Sterilization and Disinfection Chapter 3 Sterilization and Disinfection

Sterilization and Disinfection Objectives Complete the online WHMIS 2015 for Manitoba Workers in Provincially-Regulated Workplaces http://www.ccohs.ca/products/courses/course_listing.html#W Meet objectives 4 through 18 on page 84 of the text. Pronounce, define and spell the all key terms listed on page 85 of the text. Successfully sanitize, disinfect wrap and sterilize at least one item.

Introduction to Sterilization and Disinfection Air and all objects contain microorganisms MA responsible for helping to reduce and eliminate microorganisms Accomplished by practicing good techniques of medical and surgical asepsis Physical and chemical agents are used to destroy microorganisms in the medical office Agent selected depends on intended use of article What is the difference between medical asepsis and surgical asepsis?

Introduction to Sterilization and Disinfection (Cont.) Physical and chemical agents are used to destroy microorganisms in the medical office Agent selected depends on intended use of article Articles that penetrate sterile tissue or the vascular system: must be sterilized – Example: surgical instruments Articles that come in contact with the skin: should be disinfected – Examples: stethoscopes, blood pressure cuffs, percussion hammers Sanitization, disinfection, and sterilization involve hazardous chemicals MA must be knowledgeable of precautions required How would the MA know what precautions to take?

Sanitization Series of steps to remove organic material and to reduce microorganisms to a safe level Organic material left on an article may result in incomplete sterilization or disinfection Acts as a barrier preventing sterilizing agent from reaching the surface of the article to kill microorganisms Microorganisms may hide under the organic material (blood, tissue, etc.) that remains on the article.

Sanitizing Instruments Medical and surgical instruments Most frequent items sanitized in medical office Steps include Rinse: Prevents organic matter from drying on instruments Decontaminate with disinfectant: Remove pathogenic microorganisms Makes instrument safe to handle Name some examples of instruments that are sanitized. What are pathogenic microorganisms? What types of pathogenic microorganisms might be present on a contaminated instrument?

Sanitizing Instruments (Cont.) Steps include Clean instruments: removes organic matter Thoroughly rinse: removes detergent residue Dry instruments: prevents stains Check for defects and working condition Lubricate hinged instruments Makes instrument function well Last longer To remove stains, use a damp cloth or sponge and a commercial stain remover. Warm water (110°F [44°C]) should be used for rinsing. Why can’t the working condition of an instrument be checked after it is sterilized? After applying lubricant to an instrument, does it need to be rinsed?

Cleaning Instruments Manual method Most often used Use of cleaning solution and brush Can steel wool be used to clean an instrument? Why should the medical assistant wear utility gloves when cleaning an instrument?

Cleaning Instruments (Cont.) Ultrasound method Ultrasonic cleaning machine is used Advantage: sharp instruments do not have to be handled Vibrations occur that loosen and remove debris Especially good at removing debris from hard to reach areas – box locks; screw locks See Fig. 3-3 (p. 90) for an example of an ultrasonic cleaner. This prevents accidental punctures or cuts from occurring. Why is the ultrasound method often used in jewelry stores to clean jewelry?

Guidelines for Sanitizing Instruments Wear gloves during the sanitization process Utility gloves worn over disposable gloves protects from: Bloodborne pathogens and OPIM (disposable gloves) Irritating effects of hazardous chemical (utility gloves) Cuts/punctures from sharp instruments (utility gloves) Can utility gloves be reused?

Guidelines for Sanitizing Instruments (Cont.) Handle instruments carefully Never drop or throw into a basin Do not pile in a heap Keep sharp instruments separate To prevent damage or dulling the cutting edge Keep delicate instruments separate Protects from damage Damage to the instrument by handling it carelessly can cause the instrument not to work properly. Give an example of a delicate instrument and a sharp instrument.

Guidelines for Sanitizing Instruments (Cont.) Follow instructions on labels of chemical agents Review MSDS Carefully read container label Use Mixing Storage Personal safety precautions – gloves; eye protection Does CidexPlus need to be activated before it is used? What are the personal safety precautions for CidexPlus?

Guidelines for Sanitizing Instruments (Cont.) Follow instructions on labels of chemical agents Check expiration date Chemicals lose potency over time Do not use if past expiration date What might happen if you used an outdated chemical?

Guidelines for Sanitizing Instruments (Cont.) Use a proper cleaning agent Low-sudsing detergent with a neutral pH Comes in concentrated liquid or powder form Must dilute with water Never substitute with another detergent Example: dishwasher detergent - may not have proper pH; could result in stains on instruments See Fig. 3-4 (p. 91) for examples of commercially available surgical instrument cleaners. pH is the abbreviation for potential hydrogen. Why is it important to use a low-sudsing detergent?

Guidelines for Sanitizing Instruments (Cont.) Use proper cleaning devices Stiff nylon brush: to clean surface of instrument Stainless-steel brush: to clean grooves, crevices, and serrations Stain remover: to remove stains Do not use abrasives: could damage instrument - example: steel wool Why shouldn’t a stainless-steel brush be used on the surface of an instrument? Why is it important to remove organic material from the crevices and serrations of an instrument?

Guidelines for Sanitizing Instruments (Cont.) Carefully inspect each instrument for defects and proper working condition Check the following: Blades not bent Tips should approximate tightly and evenly when closed What does approximate mean? What would you do if you discovered an instrument was not working properly?

Guidelines for Sanitizing Instruments (Cont.) Carefully inspect each instrument for defects and proper working condition Check the following: Box locks should move freely but not too loose; pin should be flush against the instrument Spring handles should have sufficient tension to grasp objects tightly Cutting edge should be smooth and devoid of nicks Scissors should cut cleanly and smoothly - cut into gauze; should cut to end without catching Show an example of an instrument that has a box lock. What is an example of an instrument with a spring handle? Can dull instruments be sharpened?

Guidelines for Sanitizing Instruments (Cont.) Lubricate hinged instruments Lubricate moving parts Box locks Screw locks Scissor blades Describe the type of scissor blades available.

Guidelines for Sanitizing Instruments (Cont.) Lubricate hinged instruments Use lubricant that can be penetrated by steam (commercially available) If not steam penetrable - builds up on instrument and affects working condition Perform after final rinse (and drying) of instrument Purpose is to make instrument: Function better Last longer Open and close hinged instruments after lubrication so that it reaches all parts of the hinged areas. Why is it important not to rinse off the lubricant after it has been applied? Do you think the lubricant is steam penetrable?

Disinfection Process of destroying pathogenic microorganisms Does not kill spores In medical office: liquid chemical agents are used for disinfection What is a pathogenic microorganism? What is a spore? Why is a spore able to resist a disinfectant?

High-Level Disinfection Destroys all microorganisms with the exception of bacterial spores Used for semicritical items Semicritical item: comes in contact with nonintact skin or intact mucous membranes (e.g., sigmoidoscope) Utility gloves should be worn over clean gloves when handling a high-level disinfectant. What other PPE should be worn? Why can’t a sigmoidoscope be processed in an autoclave? What are other examples of semicritical items?

High-Level Disinfection (Cont.) Frequently used high-level disinfectant: 2% glutaraldehyde (Cidex, MetriCide) New high-level disinfectant: Cidex OPA Does not contain glutaraldehyde Less toxic Safer to handle Cidex OPA: OPA stands for Ortho-Phthalaldehyde. Compare the MSDS for Cidex OPA and Cidex. What similarities and differences do you see between these two chemicals?

Intermediate-Level Disinfection Inactivates tubercle bacilli, all vegetative bacteria, most viruses, and most fungi Does not kill bacterial spores Used for noncritical items Noncritical item: An item that comes in contact with intact skin but not mucous membranes What is “vegetative bacteria?” What is meant by “intact skin?” What is meant by “nonintact skin?”

Intermediate-Level Disinfection (Cont.) Used for noncritical items Noncritical item: An item that comes in contact with intact skin but not mucous membranes Examples: stethoscopes; blood pressure cuffs; tuning forks; percussion hammers; crutches Commonly used intermediate-level disinfectant: isopropyl alcohol What type of alcohol is used in alcohol wipes?

Low-Level Disinfection Kills most bacteria, some viruses, and some fungi Does not kill resistant microorganisms or bacterial spores Why is it important for the MA to disinfect the examination rooms?

Low-Level Disinfection (Cont.) Used to disinfect surfaces Examples Examining tables Laboratory countertops Commonly used low-level disinfectants: Sodium hypochlorite (household bleach) Phenolics What are some brand-name low-level disinfectants?

Types of Disinfectants Glutaraldehyde High-level disinfectant; rapid killing action Often used for semicritical items that cannot be exposed to heat (flexible fiberoptic sigmoidoscope) Brand names: Cidex and MetriCide Highly toxic Good ventilation necessary Wear utility gloves and safety goggles If skin comes into contact with chemical Rinse area thoroughly under running water What symptoms would occur if you inhaled fumes from glutaraldehyde? (See MSDS form.)

Types of Disinfectants (Cont.) Alcohol Frequently used in medical office In the form of antiseptic wipes Intermediate- to low-level disinfectant Most common types Ethyl alcohol Isopropyl alcohol Do we need an MSDS sheet for alcohol?

Types of Disinfectants (Cont.) Alcohol Action increased by the presence of water (70% alcohol solution recommended) Disadvantage: tends to dissolve the cement around lenses of instruments Used to disinfect: Stethoscopes Blood pressure cuffs Percussion hammers There are different percentages of alcohol available on the market.

Types of Disinfectants (Cont.) Alcohol Alcohol wipes used to disinfect small surfaces Diaphragm of stethoscope Rubber stopper of medication vial What are some other uses of alcohol wipes in the medical office?

Types of Disinfectants (Cont.) Chlorine and Chlorine Compounds Oldest and most used disinfectant Most important use: chlorination of water Used in medical office in the form of hypochlorites (e.g., chlorine bleach) It is recommended 10% solution of bleach in water for decontamination of blood spills Disadvantages Can irritate skin and mucous membranes Highly corrosive to metal What kind of container would you keep this mixture in and how would you label it?

Types of Disinfectants (Cont.) Phenolics Used on walls, furniture, floors, and laboratory work surfaces Irritating to eyes and skin Eye and skin protection should be worn when working with pure form Derivatives of phenolics are usually nonirritating Lysol Hexachlorophene Should gloves be worn when using a phenolic? What are some other examples of derivative phenolics?

Types of Disinfectants (Cont.) Quaternary ammonium compounds Used to disinfect noncritical surfaces (e.g., floors, furniture, walls) What are some patient teaching points about using household cleaners?

Guidelines for Disinfection Sanitize articles before disinfecting them Purpose: to remove all organic matter Organic matter prevents the disinfectant from reaching the surface of the article to kill microorganisms Organic matter may absorb disinfectant and inactivate it Thoroughly rinse off detergent Residue may interfere with disinfection process Dry article before disinfecting Water dilutes the chemical and decreases its effectiveness What would you do if an item that is ready for disinfectant has organic matter on it?

Guidelines for Disinfection (Cont.) Observe safety precautions Read MSDS and container label before using disinfectant Follow precautions to protect from Illness Injury Why might the MA wear PPE to follow this guideline?

Guidelines for Disinfection (Cont.) Properly prepare and use the disinfectant Prepare exactly as indicated on label To ensure destruction of microorganisms Preparation varies depending on the chemical used Must be applied for a certain length of time in order to kill microorganisms Time required is indicated on the container label Read all directions before preparing a disinfectant. How do we use the activating agent for Cidex? (See MSDS.)

Guidelines for Disinfection (Cont.) Properly store the disinfectant Should be closed tightly and stored properly Disinfectants lose potency over time Adhere to manufacturer's recommendations Shelf life Use life Reuse life Read MSDS to see how long the disinfectant can be stored after opening the container. Where would you find the expiration date? Use a permanent marker to write the expiration date on the bottle and add your initials. Use a permanent marker to write the date when the bottle should be discarded after use.

Sterilization Process of destroying all forms of microbial life including bacterial spores Used to process critical items Critical item: An item that comes in contact with sterile tissue or the vascular system Can boiling be used to sterilize articles? Why or why not? What are some examples of critical items? What are some examples of sterile tissue?

Sterilization (Cont.) Most offices also sterilize semicritical items in the autoclave Semicritical item: an item that comes in contact with nonintact skin or intact mucous membranes Examples: vaginal speculum, nasal speculum Convenient, efficient, safe, and inexpensive method for destroying microorganisms Less expensive and hazardous than using disinfectants Some vaginal and nasal speculums are disposable. Does a reusable (metal) vaginal speculum need to be wrapped before it is placed in the autoclave? Explain your answer. What are examples of intact mucous membranes?

Sterilization (Cont.) Most offices also sterilize semicritical items in the autoclave Exception: semicritical items that are heat-sensitive must be chemically disinfected Example: flexible fiber sigmoidoscope would be damaged by heat – Must be chemically disinfected Ask students to look up the procedure used to disinfect a flexible sigmoidoscope on the Internet.

Sterilization Methods Physical methods Steam under pressure (autoclave) Hot air (dry heat oven) Radiation Which of the above methods are used in the medical office?

Sterilization Methods (Cont.) Chemical methods Ethylene oxide gas Cold sterilization (chemical agents) When using cold sterilization, items are sterilized by soaking them in a particular chemical solution (such as one containing glutaraldehyde) followed by rinsing them in sterile water. Ask students to look at disinfectant containers (such as Cidex) to determine which can be used for cold sterilization.

Autoclave Most common method used in medical office to sterilize items Used to sterilize items not harmed by moisture or high temperature Name some items that are harmed by high temperature.

Autoclave (Cont.) Consists of an outer jacket surrounding an inner sterilizing chamber Distilled water is converted to steam under pressure (fills inner chamber) The pressure does not kill microorganisms Functions to attain higher temperature Steam of boiling water: only reaches 212o F (100o C) The MA must not open the autoclave while in use, as the steam will cause serious burns. Most autoclaves lock in place, which does not allow them to be opened when steam is present in the chamber. Why must distilled water be used with an autoclave?

Autoclave (Cont.) Cooler air forced out of chamber through the exhaust valve Air reduces the temperature that is adequate for sterilization Exhaust valve seals off the inner chamber when all air is removed Temperature begins to rise Look at a diagram of an autoclave, and find the exhaust valve.

Autoclave (Cont.) Steam penetrates the materials Materials are cooler: causes steam to condense and release heat Heat kills all microorganisms and spores Autoclave usually operated at Pressure: 15 pounds/square inch Temperature: 250o F (121o C) See manufacturer’s guidelines for proper temperature.

Autoclave (Cont.) Most microorganisms are killed in a few minutes (130o to 150o F) Spores can withstand a temperature of 240o F for more than 3 hours No organism can survive exposure at 250o F for 15 minutes or longer Spores are killed at this temperature and time What is the Celsius reading for 250° F?

Autoclave (Cont.) Sterilization process consists of the following: Monitoring program Sanitizing articles Wrapping articles Operating the autoclave (autoclave cycle) Handling and storing packs Maintaining the autoclave Where would you keep the operations manual for the autoclave?

Monitoring Program Recommended by CDC Consists of To ensure instruments/supplies are sterile when used Consists of Written policies for each step of the sterilization process Sterilization indicators To ensure that minimum sterilization conditions have been achieved Records for each cycle are maintained in an autoclave log Should include date and time of cycle; description of load; exposure time What does CDC stand for?

Monitoring Program (Cont.) Consists of Records for each cycle are maintained in an autoclave log – should include: Date and time of cycle; description of load; exposure time; exposure temperature; results of the sterilization indicator; initials of operator (some autoclaves automatically print this information) See Fig. 3-6 (p. 101) for an example of an autoclave log. Give the students an item that has been autoclaved and practice recording results in class.

Sterilization Indicators Purpose Determine effectiveness of the sterilization procedure Materials being sterilized must be: exposed to steam at a sufficient temperature; for a proper length of time What would happen if the instrument being autoclaved was not at the right temperature? Are all instruments autoclaved for the same amount of time?

Sterilization Indicators (Cont.) Purpose Checks against Improper wrapping of articles Improper loading of autoclave Faulty operation of autoclave Why is it important to load the autoclave properly?

Sterilization Indicators (Cont.) An article is not sterile unless steam has penetrated to its center Most indicators are placed in the center of the pack Important: Read manufacturer's instructions To determine where to place indicator Most reliable indicators check for Attainment of proper temperature Duration of temperature If an indicator is placed in the center of the pack, when would you know if the item was sterile or not sterile?

Sterilization Indicators (Cont.) If indicator does not change properly May be a problem in Sterilization technique Working condition of autoclave Check manufacturer’s guidelines Resterilize items following proper technique Indicators change colors when exposed to steam. What are some examples of improper sterilization techniques?

Sterilization Indicators (Cont.) If indicator does not change properly If indicator still does not change properly Autoclave is in need of repair Should not be used until serviced Store indicators in a cool, dry area Heat and moisture damage indicators What is a proper storage area for sterilization indicators? Where should sterilization indicators not be stored?

Wrapping Articles Purpose: protect sterile articles from recontamination during handling and storage Articles must be sanitized first Articles should be completely dry before wrapping.

Wrapping Articles (Cont.) Wrapping material should Allow steam to penetrate Prevent dust, insects, and microorganisms from entering during handling/storage Not tear or puncture easily Allow pack to be opened without contaminating the contents Do not use the wrapper if Torn Has a hole Only wrapping materials intended for the use of the autoclave should be used.

Sterilization Paper Disposable and inexpensive Square sheets of different sizes Why is sterilization paper manufactured in different sizes?

Sterilization Paper (Cont.) Articles must be wrapped using proper method So they do not become contaminated when pack is opened Disadvantages Difficult to spread open for removal of contents (flips back) Opaque: cannot view contents before opening The indicator must be checked inside the wrapper after opening the pack.

Sterilization Pouches Consists of paper and plastic Available in different sizes The most common sizes of sterilization pouches (in inches) are: 3 × 9, 5 × 10, and 7 × 12.

Sterilization Pouches (Cont.) Peel-apart seal on one end; used later to open pouch Other end open to insert item; then sealed with heat or adhesive tape Provide good visibility of item Indicator on outside of pouch Check for color change after autoclaving If indicator does not change color, must resterilize the item The name of the item, date, and initials of the MA are written on the front of the pouch.

Muslin Consists of reusable woven fabric Available in different sizes Lies flat when opened Flexible and easy to handle Most economical: can be reused Frequently used to wrap large packs (e.g., minor office surgery tray setups) Wrapped pack opened on a table Wrapper becomes a sterile field Most physician offices use peel-apart pouches. Why is muslin used for large packs?

Operating the Autoclave Operated according to operating manual Carefully read manual before running the autoclave Autoclave cycle: steps involved in achieving sterilization Based on whether the autoclave is operated manually or automatically What is the difference between a manual and an automatic autoclave?

Location of the Autoclave Place on a level surface Ensures the chamber fills correctly Where would the appropriate place be for the autoclave in the medical office?

Filling the Water Reservoir Use distilled water Tap water contains minerals: produce corrosive effects Fill to proper level If overfill or if not enough water in reservoir Autoclave may malfunction Distilled water can be purchased at a local store.

Loading the Autoclave Position packs to allow free circulation and penetration of steam Small packs are best: steam penetrates them easier More time required for steam to reach center of large packs Do not stack packs on top of each other.

Loading the Autoclave (Cont.) Position packs to allow free circulation and penetration of steam Pack loosely inside autoclave 1 to 3 inches apart for small packs 2 to 4 inches apart for large packs Packs should not touch walls Placing packs too close together retards flow of steam How many packs can be placed in an autoclave? (Show autoclave, give sizes of packs.)

Loading the Autoclave (Cont.) Position packs to allow free circulation and penetration of steam Place jars and glassware on sides with lids removed If placed upright: air may be trapped Packs containing layers of fabric (e.g., dressings) Should be placed in a vertical position to allow steam to penetrate layers of fabric Place pouches on their sides or on the tray with paper side up and plastic side down Maximizes steam circulation Facilitates drying Check the appropriate drying time for packs containing layers of fabrics.

Timing the Load Operated at 15 pounds of pressure Temperature of 250o F Length of time varies according to item being sterilized Hard, nonporous items Need less time (15 minutes) - example: Unwrapped instruments Large packs Requires more time (30 minutes) – steam needs to penetrate to center of pack Example: minor office surgery pack Look at an operating manual and describe the different articles and the length of time to the students.

Timing the Load (Cont.) Do not start time until desired temperature has been reached Automatic method: begins timing automatically when temperature has been reached Manual method: must set timer by hand Use timing control – do not set timer until temperature gauge reaches the desired temperature What would happen if the timer in a manual method is set at the wrong time?

Timing the Load (Cont.) Articles are not sterile unless they have been subjected to steam for: Proper length of time Proper temperature What might happen if an article is used that has not been processed for the proper length of time and at the proper temperature?

Drying the Load Articles are moist Must be dried before removal from the autoclave Microorganisms can move through moisture on a wet wrap and contaminate the sterile article inside Steam must be vented from chamber (most vent automatically) Makes it safe to open the door When opening the door for additional drying time, the autoclave may still be hot. What sound will you hear when steam is venting from the chamber?

Drying the Load (Cont.) Open door ½ inch More than 1 inch causes condensation of water on packs Cracking door allows moisture to change from liquid to vapor Dry load for 15 to 60 minutes depending on the load Large packs require a longer drying time The MA should step back when opening the door for safety precautions. Some autoclaves automatically open the door of the autoclave.

Handling and Storing Packs Handle packs as little as possible Event-related sterility: Sterile pack is considered sterile indefinitely unless an event occurs that interferes with sterility, such as being: Crushed Dropped Compressed If interference with sterility happens, what steps would the MA take?

Handling and Storing Packs (Cont.) Store packs in clean dry areas Most recent sterilized articles stored in back Check pack before storing it and before using it Where is the appropriate place for storing packs in the medical office? Why are the most recent sterilized articles stored in back?

Handling and Storing Packs (Cont.) Check pack before storing it and before using it No longer sterile if: Torn Opened Wet Must rewrap and resterilize Always inspect the packs before using.

Maintaining the Autoclave Operating manual: information on care and maintenance Before performing maintenance: Autoclave should be cool Pressure gauge at zero Power cord disconnected Why should the autoclave be cool before maintenance?

Daily Maintenance Wipe outside with damp cloth and mild detergent Wipe interior and trays with damp cloth Clean the rubber gasket on door with damp cloth Inspect rubber door gasket Damaged gasket prevents a good seal Inspect the rubber gasket for cracks, nicks, and proper fit.

Weekly Maintenance Drain water reservoir Wash inside of chamber and trays with commercial autoclave cleaner Observe all personal safety precautions Use soft cloth or brush If you run out of autoclave cleaner, can you clean the autoclave with a household cleaner?

Monthly Maintenance Flush system to remove built-up residue (follow manufacturer's instructions) Check air trap jet and safety valve to make sure they are functioning properly How would you check the air trap jet and safety valve?

Assignments Definitions Watch videos 3.1 to 3.5 Groups to Lab