What%20Can%20Go%20Wrong%20in%20Cleaning,%20Disinfection%20

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What Can Go Wrong in Cleaning, Disinfection
Sterilization?

• TSICP October 2006
• Barbara Moody, RN, CIC
• Director Infection Control
• Denton Regional Medical Center

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and how would you know?
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Objectives

• Describe at least one infection associated with
  each improper cleaning, disinfection
  sterilization
• Identify gt 3 indicators that could implicate
  inadequate processing.
• List 3 methods for investigating possible
  processing failures.

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Background

• 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)

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Basic principles

• Hosp. Environment visibly clean, free from dust,
  soil
• Equipment used for gt1 pt must be cleaned,
  disinfected or sterilized between patients
• Established procedures must be used for clean
  soiled linen, food hygiene pest control
• All staff must be educated trained in
  prevention of HAI ( competency updated)

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Baseline Info Things you know

• 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

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WMD Weapons of Microbe Destruction

• The
• Weapons Manual cleaning automated
• processors, disinfectants, Sterilants
• Microbes fungi, bacteria, viruses, spores,
• prions
• Destruction methods Chemicals, Steam
• Gas (EO), H202 Plasma,
  Irradiation

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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 )

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Legal aspectsHeadlines re failure of
disinfection, 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!

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Disinfectant contamination

• Intrinsic contamination possible
• Phenolic solutions
• Benzalkonium chloride
• Other Quats
• Extrinsic contamination frequent
• Most detergent/disinfectants
• Quats especially
• Alcohol bacillus spores

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Environment 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

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Environmental Cleaning agents(low level)

• Chemical Disinfectant Strength
• Ethyl, Isopropyl alcohol 70-90
• Chlorine bleach 1500 (100 ppm)
• Phenolic (1120/1256) 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

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When to check cleaning ? (Cluster 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

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Examples of Improper / inadequate
cleaning

• Under-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, redipping used cloth
  in solution

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Problems Pre- Cleaning instruments

• Wrong product
• Misunderstanding label or type product
• wrong assumptions
• Failure to rinse organic matter promptly
• Incorrect dilution (Over -, under -)
• Inadequate soak time
• Failure of disinfectant to reach all crevices

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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)

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What 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?

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Device-associated infections

• Automated reprocessors
• Bronchoscopes
• Depth electrodes
• Electrosurgical units
• Endoscopes
• Laryngoscope blades
• Transducers
• Rectal/vaginal probes

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Device assoc.infections contd

• Electronic thermometers
• EKG leads
• Tonometers
• Cardioplegic solution/ice machine
• Surgical instruments
• Powered instruments
• BP Cuffs

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Powered 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.

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Endoscopes The IC issues

• Narrow lumen
• Complex inside parts
• Easily damaged
• Manual pre-cleaning essential
• Frequent repairs necessary
• Surface integrity essential
• Special connectors to AER a MUST !

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Endoscopes issues contd

• Mechanical failure
• Faulty design
• Poor manufacturing quality
• Adverse effects of materials
• Improper maintenance
• User error
• Compromised sterility

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Endoscopes Bronchoscopes

• GI endoscopy infections
• gt 300 published cases
• - 70 Salmonella, Pseudomonas
• - C.difficile
• Scope colonization
• Bronchoscopy infections
• - gt90 published cases
• - M.tb, atypical mycobacterium, pseudomonas
• Spach et al Ann Int. Med 1993 Weber D J
  Gastrointest Dis.2002

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Whats 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

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Assessing 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 staffs vacations

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Rinsing after HLD

• Endoscopes
• Rinse immediately after patient use
• After HLD soak, water flush, alcohol flush

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Endoscope contamination

• Inadequate channel cleaning
• Lack of proper connectors for channels
• Improper methods (Time exposure, some channels
  non-perfused, over-diluted solution)
• Failure to follow recommended disinfection
• procedures
• Flaws in design of endoscopes AERs
• Lack of proper training, competency , etc.

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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!!

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Findings that prick up your EPI-EARS

• Unusual gram-negatives in Bronch washes (gt2 same
  one) or duplicate other sites (Urines, surgical
  wounds, etc)
• gt1 atypical mycobacteria (same species)
• from same sites

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Initial Steps to Investigate

• 1
• Notify lab to SAVE THE ISOLATES!
• (give a time frameseveral weeks,
• lab to discuss w/IC before discarding)

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Check your usual incidence 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)

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3 Investigation

• Formulate an initial hypothesis
• Key factor is whether the
• patients are clinically ill
• or
• pseudo-infection possible

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Single vs Clusters SSI

• Single SSI cases, different pathogens
• frequently patient source, possible
• aseptic breach
• Clusters of single pathogen often common
• source contaminated source or
• aseptic breach

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Sterilization problems

• Inadequate pre-cleaning
• Improper sterilization parameters
• Personnel not trained sufficiently to recognize
  seriousness of gt 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

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Sterilization problems

• Failure to meet parameters
• Biological failure next test ok
• Biological failure episodic,
• 
  intermittent
• Bowie Dick test uneven, not clear failure

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Assessing 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

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Sterilizer practice assessment contd

• 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?

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Maintenance issue

• Sterilizer cleaning
• Check procedure, frequency
• Responsibility?
• Agent used ?
• Documentation?
• Preventive Maintenance Log
• Look for repeated problems
• Check the repairs listed
• Repair person credentials

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Peel Pack Pitfalls

• Peel Pack standards
• Remove air Seal must be intact
• No 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

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Other Packaging issues

• Package too small for contents
• Crowded instruments in a container
• Failure to put indicator inside
• Use of non-standard packaging (washcloth, paper
  bag, plastic baggies)
• Use of non-standard seals (rubber bands, scotch
  tape, bandage tape, safety pins)

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Preventing Infection in the OR

• 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