Cleaning and Disinfection in the Ambulatory Care Setting

Infection Prevention and Control

Henry Ford Health System

This program is approved for 1.0 CE per:

Henry Ford Health System Nursing Development (Provider OH 312, 11/01/2015) is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

The authors and planners of this program have declared no conflicts of interest.

IN order to receive the CE you must complete a survey at the end of the program. The link is provided on the last slide.

This program is available from October 1, 2013 to October 1 , 2014

Objectives Describe basic principles of cleaning,

disinfection and storage of patient care equipment in the clinic setting.

Identify when to use cleaning, disinfection or sterilization with devices or the clinic environment.

Understand how to complete an Infection Control Risk Assessment related to cleaning patient care equipment.

Risk Factors For Cross Contamination in Outpatient Clinics

1. Inadequate disinfection and sterilization of instruments and equipment

2. Improper use of barrier precautions by infected health care workers (or not taking sick leave)

3. Inadequate hand hygiene practices among health care personnel

Infection Risks In The Healthcare Environment

One of the easiest ways that pathogens are transferred in the healthcare environment is via hand carriage. Surfaces and equipment that are contaminated will colonize the hands of healthcare workers’ with pathogenic microorganisms.

These pathogens are then transferred to the patient & may cause infection.

The importance of the environment as a source of infection is gaining more attention.

CDC Recommends: Training for all care providers on equipment

cleaning and disinfection, specific to their job duties Training that focuses on worker safety and patient

safety Training at orientation and repeated regularly (e.g.,

annually) Competencies in each worker’s personnel file that

document their training.

Healthcare Equipment Is Classified According To Risk For Infection

Critical Enter tissue or vascular system

Sterile

Semi- Critical

Contact mucous membranes or non-intact skin

Sterile or High Level Disinfected

Non-Critical

Contact intact skin Medium or Low-Level Disinfected

CleaningGeneral removal of debris (dirt, food, feces, blood, saliva, etc.)Reduces amount of organic matter that contributes to proliferation of bacteria and viruses

DisinfectionRemoves most organisms present on surfaces that can cause infection or disease

SterilizationEliminates all living microorganisms, including bacterial spores

Terminology

More on Cleaning

Accomplished with water, detergents and mechanical action (friction)

The physical removal of foreign material such as dust, oil, secretions and micro-organisms.

Reduces or eliminates the reservoirs of potential pathogenic organisms.

Many Reservoirs For Infection

Disinfection

Eliminates or kills most bacteria, many virus types and some fungi

Time-dependent process

Cannot be accomplished without first cleaning

Disinfection

Follow manufacturer’s recommendations to achieve disinfection and to avoid medical device damage.

Use correct dilution – more is not better!Use correct contact timeUse correct temperature

Understand employee and environmental safely issuesDo not exceed exposure limitsKnow permissible exposure levelsAssess compatibility with gloves, basins, other

products

Sterilization

Required for any items that enter tissue or vascular system.

If item is reprocessed for use on another patient, it MUST be cleaned properly before sterilization.

Non-critical Items

Include items in contact with intact skinTherefore sterility is not criticalRequire intermediate-level or low-level disinfection products

Examples include BP cuffs, stethoscopes, durable mobile patient equipment

Medical Equipment

Labeled by manufacturer as either reusable or single-use.

Reusable equipment should have instructions for cleaning, disinfection or sterilization as appropriate. Must follow these instructions for cleaning & maintenance.

Single-use devices are labeled for only one use and do not have reprocessing instructions.

Reusable Medical Equipment

Disinfection of Supplies & Equipment

Certain reusable devices must be cleaned and reprocessed between uses with different patients, such as:

Ultrasound and X-ray equipment that touch a patient or are handled by the technician

To Disinfect Noncritical Medical Devices:

Must use an EPA-registered hospital disinfectant using the label’s safety precautions and directions for use.

EPA Registration Of Disinfectants:

Labeled as high level vs. intermediate vs. low level

May include degrees of approval• Limited approval, e.g., kills Hepatitis B and HIV but not

approved for spores.

Select disinfectant based on what you are trying to accomplish

• Environmental vs. medical device disinfection• Make certain product is compatible with device

Can search EPA website by product name:www.epa.gov/oppad001/chemregindex.htm

Glucometers

Multiple outbreaks have occurred associated with blood glucose monitoring

Hepatitis B outbreak in an assisted-living facility in 2010 resulted in 6 deaths. Findings:

Finger stick devices used for > 1 patientDid not clean and disinfect meters between patients

Glucometer Recommendations From CDC:

A new single-use, auto-disabling lancing device is used for each patient

The glucose meter is cleaned and disinfected after every use.

Glucometers

Must be cleaned between each patient or

before going into storage.

Glucometers

Routine use After C.diff patient

Use the proper wipe! After every use!

Clostridium Difficile

Also called “C. diff ” Recurrent, severe diarrhea Abdominal cramping, vomiting Difficult to treat Sometimes results in patient death More often seen in community & long-term care

setting Increasing incidence.

C. Difficile / Norovirus

Suspect with any acute diarrhea

Requires bleach cleaning of equipment and surfaces to eliminate spores.

Hand hygiene must be with soap and water

Environmental Cleaning

Patient environment can facilitate transmission of bacteria and viruses

By direct contactOn hands of healthcare personnel

Contaminated surfaces increase potential for transmission of bacteria and viruses between patients

Infection Risks In The Healthcare Environment

Bacteria may persist for long periods on dry surfaces:

MRSA 7 days to 7 months

Acinetobacter 3 days to 5 months

C. difficile (spores) 5 months

Escherichia coli 1.5 hours to 16 months

Influenza few days

Source: Kramer et al, BMC infectious Diseases, 2006

CDC has three recommendations for environmental cleaning and disinfection.

#1

Have policies in place for routine cleaning and disinfection of environmental surfaces in ambulatory care settings

Focus on those surfaces in proximity to the patient and those that are frequently touched.

Example: Once / day unless visibly dirty or risk assessment requires additional cleaning.

#2

Select EPA-registered disinfectants or detergents with label for use in healthcare.

#3

Follow the manufacturer’s recommendations for use of cleaners and EPA-registered disinfectants (e.g., amount, dilution, contact time, safe use and disposal)

What Is “Contact Time”?

Sometimes called “dwell time”

Time necessary to kill disease causing

organisms

Varies with each product

1 minute – 2 minutes – 10 minutes

Can’t I Just Eyeball Dilution?

Proper dilution is important Ability to kill disease causing organisms

depends on strength of solution Developed / tested by manufacturer Recommended concentration is the only

guarantee. Don’t guess!

Dilution Of Disinfectant

Too weak ---- not effective in killing organisms

Too strong --- corrosive to equipment or dangerous to the user.

Proper PPE is important to protect the healthcare worker.

High Touch Surfaces In Patient Rooms

Considered non-critical Must be cleaned then disinfected on a regular

basis. What are your clinic’s high touch surfaces?

Sample Cleaning Schedule

Each clinic needs a rational approach to

cleaning.

How often?

Who? When? With what?

Who – Designated Staff

Responsibilities for cleaning and disinfection of surfaces & medical equipment are assigned to specific personnel.

If Environmental Services are only available after hours, then designated facility staff are assigned cleaning/disinfection duties during clinic hours.

All assigned personnel are trained in the appropriate cleaning/disinfection procedures and the proper use of PPE and cleaning products.

Supplies & Cleaning Products

Designated staff regularly stock necessary supplies (e.g., gloves, gowns, facemasks) and replenish dispensers of hand sanitizer and soap.

Follow manufacturer’s instructions, ensure that the cleaning product is compatible with the surface/device being cleaned.

Follow safety precautions and instructions.

Frequency Of Cleaning

Patient-care areas, medication preparation areas and bathrooms are cleaned at least daily, with the following exceptions: Promptly clean and decontaminate any

location with spills of blood and other potentially infectious materials

Disinfect environmental surfaces and noncritical patient-care devices when visibly soiled.

Frequency Of Cleaning

Clean medication preparation areas when visibly soiled; if medication preparation takes place in the patient treatment area (outside a designated mediation room), clean this area after each patient encounter

Ensure medication preparation area is free of any items contaminated with blood or body fluids (e.g., used equipment such as syringes, needles, IV tubing, blood collection tubes, and needle holders)

Frequency Of Cleaning

Disinfect environmental surfaces and noncritical patient-care devices in between patient use if:

There was direct contact to non-intact skin or mucous membrane or potential contamination with body fluids (e.g., blood, secretions)

The patient-care device involves a blood glucose meter or other point of care testing device (e.g., PT/INR readers) that utilize blood samples

Frequency Of Cleaning

Disinfect bathrooms after use by a patient with known or suspected infectious diarrhea and before use by another person.

Cleaning Decision Guide

Classification Contact Cleaning Level Cleaning Frequency

Critical Enters tissue or vascular system

Sterile After Every Patient

Semi-Critical Contacts mucus membrane or non-intact skin

Sterile or high level disinfect

After Every Patient

Non-Critical Contacts intact skin

Medium or low level disinfect

Not visibly soiled

Per schedule

Visibly soiled

After Each Patient

To help determine how often to clean your equipment use the above table. Start in the contact column and ask what does this piece of equipment come in contact with, then move to the right to determine the type of cleaning and frequency of cleaning. The exception is any equipment that comes in contact with blood (Glucometers). Must be medium level disinfected after each patient.

Cleaning Patient Care Areas

General cleaning and disinfection measures that apply to any patient-care area:

Wear appropriate PPEIn general, cleaning should be performed before disinfection unless a one-step detergent disinfectant is used.

Concentrate on high-touch surfaces (frequently touched by patients or staff)

PPE to Clean … WHY it’s just cleaning?

There are several reasons to wear gloves when cleaning equipment

• Hospital grade cleaning solutions are stronger than what you use at home

• Stronger solutions are more likely to cause skin irritation

• Your skin is a very porous organ and easily absorbs the chemicals in the cleaning solutions

Items Requiring Only Cleaning*

Floors, walls and windows Chairs and other furniture used by individuals

who are clothed Private offices and other non-public, non-

patient care areas

* Unless an exposure to body fluids or other potentially infectious material has occurred.

Cleaning Patient Care Areas

Clean walls, blinds, and window curtains when they are visibly dirty

Avoid dusting methods that disperse dust

Exam Rooms

Focus cleaning on high-touch surfaces (at least daily), e.g., exam bed, bedrails, blood pressure cuff, stethoscope, wall-mounted opthalmoscope and otoscope (per manufacturer’s instructions), chair and bedside stool, and door knob.

Change the paper covering the exam table and pillows between patient use

Exam Rooms

Decontaminate high-touch surfaces using an EPA-registered disinfectant

If patient has suspected infectious diarrhea and the infective agent is C. difficile or unknown, clean high-touch surfaces using a sodium hypochlorite (bleach)-based product (e.g., 1:10 dilution prepared fresh)

Can We Measure How Clean A Surface Is?

Testing available, but not routinely used in outpatient setting

ATP testing, Fluorescence, Bioluminescence Need special equipment, can be expensive Culturing – should not be done; sometimes

used during outbreak investigation Visual inspection

Risk Assessment in Your Clinic

General Guidelines Do we need additional procedures as

determined by our:

Patient population? Care / procedures provided? Type of equipment / devices used?

Temperature/alarm control Signage Logs maintained for medication and specimen refrigeratorsClean on a regular basis or when visibly dirtyAlways separate food from medication or specimens

Refrigerators

Myth Busters

Common Misconceptions

about Sterilization/Disinfection

in the Office Setting

Myth

“My patient is not in isolation, so I don’t have to clean my equipment or wash my hands.”

A Patient’s Infection Status is Not Always Known!

A patient may appear healthy but be colonized with an organism such as MRSA.

Patients who are in the early stages of infection may not have symptoms but are still capable of spreading disease.

The only way to keep your patients and yourself safe is to use good hand hygiene with every patient encounter.

Standard Precautions gives a high level of protection to you as the healthcare worker and all of your patients.

Myth

“Since I will be sterilizing these instruments, I can just rinse them off.”

Preparing Items For Sterilization

In order for sterilization to occur, all surfaces must be cleaned.

If organic material is still present on items that are placed into the sterilizer, processing cannot reach those surfaces and sterilization will be compromised.

Thorough cleaning is critical to successful sterilization is the first step in the process.

Myth

“ I package instruments in the closed position so they will fit into a smaller package and take up less room in the drawer.”

PREPARING ITEMS FOR STERILIZATION

Steam cannot properly contact instruments that are closed.

Instruments should be packaged in the open position and disassembled.

Tip protectors should be loosely applied and made of materials that do not interfere with steam contact.

Myth

“ We package multiple instruments in single peel packages.”

Peel Pouches

Peel pouches are designed for lightweight items. Multiple items can be heavy and predispose the package to

tearing. When a peel pouch containing multiple instrument is

opened, instruments can go in various directions, contacting the outer edge of the package, which is non-sterile.

The best option for multiple instruments is a tray designed for this purpose.

Myth

“ I often remove items from the sterilizer when they are hot and allow them to cool on the countertop.”

Proper Drying For Sterilized Items

Hot metal items placed on cool surfaces may develop condensation.

This moisture puts your sterile packages at risk for contamination.

Bacteria can be wicked inward through the wet packaging material.

Myth

“Three minutes in a flash sterilization cycle is good for anything that I need in a hurry.”

Flash Sterilization (IUSS) IUSS is performed on unwrapped items using

time and temperature guidelines as per manufacturer’s recommendations.

Chemical indicators must be included in each load.

Porous items or those with lumens have different requirements.

Taped instruments require 10 minutes. Flash sterilization should not be used for

implantable devices.

Myth

“We do not date our sterile packages since expiration dates are not longer required.”

Dating Of Sterile Supplies

Expiration of supplies is event-related—Can use unless the package is breached or damaged

Dating helps with proper rotation of supplies Older packages are more likely to have a

contamination event. Have a failed biological spore test? You can

identify and isolate supplies processed since the last test.

Dating is still important!

Myth

“We store our sterile supplies in the cabinet under the sink or above the steam sterilizer.”

Sterile Storage

Proper storage of supplies helps to prevent contamination and extends their shelf life.

Sterile storage should never be located in the vicinity of water or water pipes due to the potential for moisture contamination (growth of mold and bacteria)

Sterile Storage

Optimally, closed cabinets or drawers should be used to protect and store sterile items.

Shelving should elevate sterile items at least 8 – 10 inches above the floor.

If items are stored on open shelves or carts, they should be in low traffic areas and dust covers will help prevent dirt and dust from settling on packages.

Now that I know this, why do I need to repeat training and show a competency in my file?

Need For Training

Patient care equipment is always changing Cleaning products change every few years New pathogens emerge (e.g., MDROs) Every job has different cleaning /

disinfectant duties It’s a requirement by TJC and CMS

Infection Prevention Specialist:

(313)876-8703Office, Mon – Fri

(313)350-4215On call, after hours

Infection Control Manual & Resources:

HENRY Main pageClinical Quality & Safety Infection Control Resources

For Additional Information

References

APIC Text of Infection Control & Epidemiology, 3rd Edition, Vol. 1, Essential Elements, 2009. Recommendations for Disinfection & Sterilization in Health Care Facilities, Chapter 21.

APIC Course, Basics of Infection Prevention, 2012.

Boyce, John M., Environmental contamination makes an important contribution to hospital infection, Journal of Hospital Infection (2007) 65: 50-54.

Centers for Disease Control and Prevention. Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care, 2011. www.cdc.gov/HAI/pdfs/guidelines/standatds-of-ambulatory-care-7-2011.

CDC. Basic Infection Control and Prevention Plan for Outpatient Oncology Settings.

Goodman, Richard A., et al., Transmission of Infectious Diseases in Outpatient Health Care Settings, JAMA, May 8, 1991, Vol. 265, No. 18: 2377-2381.

Thank you for your attention !

Link to survey on the next slide.

Survey link

For Nurses and CMA’s please follow this link to complete the

Cleaning and Disinfecting in the Ambulatory Care Setting Survey