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