcrowded by too many people to maintain cleanliness of air.

• Humidity should also be controlled using dehumidifier.

AHU Exterior

Autoclaving

• We trust most on autoclaving for sterilization. • Packing should never be tight. • The indicator tapes should be pasted properly. • Windows of the drums should be open while

autoclaving and immediately shut after the process. • Time, pressure should be strictly maintained.

Sterilization Log Book needs to be regularly maintained.

• Care is needed about storing of autoclaved items.

Windows – open during autoclaving

Windows immediately closed after autoclaving

Sterilization Protocol (Time Management) Autoclave

Date Load Number

Starting Time

20 Pounds Pressure

Reaching Time

121 Degrees Temperatures Reaching Time

Sterilization Time

Unloading Time

Autoclave Operator Signature

Theatre Incharge

Sing.

                 

Log book

Chemical sterilization

• Adequate cleaning and allowing adequate contact period is mandatory for chemical sterilization.

• Ethyline oxide and Gluteraldehyde are most dependable.

• Care should be taken about thoroughly washing gluteraldehyde from the instruments before use.

• One should not depend much on formalin sterilization of non autoclavable instruments. ETO is a better choice here.

Cleaning and inspection of instruments

• Clean immediately after use. • Sterilization is never effective

when an instrument is covered by blood or lens matter.

• The instruments should be cleaned using ultrasonic cleaners and inspected under illuminated magnifier before drying and packing.

• Use of compressors is a good practice to blow the tubes and canulae.

Personal discipline• The effectiveness of Hand Washing has been proved beyond

doubt. • Any person entering the theatre should wash hands with

soap and running water before touching anything.• A good practice is washing and drying feet as well before

entering the clean area since most of the people use chappals. Alternately, disposable shoe cover should be used.

• Change of street cloth, adequately covering hairs and mouth are mandatory. Nose should not remain exposed.

• One should not enter theater with infectious disease. • Every care should be taken about movement inside the

theatre to prevent contamination. • Theatre size should be adequate to allow free movement of

personnel.

Goddess Lakshmi’s foot print?

Good & Bad

Head nicely covered Nose open - bad practice

Scrubbing • Before scrubbing all the

ornaments, threads should be removed from wrist and fingers. Nail polish is better avoided.

• Liquid soap is always preferred to soap cakes for scrubbing.

• Prescribed contact time for medicated scrubs (Betadine, Chlorhexidine) should be allowed.

• RO water is the preferred choice for scrubbing.

Read the instructions

High volume surgeries

• The theatre team should be most vigilant while performing many surgeries in one session.

• Using the same instrument with inadequate sterilization in next case is out of question.

• The high speed sterilization in between surgeries should be carried out efficiently.

• Optimum sterile items should be laid on table and covered properly. No sterile item should be left open for a long time.

• In long sessions microscope caps should be changed time to time.

Covering the consumables

Attitude matters

• Effective Sterilization and disinfection practices depend on discipline and commitment of staff.

• Leadership of the hospital should create a culture of quality consciousness and put a process of measuring the quality outcome.

• Infection Control Committee should meet regularly • Most important is sharing the data with staff and

include them actively in the process of quality assurance.

Thank you