IAHCSMM CCSVP Vendor Education Program

Module Two

Decontamination

Introduction

• The primary purpose of the Central Service (CS) Department is Infection Prevention. CS departments protect patients by providing infection prevention services such as cleaning, disinfection, sterilization and sterile storage.

• This module is designed to provide you with an overview of the cornerstone of Infection Control; Decontamination.

Objectives: • Upon completion of this module, you will be

able to: – Discuss the role of CS in managing bacterial transmission

– Discuss basic infection prevention strategies used by CS

– Discuss Manual Cleaning Protocols

– Discuss Mechanical Cleaning Protocols

– Identify basic Decontamination Chemicals

– List factors that impact decontamination outcomes

Instructions • Read Chapters 6, 7, 8 and 9, in

the IAHCSMM Central Service Technical Manual, Eighth Edition, 2016.

• Review this module.

• Complete the online quiz for Module Two.

Infection Prevention and Control Goals of CS

• Eliminate and/or destroy all potentially infectious contaminants present on reusable instruments and equipment.

• Establish and enforce standards for decontamination, disinfection and sterilization in various healthcare settings.

Medical Devices that have not been properly cleaned, disinfected or sterilized…

…are dangerous to patients and staff.

Decontamination

• How an item was, or will be used determines the level of decontamination required.

The primary purpose of the Central Service department is to stop the spread of disease-producing microorganisms in the healthcare facility.

Healthcare-Acquired Infections: Cause for Concern!

In 2011, the CDC reported that approximately 1 out of every 25 patients hospitalized contracted a Healthcare-associated infection (HAI).

Surgical Site Infections (SSI) account for a portion of those infections.

Principles of Asepsis

• Asepsis – The absence of microorganisms that cause disease.

• Aseptic Technique – Any activity or procedure that prevents infection or breaks the chain of infection.

Medical Asepsis

• Procedures performed to reduce the number of microorganisms or minimize their spread.

Surgical Asepsis

• Procedures performed to eliminate the presence of all microorganisms and/or to prevent the introduction of microorganisms into an area.

Principles of Asepsis

1. Know what is Dirty.

2. Know what is Clean.

3. Know what is Sterile.

4. Keep the 3 conditions separate.

5. Remedy contamination immediately.

“Sterile Conscience”

• A careless attitude may lead to increased risk of infection.

Hand Hygiene • Remove Watches and

other Jewelry before entering the work area.

• Wash hands with soap and water or use an alcohol-based hand rub.

Appropriate Attire for CS

• A facility-issued scrub uniform.

• Hair covering that covers all head and facial hair except eyebrows and eyelashes.

• Shoes with non-skid soles.

Personal Protective Equipment (PPE)

• Required by OSHA for technicians in the decontamination area: – General purpose utility

gloves

– A fluid-resistant covering with sleeves

– Full face protection

– Shoe covers

Fluid-Resistant Gowns (Coverings)

• Regular scrub attire splashed with liquid.

• Fluid-resistant attire splashed with liquid.

Standard Precautions

• Place emphasis on the use of blood and body fluid precautions for all patients.

Environmental Concerns

Controlling bacteria by controlling the environment.

The Physical Design of the CS Department

• Physical Barriers (walls) between clean and dirty areas.

• A method to reduce the likelihood that airborne bacteria can be transmitted from the decontamination area to the clean areas.

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The Use of Air Pressure to

Control Airborne Bacteria

Clean Area

Positive Air Pressure

Decontamination Area

Negative Air Pressure

Airflow

Controlling Airflow

• Windows and doors between areas with positive and negative air pressures must be kept closed.

Traffic Control

• Traffic control requirements must be enforced for everyone.

• Dress codes for all areas apply to everyone.

Traffic Control Designations

• Biohazard – OSHA-required PPE

• Unrestricted – Normal traffic areas: cafeteria, waiting rooms, etc. Street

clothes may be worn.

• Semi-Restricted – Clean assembly and storage areas, access corridors to operating rooms, etc. Surgical scrub attire and hair covering required.

• Restricted – Areas where sterile procedures are performed. Surgical scrub attire, hair covering, and masks required. *Persons working within the sterile field will have additional requirements.

What to WearCS Dress Requirement Review

Decontamination

Area

Clean Assembly

and

Sterile Storage

Operating

Room

Non-restricted

Hallways and

Offices;

Cafeteria, etc.

Surgical Scrubs and OSHA-required PPE

Surgical Scrubs and Hair Covering

Surgical Scrubs, Hair Covering, Masks may be required

Regular Street Attire

Environmental Cleaning

• Floors should be wet-mopped at least daily.

• Work surfaces should be cleaned at least daily.

• Light fixtures should be cleaned at least every 6 months.

• Walls cabinets and racks should be cleaned on a regularly scheduled basis.

Control Microorganisms Entering the Work Areas

Clean Routinely

Other Requirements:

• Open Rack storage systems should have a solid bottom to prevent contamination during housekeeping tasks.

No Food or Drink should be allowed in CS work areas.

Infection Prevention...

…manages the growth and transmission of bacteria in the healthcare facility.

The Chain of Infection from a CS Perspective

Controlling the Spread of Microorganisms…

…is the responsibility of every CS technician.

Point-of-Use Preparation and Transport

Instrument Decontamination Begins at Point-of-Use

Reasons for Point-of-Use Preparation

• Point-of-use preparation

helps prolong instrument life.

• If soil is allowed to dry on instruments it is much more difficult to remove.

• Soil and excess moisture promote the formation of biofilm.

Biofilm • A collection of microorganisms that

attach to surfaces and each other to form a colony. The colony produces a protective gel that is very difficult to penetrate with detergents and disinfectants.

Point-of-Use Guidelines • Remove Gross Soil

• Follow manufacturer’s instructions for point-of-use cleaning

• Keep soiled instruments moist

• Separate sharps from other instruments

• Separate reusable linen

• Remove disposable items

• Open hinged instruments and disassemble multi-part instruments

• Keep items together

• Empty fluids from containers

• Notify CS if any items need repair

• Notify CS if there is a possibility of CJD contamination

Gross Soil

• Tissue, body fat, blood and other body substances.

Reusable Equipment, Instruments and Utensils

Must be safely transported from patient care and treatment areas to the

CS decontamination area.

Goals of Soiled Item Transport:

• Prepare contaminated items so they will not be damaged after use or before return to the CS decontamination area.

Goals of Soiled Item Transport:

• To transport soiled items without cross-contaminating the environment between point-of-use and the decontamination area.

Goals of Soiled Item Transport:

• To assure that all individuals who may come in contact with contaminated items remain safe during the transport process.

Sources of Contaminated Items:

• Surgery (largest volume)

• Labor and Delivery

• Emergency Services

• Cardiac Catheterization Lab

• Endoscopy

• Clinics

• …any patient care and treatment area.

Methods of Transport

• Covered Transport Carts

Methods of Transport

• Lifts, elevators, or dumbwaiters dedicated to soiled item transport.

Methods of Transport

• Hand delivery by employees of the user department.

User Departments • Should have dedicated

holding areas to hold items until they are picked up by CS staff.

• Those areas should be marked with Biohazard Signs.

Off-site Processing

• When items are transported between buildings and facilities, Department of Transportation (DOT) and State and Local requirements must be followed.

Education

• Everyone who has contact with contaminated items must understand the dangers associated with the transport of biohazard items.

Cleaning and Decontamination

Important Facts • Cleaning is the first step in device processing

after use.

• You can clean without sterilizing, but you can never sterilize without cleaning.

• Cleaning is the cornerstone of the sterilization process.

What is clean? Residual protein soils detected by

Fluorescence Based Protein Detection Testing An item may look clean,

but still harbor soil.

Terminology • Cleaning – The removal of

all visible and non-visible soil and any other foreign material from the medical device being processed.

• Decontamination – To make safe by removing or reducing contamination by infectious organisms or other harmful substances.

Design of the Decontamination Area

• Floors and walls should be constructed of materials that can tolerate harsh chemicals.

• Traffic should be restricted and PPE is required.

Personal Protective Equipment (PPE) • Hair covering.

• Eye protection, such as goggles or eyeglasses with solid side shields or a chin-length face shield.

• Fluid-resistant facemask

• A gown with reinforced sleeves, and a front that acts as a barrier to fluids.

• Strong general-purpose utility gloves that cover the sleeves of the reinforced gown, and that can resist cuts and tears.

• Decontamination shoe covers that are skid-resistant.

• Employer-provided cloth scrub attire that is changed at the end of each shift.

All soiled items should flow from dirty to clean

Remove Gross Soil as Soon as Possible to:

• Reduce the number of microorganisms on the item.

• Reduce the nutrient material that can support microbial growth.

• Reduce the potential for environmental contamination, aerosolization, or spillage.

• Minimize damage to devices from blood and other substances.

Temperature of Solutions should be monitored

Identify sink water levels to help ensure correct chemical dilutions

Using the correct brush size is critical

Ultrasonic Cleaners

• Used to remove fine soil from joints, crevices and other hard to clean areas of instruments.

• Uses cavitation where low pressure bubbles in a cleaning solution implode and dislodge soil from instruments.

Important Facts about Ultrasonics

• Instruments must be precleaned before placing them in an ultrasonic.

• Instruments should be placed in trays designed for use in an ultrasonic.

• All lumens must be completely filled with fluid.

• All instruments should be completely submerged.

• Hinged instruments must be opened.

Do Not: • Place needles in an ultrasonic unless they have been

approved for the process by the needle manufacturer

• Place instruments that have fiberoptic components in the ultrasonic

• Place chrome-plated or ebonized instruments in the ultrasonic

• Mix stainless steel instruments with instruments made of copper, brass or aluminum

Washer Disinfectors

• Can be multi-chamber or single chamber

• Use a spray force action called Impingement

• Rely on water temperature, detergent and spray force to clean items

• Will only clean if loaded properly

Important Facts about Washer Disinfectors

• Disassemble multi-part instruments

• Open hinged instruments

• Load single trays from multi-level containers to help ensure each tray is exposed to the wash action

• If available, use flushing manifolds for lumened instruments

Make certain washer spray can make contact with tray contents

Remove lids from trays Do not stack trays

Protect Instruments from Damage

Use small part holders to contain lightweight items

Debris should be removed from washer screens daily

Cart Washers

• Use a spray force action

• Must not be used for instruments unless they have a specific designated cycle for instruments (consult IFU)

Mechanical Cleaning Equipment should be tested to ensure it is working properly

Cleaning Chemicals and Lubricants

Chemicals are different Read the labels

When should instruments be cleaned?

Clean Instruments:

After Use

After they have been opened, placed on the sterile field but have not been used

When new instruments are received at the facility

When used instruments are returned from repair or refurbishing

When instruments are pulled from back up stock

When instruments are inadvertently contaminated

When loaner instruments are received

Back up instruments contain dust and other contaminants from storage

Manual Cleaning Tips

Clean All Items in Accordance with Manufacturers’ Instructions.

Disassemble Multi-part Instruments

Watch for lumens

Instruments with Lumens

• Place under water to prevent aerosols when brushing

• Brush lumens using an appropriate size brush

• Flush water and detergent through them using a syringe or cleaning nozzle

Tips and crevices are hard to clean

Kerrison Rongeur

Brush under the surface of the water to prevent aerosols

Toxic Anterior Segment Syndrome (TASS)

An acute post-operative inflammatory reaction in which a noninfectious substance enters the anterior segment and induces toxic damage to the intraocular lens.

TASS Precautions in the Decontamination Area

• Follow manufacturer’s IFU for all steps in cleaning and use the enzymes and detergents recommended by them.

• Take actions to prevent the formation of Biofilm.

• Keep cleaning tools clean.

• Flush lumens.

• Rinse thoroughly.

Cleaning PSI Cannulas

Powered Surgical Instrument (PSI) Precautions

Moisture can damage a PSI Prevent moisture from entering

connection areas

Be aware of hidden areas that must be cleaned

Effective Cleaning Agents

• Are non-abrasive • Are low-foaming • Are free-rinsing • Allow for rapid soil dispersion • Are non-toxic • Are effective on all types of soil • Have a long shelf life • Are cost-effective • Can be monitored for effective concentration and

useful life

Detergents

• Substances that dislodge, remove, and disperse solid and liquid soils from the surface being cleaned.

Detergents • Detergents are specially

formulated for the specific uses. For example, manual cleaning or

mechanical cleaning.

Enzyme Products

• Breakdown or “digest” large organic molecules to facilitate their removal.

• Are very specific in their actions. Different enzymes work on different soils.

Enzyme Products • Protease – Breaks down blood, mucous, feces,

and albumin.

• Lipase – Breaks down fatty deposits such as bone marrow and adipose tissue.

• Amylase – Catalyzes (changes) starch.

Technology Creates Cleaning Challenges

Power Equipment

• Must be manually cleaned.

• Do Not Immerse.

• Clean cannulations (lumens) thoroughly.

• Follow Manufacturer’s instructions for use.

Mobile Patient Care Equipment

• Follow Original Equipment Manufacturer’s (OEM) instructions.

• Pay attention to details such as access doors, latches, etc.

Cleanliness Testing

Swab Prepare Read Record

Disinfection Processes

Terminology • Disinfectant - A chemical used on

inanimate objects, such as medical instruments, to kill all microorganisms , except spores.

• Antiseptic – A chemical used on living tissue, such as skin, to slow the growth of microorganisms.

Terminology

• Sterile – Free from all living organisms.

Terminology

• Disinfection – The destruction of nearly all pathogenic microorganisms on an inanimate surface. Disinfection is accomplished using chemical or heat processes.

Chemical Disinfection

Reduces the number of microorganisms on an object.

• Type and number of microorganisms present.

Factors Impacting the Effectiveness of Disinfectants:

Factors Impacting the Effectiveness of Disinfectants:

• Direct Contact with the Item.

• In order to be effective, disinfectants must make direct contact with all surfaces being disinfected.

Factors Impacting the Effectiveness of Disinfectants:

• Time

• Disinfectants must be allowed time to work.

• Check manufacturer’s instructions for the correct exposure time required to achieve the desired biocidal effect.

Other Factors Impacting the Effectiveness of Disinfectants:

• Temperature of the Disinfectant

• pH

• Hardness of the Water

• Material Compatibility

• Positioning of the Device(s) being disinfected

Selecting a Disinfectant

• Selection should be based on:

– The Manufacturer’s IFU

– The degree of disinfection required for the device

– Risk levels are based on the Spaulding Classification System

Critical Items • Items introduced

directly into the bloodstream or other normally sterile areas of the body.

• Surgical Instruments, Implants, etc.

Semi-Critical Items • Items which come in

contact with intact mucous membranes.

Non-Critical Items • Items which come in

direct contact with the patient’s unbroken skin.

• Crutches, Blood Pressure Cuffs, equipment, etc.

Disinfectant Activity Levels

• High-level

• Intermediate-level

• Low-level

High-Level Disinfection

• A liquid chemical that destroys all microorganisms, except bacterial spores.

Intermediate-Level Disinfection

• Process that utilizes an agent that kills viruses, mycobacteria, fungi, and vegetative bacteria, but not bacterial spores.

Low-Level Disinfection

• Process that utilizes an agent that kills vegetative forms of bacteria, some fungi and lipid viruses.

Using High-Level Disinfectants

• Follow manufacturers’ instructions • Use appropriate containers • Cover the containers • Wear gloves and required PPE • Follow SDS Safety Guidelines • Reuse only those products labeled for reuse • Watch expiration dates • Test as necessary • Rinse thoroughly • Dispose of according to established guidelines

Thermal Disinfection

• Thermal Disinfection – Disinfection accomplished by heat.

Thermal Disinfection

• Check spray arms and nozzles of mechanical washer disinfectors daily to insure they are working correctly.

• Monitor to help ensure proper temperatures were reached.

A Final Note on Training • No employee should work

in the decontamination area without training on: – Standard Precautions

– PPE

– Safety

– Handwashing

– IFU

– Proper handling of contaminated items

– Machine operation

Decontamination Quiz

To gain access to Module 3, you must first complete the Module 2 online quiz.