DECONTAMINATION
influencing germicidal procedures are met. When a disinfectant is selected for use with certain patient-care items, the chemical compatibility after extended use with the items to be disinfected also must be considered.
“High-level disinfection traditionally is defined as complete elimination of all microorganisms in or on an instrument, except for small numbers of bacterial spores. Cleaning followed by high-level disinfection should eliminate enough pathogens to prevent transmission of infection. “Laparoscopes and arthroscopes entering sterile tissue ideally should be sterilised between patients. Meticulous cleaning must precede any high-level disinfection or sterilisation process. Although sterilisation is preferred, no reports have been published of outbreaks resulting from high-level disinfection of these scopes when they are properly cleaned and high-level disinfected. Newer models of these instruments can withstand steam sterilisation and for critical items this would be preferable to high-level disinfection. “Rinsing endoscopes and flushing channels with sterile water, filtered water, or tap water will prevent adverse effects associated with disinfectant retained in the endoscope (eg: disinfectant-induced colitis). Items can be rinsed and flushed using sterile water after high-level disinfection to prevent contamination with organisms in tap water, such as nontuberculous mycobacteria, Legionella, or gram-negative bacilli such as Pseudomonas. Alternatively, a tap water or filtered water (0.2m filter) rinse should be followed by an alcohol rinse and forced air drying. Forced-air drying markedly reduces bacterial contamination of stored endoscopes, most likely by removing the wet environment favourable for bacterial growth. After rinsing, items should be dried and stored (eg: packaged) in a manner that protects them from recontamination.
“Some items that may come in contact with nonintact skin for a brief period of time (ie: hydrotherapy tanks, bed side rails) are usually considered noncritical surfaces and are disinfected with intermediate-level disinfectants (i.e. phenolic, iodophor, alcohol, chlorine). Since hydrotherapy tanks have been associated with spread of infection, some facilities have chosen to disinfect them with recommended levels of chlorine.
Sid Mookerjee, Imperial NHS Trust
“In the past, high-level disinfection was recommended for mouthpieces and spirometry tubing (eg: glutaraldehyde) but cleaning the interior surfaces of the spirometers was considered unnecessary. This was based on a study that showed that mouthpieces and spirometry tubing become contaminated with microorganisms, but there was no bacterial contamination of the surfaces inside the spirometers. Filters have been used to prevent contamination of this equipment distal to the filter; such filters and the proximal mouthpiece are changed between patients.
“Non-critical items are those that come in contact with intact skin but not mucous membranes. Intact skin acts as an effective barrier to most microorganisms; therefore, the sterility of items coming in contact with intact skin is not critical. In this guideline, noncritical items are divided into noncritical patient care items and noncritical environmental surfaces. Examples of noncritical patient-care items are bedpans, blood pressure cuffs, crutches and computers. In contrast to critical and some semicritical items, most noncritical reusable items may be decontaminated where they are used and do not need to be transported to a central processing area. Virtually no risk has been documented for transmission of infectious agents to patients through noncritical items when they are used as noncritical items and do not contact non- intact skin and/or mucous membranes. Most
Long term data enables us to analyse trends, pick up issues and make necessary changes. We’re currently setting up an SSI surveillance group at Imperial, which will mean systematic data collection, estimating and monitoring SSI
incidences and rates. Sid Mookerjee, Hammersmith Hospital
100 I
WWW.CLINICALSERVICESJOURNAL.COM
Vanessa MacGregor, Public Health England
Environmental Protection Agency (EPA)- registered disinfectants have a 10-minute label claim. However, multiple investigators have demonstrated the effectiveness of these disinfectants against vegetative bacteria, such as listeria, escherichia coli, salmonella, vancomycin-resistant enterococci, methicillin-resistant staphylococcus aureus, yeasts, mycobacteria and viruses at exposure times of 30–60 seconds. “Non-critcal environmental surfaces include bed rails, some food utensils, bedside tables, patient furniture and floors. Noncritical environmental surfaces frequently touched by hand, such as bedside tables and bed rails, potentially could contribute to secondary transmission by contaminating hands of healthcare workers or by contacting medical equipment that subsequently contacts patients.
“Mops and reusable cleaning cloths are regularly used to achieve low-level disinfection on environmental surfaces. However, they often are not adequately cleaned and disinfected, and if the water- disinfectant mixture is not changed regularly (eg: after every three to four rooms, at no longer than 60-minute intervals), the mopping procedure actually can spread heavy microbial contamination throughout the healthcare facility. In one study, standard laundering provided acceptable decontamination of heavily contaminated mopheads but chemical disinfection with a phenolic was less effective. Frequent laundering of mops, therefore, is recommended. Single-use disposable towels impregnated with a disinfectant also can be used for low-level disinfection when spot- cleaning of noncritical surfaces is needed. “For me, the Spaulding Classification works for these categories. However, if we insist on ‘sterile’ we would stop these procedures overnight, so we need to minimise the risk.”
Karren proposed that the Spaulding Classification should be modified, so that ‘non-critical’ meant an ‘intermediate risk’; ‘semi-critical’ meant the ‘highest risk’ (due to
NOVEMBER 2019
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