CSSD Course Chapters 7, 8 & 9 PDF

Chapters 7, 8, 9 CSSD Course  Chapter 7 Decontamination: Point-of-Use Preparation and Transport  Learning Objectives: As a result of successfully completing this chapter, readers will be able to: 1. Review the four main goals of soiled item preparation and transport...

Chapters 7, 8, 9 CSSD Course  Chapter 7 Decontamination: Point-of-Use Preparation and Transport  Learning Objectives: As a result of successfully completing this chapter, readers will be able to: 1. Review the four main goals of soiled item preparation and transport 2. Identify the sources of contaminated items 3. Explain point-of-use preparation procedures 4. Review basic procedures to transport soiled items from user areas to the Central Service decontamination area 5. Discuss safety guidelines for transporting soiled items to the Central Service decontamination area 6. Identify basic sources for education and training information applicable to the transport of contaminated items  Introduction  RMDs and other medical devices are processed in CS department; to- and from- patient care units  Transportation maybe few feet away or miles away  Proper handling and transportation is a must Goals of Point-of-Use Preparation and Transport  Removal of gross soil  Prevention of damage  Prevention of cross-contamination  Keeping other safe Sources of Contaminated Items  Perioperative department generated high volumes of contaminated items; also ED, Endoscopy, L&D, Cardiac  CS department is near perioperative department  Exclusive elevator/dumbwaiter system  Other department have scheduled pick-up rounds held in a soiled utility room – must be Labelled with biohazard signage  Point-of-Use Preparation  Instrument decontamination start at point of use  Instruments must be prepared properly to help ensure safe transportation  Reasons:  Helps prolong the life of instruments  Soils in crevices, channels and hard to reach areas must be moistened  Soils also promote biofilm formation  Dry soil on instruments are hard to clean Point-of-Use Preparation Guidelines  This step is to begin the cleaning process  Guidelines:  Wear PPE, remove gross soils  Follow manufacturer’s IFU  Separate reusable sharps from other instruments  Separate reusable linen, ensure instruments are not together with linens  Remove disposable components, thrown to a biohazard container or sharps container  Open hinged instruments, disassemble multi-part instruments  Keep items together  Keep instruments moist  Empty fluid containers  Notify CS department if instruments need repair and for fast turnover  Any rare infectious disease that patient has must be reported  Transport of Soiled Items  Gloves and mask for the transport personnel  Use closed case carts or closed bin with Biohazard label  Must minimize cross-contamination  Do not mix opened and unopened packages  Do not use soiled case cart to dispatch sterile items  Average time for turn around of items kept in soiled utility rooms is 2-4 hours  Safety Guidelines for Soiled Item Transport  All items used to a patient should be considered as contaminated  CS techs should maintain control of transport carts at all times; slowly and short distances  Carts containing soiled items should never be left unattended  CS techs should yield to patients and visitors in hallways and elevators  Prefer to use dedicated elevator for soiled carts  OFF-SITE Processing  Facility must consult local health authority and transportation authority of the means to transport biohazard materials  Instruments must be kept properly arranged on a tray and in a closed cart to prevent damages  Education and Training  Infection Control Team must be involved in policy making  AAMI, OSHA, AORN provides standards on transportation  Chapter 8 Cleaning and Decontamination  Learning Objectives: As a result of successfully completing this chapter, readers will be able to: 1. Define cleaning and identify challenges to cleaning medical devices 2. Discuss the purpose and set up of the decontamination area 3. Identify the importance of personal protective equipment and standard precautions 4. Explain the role of common cleaning tools 5. Discuss mechanical cleaners 6. Discuss the use of chemicals in the decontamination area 7. List steps in the cleaning process 8. Explain manual cleaning processes  Introduction  Cleaning  DEF: removal of all visible and non-visible soil and other foreign materials from RMDs  Is the cornerstone of instrument reprocessing  “Items that have not been cleaned properly cannot be sterilized”  In hospital setting – performed to the highest level and it must be consistent  Improper cleaning can cause infections and even death  It may become challenging due to complexity of RMDs  Requires right tools, right technique and attention to detail  Introduction  Instruments may appear clean in the naked eye but when fluorescence test are done, residues still remain  Lumens, channels, hinges, etc  Introduction  Decontamination  Involve the use of physical or chemical procedures to remove, inactivate or destroy bloodborne pathogens on an item’s surface  This is to make instruments safe to handle  Decontamination Work Area  Serves as receiving area for soiled instruments and other medical devices  Centralized function for the whole hospital  Location of the area should consider the ease of transport of soiled items to reduce risks – near OR  Floor material must withstand chemical detergents  Walls should not have fiber-shredding materials  Ventilation of 10 air exchanges per hour, with negative pressure  Temperature: 16C-20C; Humidity: 30%-60%  Decontamination Work Area  Lighting is essential  Traffic should be restricted to decontamination personnel  Emergency eyewash/shower equipment should be placed within 10 seconds/ 3o meters away from potential chemical exposure  Horizontal work surfaces should be cleaned at the beginning, in between and at the end of each shift  Spills should be spot-cleaned immediately  Floors should be cleaned and disinfected daily  Biohazardous waste should be removed at intervals  Housekeeping materials for decontamination area should not be used to other clean areas  Decontamination Work Area  Dress Code and Personal Behaviors  Assume all items received are contaminated  Must follow PPE usage and proper handwashing  Traffic Control and Environmental Management  Technicians must be vigilant with the area and keep other staff from coming in without proper PPE  Work Area Setup  Sinks  Workflow – dirty to clean  Three sink bays for washing, intermediate rinsing and final rinsing  1st – water with detergent in correct dilution, less than 40C, mark sink with correct volume  2nd – plain or softened water  3rd – RO, distilled, deionized water  Cleaning Tools  Water  Often taken for granted but the most important  Water contains a lot of minerals, contaminants, dissolved solids, particles, gases, organic and non-organic chemicals  REVERSE OSMOSIS – best supply of water in CSSD  Water test must be done by in-house or third party  Poor quality leaves stains  PH level: lower number: ACID; higher number: ALKALINE; BEST: NEUTRAL 6-8  Manual Cleaning Tools  Brushes  Different sizes in length and diameter and specific for cleaning surgical instruments  Rigid or flexible  Reusable or disposable  Reusable brushes should be disinfected daily  Abrasive brushes should not be used – metal or wire have specific instructions  Snuggly fit and length appropriate brushes must be used to channels or lumens  Manual Cleaning Tools  Cleaning Cloths  Lint-free cloth and should be disposed after being soiled  Sponges  Sponges are impregnated with chemical detergents and must be discarded after use  Decontamination Work Area  Water Irrigators and Forced Instrument Air Devices  Water and Air supply should be consistent  Clean Air should be supplied  Floor Drains and Spray Nozzles  To manually clean bulkier items  Additional Tools  Leak testing devices, specific tools to clean items, etc  Mechanical Cleaners  Reduce microbial contamination through a multi-step approach  Ultrasonic Cleaners (Sonics)  Used for fine cleaning but not for disinfection or sterilization  Remove soils from joints, crevices, lumens and other difficult areras  “Ultra” – beyond; “Sonic” – sound: wave passes through liquid and makes it vibrate – 20,000 to 38,000 vibrations/sec  CAVITATION – is a low-pressure bubbles in a cleaning solution burst inward (implode) and dislodge soil from instruments  Process: waves pass through dilution, solution are in very rapid motion, small gas bubbles develop, grow larger and implode, creates a vacuum that draws bits of foreign matter out  Mechanical Cleaners  Ultrasonic Cleaners (Sonics)  Items must still be pre-cleaned to remove gross soils  Bath temperature: 27C – 43C; above 45C causes coagulation  Instruments must be in a tray  Lumens must be filled with water  Hinged instruments must be in open position  Rinse the instruments after ultrasonic cleaning  Water changed when visibly soiled or in intervals  Manual vs Automated; single vs multi chamber  Do daily maintenance  De-gassing every first load for 5-10 minutes empty load  Clean drains and body  Mechanical Cleaners  Ultrasonic Cleaners (Sonics)  Avoid following items to be reprocessed  Chrome-plated/ ebonized, plastics, cork, glass, wood, chrome and rubber  Needles, telescopes, etc  S/S and other items must not be mixed during a cycle  Sonic detergents may change or dull the color of anodized aluminum  Irrigating Sonics  Sonics with ports to be used for lumens like laparoscopic or robotic instruments  Quality Assurance  Soil test vs Foil test  Mechanical Cleaners  Washer-Disinfector  Can perform multiple cleaning functions automatically  Impingement – spray-force action of pressurized water against instruments being processed to physically remove bioburden with thermal action  Factors – water temperature, special detergent and force  Single vs Indexed Model  Steps/ Phases  Cold Pre-rinse with Tap  Detergent Phase  1st Rinse with Tap  Thermal Disinfection with RO  2nd Rinse with RO  Drying Phase  Mechanical Cleaners  Washer-Disinfector  Factors  Washer racks should not be overloaded – check movement of spray arms  Instruments must be disassembled and small parts placed in a basket  Hinged instruments opened to permit contact  Trays with multiple levels must be separated  Trays with lid must be opened  Delicate instruments are placed in a small perforated baskets  Routine Daily Maintenance  Check spray arms and drain basket (washer traps)  Daily decontamination cycle with descaling  Check detergent levels  Pre set cycles are installed  Quality Assurance: Soil test  Mechanical Cleaners  Cart Washers  Can process transport carts, rigid containers and other materials in large quantity and sizes  Others can also do instrument cycle  Routine Daily Maintenance  Check spray arms and drain basket (washer traps)  Daily decontamination cycle with descaling  Check detergent levels  Factors  Ensure carts are approved for reprocessing  Do not process instrument in the CW otherwise  Do not keep items inside carts during cycle  Mechanical Cleaners  Automated Endoscope Reprocessor  To chemically disinfect approved flexible endoscopes  Items must be manually cleaned prior to AER reprocessing  Will be tackled later in Chapter 9  Equipment Testing  ANSI/AAMI ST79 10.2 recommends quality assurance program to ensure machine is working properly  Printouts should be reviewed and initialled every after cycle  Human factor still play a role in decontamination Cleaning Chemicals and Lubricants  Using proper chemicals in the correct concentrations rehydrates and loosens the soil and helps to properly clean the devices  Detergents must be compatible for both medical devices and equipment  Enzyme Products  Are biodegradable, non-toxic agents used to breakdown soils, stains and other debris  Protease – breaks down protein like blood, mucus, feces and albumin  Lipase – breakdown of fatty deposits like bone marrow and adipose tissue  Amylase – catalyzes/ changes starch or carbohydrates  Mannanase – hydrolyse mannan (yeast)  Cellulase – targets cellulose that produce glucose Cleaning Chemicals and Lubricants  Point-of-use cleaning is important to moisten or rehydrate soils  Temperatures should not exceed 60C  Utilize IFUs  Detergents  Contains emulsifiers, surfactants and chelating agents  Chelating agents - have an ionic charge that allows soils with opposite charge to break away and attach to it  Emulsifier - used to bind together substances that does not normally combine, oil and water  Surfactant - that lowers the surface tension of the water and increases the solubility of organic compounds  Detergents do not kill microorganisms Cleaning Chemicals and Lubricants  Neutral detergents are commonly used at 6-8 PH level  Advantage: effective on organic and inorganic soils  Disadvantage: not effective on hard water, foam producing  Alkaline detergents are highly effective at removing organic soils with PH from 8-11  Advantage: effective and low foaming  Disadvantage: require thorough rinsing because it leaves powdery residue  Acid detergents are used to remove mineral deposits of hard water scale, urine and minerals with PH from 1.6-3  Advantage: neutralizes alkaline residues and removes deposits  Disadvantage: can damage surfaces of materials Review of Common Chemicals Used in the Decontamination Area  Chemicals are different from each other; READ labels  Pre-Cleaning  First step in the process; either detergent or enzyme containing  Done after a procedure or point-of-use location  Manual Cleaning  Other detergents can only be used in a manual sink  Detergents not Disinfectants  Mechanical Cleaner  Detergents are specific to WDs and can be concentrated  Descalers  These are acid based detergents to remove scaling  Lubricant  Called as instrument milk and is an important step in maintaining instruments; can be with the WDs or manually applied  Stain and Rust Removers  These are either powder or water based in order to remove stains  Steps in the Process of Decontamination  Point of Use  End-user must pre-clean the instruments, keep moistened  Dispose consumables and arrange instruments and keep in a closed cart or bin  Soiled Receiving  Handed over by hand or thru dumbwait or elevator  Open carts carefully  No sharps, consumables, fluids and other contaminants except for RMDs must be received  Rigid containers are sent to CW separating all items  Check the completeness of the set or items and brief visual and function inspection  Steps in the Process of Decontamination  When Should Instruments be Cleaned?  After use  After they have been opened and not used  New instruments received  When returned from repair or refurbishing  When pulled out from back up stock  When instruments are inadvertently contaminated  When loaner instruments are received  Steps in the Process of Decontamination  Cleaning  Primary function in the area  Manual Cleaning vs Manual Preparation  Manual Cleaning  Done in three phases when items could not go through WDs  Optimal to do when detergents are having disinfectant properties  Thorough process to ensure items are cleaned and disinfected  Manual Preparation  Done if items will go through WDs  Removal of gross soil not to impede the mechanical process in ultrasonic or WDs  Disassemble instruments when possible  Steps in the Process of Decontamination  Hinged instruments opened and immersed  Lumens/ cannulated items must be flushed with solution and immersed  Should brush under the water “to and fro” with the appropriate size  Instruments for repair still needs to be cleaned  Delicate instruments must be reprocessed separately  Ophthalmic instruments have special cleaning protocols due to TASS (Toxic Anterior Segment Syndrome)  Complexity of Instruments poses challenge in cleaning process  Always follow IFU Cleaning Instruments That Cannot Be Immersed  Some Power Surgical Instruments (PSI) could not be sent through mechanical cleaning or immersing  Wipe these kinds of items with the solution and take time to brush and wipe parts of PSI  Dark color cords or cables can be a problem to see blood Cleaning Instrument Containers and Basins  Can be manually or mechanically cleaned  Must be positioned in the racks not damaging handles and surfaces and also positioning them to allow drainage Mobile Patient Care Equipment  Can use mild cleaning agents and disinfectants  Proper inspection of areas to be cleaned must be thought of  Inspection of Cleanliness  Inspect for any visible debris left in the instrument specially in crevices, hinges and inside of lumens  Quality Testing  Protein test  Swabbing of surfaces to check the presence of residual soil  Chapter 9 Disinfection  Learning Objectives: As a result of successfully completing this chapter, readers will be able to: 1. Define the term disinfection and explain how disinfection differs from sterilization 2. Explain disinfection levels as identified in the Spaulding Classification System: Low-level disinfection Intermediate-level disinfection High-level disinfection 3. Provide basic information about the types of disinfectants commonly used in healthcare facilities: Quaternary ammonium compounds, Alcohol, Phenolics, Chlorine, Iodophors, Glutaraldehyde, Ortho-phthalaldehyde, Hydrogen peroxide, Peracetic acid 4. Identify good work practices for manual disinfection processes 5. Discuss automated equipment utilized for disinfection, and good work practices for working with automated disinfection processes 6. Explain disinfection quality assurance practices  Introduction  Disinfection vs Sterilization  Bactericidal process  Relating to the destruction of bacteria  Disinfection  Destruction of nearly all pathogenic microorganisms on an inanimate (non-living) surface  Sterilization  Destruction of all forms of microbial life, including bacteria, viruses, fungi and spores  There must be no presence of soils during disinfection  The Spaulding’s Classification  Classification of items based on the risk of infection The Spaulding’s Classification The Spaulding’s Classification  Types of Disinfectants  Low-Level and Intermediate-Level Disinfectants  Destruction of vegetative forms of bacteria, some fungi and lipid viruses; viruses, mycobacteria and fungi but not spores  Quaternary Ammonium Compounds (QUATs)  Alcohol  Phenolics  Chlorine  Iodophors  High-Level Disinfectants  Destruction of all forms from Low and Intermediate, fungal spores and some bacterial spores  Glutaraldehydes (GTA)  Ortho-Phthalaldehydes (OPA)  Hydrogen Peroxide (H2O2)  Peracetic Acid (PAC)  Types of Disinfectants  Quaternary Ammonium Compounds  Advantages  Bactericidal, fungicidal and virucidal against lipophilic viruses  Wetting agents with built-in detergent properties  Disadvantages  Not sporicidal  Generally not tuberculocidal or virucidal against hydrophilic viruses, unless multiple compounds are included  May be inactivated by cotton and charcoal  Incompatible with soap  Not effective against some gram-negative organisms commonly found in hospitals  Deactivated by organic material  Uses  Environmental sanitation of non-critical surfaces such as floors, walls and furniture  If multiple compounds in solution may be used on instruments if properly rinsed  Must remain wet on surface to be disinfected 6-10 minutes  Types of Disinfectants  Ethyl or Isopropyl Alcohol  Advantages  Rapid bactericidal agent against vegetative microorganisms; tuberculocidal, fungicidal and virucidal  Fast acting; no residue; non staining  Disadvantages  Requires wet contact of at least 5 minutes to achieve a reasonable level of disinfection; Non-sporicidal  No residual activity  Volatile; flammable; inactivated by organic material  Can dissolve lens mountings on certain optical instruments  Tends to harden and swell plastic tubing – polyethylene  Uses  To disinfect fixed equipment after cleaning and for patient-use items, such as ear specula, stethoscopes, etc  Can be used as a drying agent  Types of Disinfectants  Phenolics  Advantages  Broad spectrum of use; bactericidal for gram-negative and gram- positive bacteria, fungicidal and tuberculocidal; active against lipophilic viruses  Residual activity  Disadvantages  Residual activity; not sporicidal  Inactivated by organic material (lesser)  Corrosive to some plastics  Uses  Housekeeping usage for walls, floors, countertops and furniture  Phenolics are used in the decontamination area for disinfection of hard surfaces  Copious rinsing is required to eliminate the potential for skin burns  Types of Disinfectants  Chlorine  Advantages  Effective against gram-positive and gram-negative (vegetative) microorganisms; tuberculocidal, fungicidal, virucidal  Fast acting  Disadvantages  Inactivated by organic matter  Corrosive to metals; stains fabrics, plastics and other synthetic materials  Non-sporicidal; relatively unstable  Uses  Widely used for disinfection of dialysis machines, hydrotherapy baths, toilets, lavatories and bathtubs; also used as a bleach for laundry and as a sanitizer for dishwashing  A 1:10 dilution of 5.25% sodium hypochloride has been recommended by the CDC for cleaning blood spills  Must remain wet on items to be disinfected one to two-and-a-half minutes  Types of Disinfectants  Iodophors  Advantages  Bactericidal, virucidal and tuberculocidal  Rapid action against vegetative bacteria  Disadvantages  Corrosive to metals unless combined with anti-corrosive agents when formulated  Detrimental to some plastics  Stains fabrics and other materials  May require long contact time to kill some fungi  Uses  Used in skin preparations  Disinfection of some equipment  Corrosive nature limits its use as a primary disinfectant  Must remain wet on items to be disinfected for at least 2 minutes  Types of Disinfectants  Glutaraldehydes  Advantages  Kills vegetative bacteria (2 minutes)  Bactericidal, tuberculocidal, fungicidal, virucidal and sporicidal (chemical sterilization = 6-10 hours)  Disadvantages  Noxious odors; good ventilation is required  Unstable (14-28 day product life)  Dilution of product reduces the activity necessary for HLD  Uses  Semi-critical items – laryngoscope blades, flexible scopes, etc  Kills microorganisms by alkylation of protein  Needs activation  Types of Disinfectants  Ortho-Phthalaldehydes  Advantages  Solution is compatible with a wide range of endoscopes and other medical devices  Requires no activation or mixing  14-day reuse life  Can be discarded down facility drains in accordance with local regulations  Disadvantages  Does not have a sterilant label claim  Uses  Semi-critical items – laryngoscope blades, flexible scopes, etc  Types of Disinfectants  Hydrogen Peroxide  Advantages  Broad spectrum HLD. Kills bacteria and viruses including norovirus, rotavirus, RSV, MRSA and TB  Can be used as a sterilant at the right concentrations  Disadvantages  Corrosive to some materials  Discoloration of anodized instruments  Uses  Disinfection of hard and soft surfaces  Types of Disinfectants  Peracetic Acid  Advantages  Broad spectrum HLD  May be used as a sterilant in the appropriate AER  Compatible with many materials  Disadvantages  Corrosive to some materials  Uses  HLD of laryngoscopes blades, endoscopes  Types of Disinfectants  High-Level Disinfectants  Needs to check daily of its efficacy with strips  Minimum Effective Concentration (MEC/MRC)  Percentage concentration of the active ingredient in a disinfectant or chemical sterilant that is the minimum concentration at which the chemical meets all its label claims for activity against specific microorganisms  Disinfection process should be done in an enclosed well- ventilated area  Preparation instructions must be followed cautiously  Labelling of solution must be kept clear for all staff to see  Contact and Exposure Time must be confirmed in order for the solution to be effective  Right Chemical, Right Contact Time and Coverage, Right Dilution  Thorough rinsing with RO water must be done  Achieving Disinfection Using Mechanical Processes  Thermal Disinfection  Uses heated RO water to disinfect instruments inside the WDs  Achieving Disinfection Using Mechanical Processes  Thermal Disinfection  Uses heated RO water to disinfect instruments inside the WDs  Achieving Disinfection Using Mechanical Processes  Pasteurizers  Disinfection through pasteurization with temperatures at 65C-77C for 30 minutes  AER  Automated Endoscope Reprocessor  Disinfection of endoscope simpler and safer  Advantages  Reduces personnel exposure to HLD  Consistent contact of chemicals to instruments  Timed contact with liquid chemical disinfectant  Continuous movement of HLD  Alcohol flush for drying  Use of air flush cycle and consistent water  Monitoring of channels during reprocessing  Documentation of cycle parameters  Quality Assurance Practices for Disinfection  Education  Is a must. Train the staff in all proper ways of handling chemicals and equipment  Safety  Ensure staff have ample amount of PPEs and precautions when reprocessing items  PPE, Environmental, Spill and Leak, Storage and Disposal requirements  MEC  Documentation  Item Name and Serial, Patient Identifier, Physician’s Name, Procedure, HLD Dilution date and last MEC, MEC Result, Lot number of HLD, Exposure Time and Temperature, Date and Time of Process, Technician ID