Decontamination Procedures for Medical Equipment

Introduction Decontamination of medical equipment involves the destruction or removal of any organisms present in order to prevent them infecting other patients or hospital staff.

Microbes (bacteria & viruses) Microbes can be carried from one person to another on the surface of any equipment that is shared between them unless it is decontaminated between use. They can also be carried on the skin surface which is why hand washing between examining patients is important. Microbes gain access to the body, through open wounds, inhalation of infected secretions or by close contact with mucous membranes.

decontamination process The process by which microbes are passed from one infected person, to cause infection in another, is known as 'cross-infection'. Cleaning, disinfection and sterilization are all procedures that are used in the decontamination process. Decontamination reduces the risks of cross infection and helps to maintain the useful life of equipment.

Cleaning is the process that removes contaminants including dust, soil, large numbers of micro -organisms and organic matter (e.g. blood, vomit). It is an essential prerequisite to disinfection and sterilization. It also removes the organic matter on which micro-organisms might subsequently thrive.

Disinfection Is a process used to reduce the number of micro-organisms but not usually bacterial spores. The process does not necessarily kill or remove all micro- organisms, but reduces their number to a level which is not harmful to health.

Sterilization removes or destroys all forms of microbial life including bacterial spores.

Groups of risk Each instrument or piece of medical equipment which comes into contact with a patient is a potential source of infection. These are divided into 3 groups of risk: High risk Intermediate risk Low risk.

High risk items come into close contact with a break in the skin or mucous membranes or are introduced into a normally sterile body area. e.g. surgical instruments, needles, urinary and other catheters. Sterilization is required for this group.

Intermediate risk items come into close contact with mucous membrane or are items contaminated with particularly virulent or readily transmissible organisms. e.g. Items of respiratory equipment including laryngoscope blades, endotracheal and tracheostomy tubes, oropharyngeal and nasal airways. Disinfection is required for this group.

Low risk items only come into contact with normal intact skin. e.g. stethoscopes or washing bowls. Cleaning and drying is usually adequate for this group

Techniques of disinfection and sterilization Before equipment is to be disinfected or sterilized, it should be thoroughly cleaned to remove any visible dirt or secretions. This involves washing with water and detergent (soap). Protective clothing (an apron, gloves and a facemask) should be worn.

Disinfection Disinfection is best achieved by moist heat such as boiling in water (100°C for 10 minutes at sea level) which kills all organisms except for a few bacterial spores. temperature at which water boils decreases with altitude and a longer boiling time will be required. e.g. at 4000m above sea level where boiling occurs at 86°C a minimum of 20 minutes is required for disinfections. It is important to note that boiling equipment items in water will not achieve sterilization.

Disinfection Disinfection can also be achieved by using chemicals which however may themselves be toxic when allowed contact with skin or are inhaled. They can also be corrosive and flammable so that protective clothing (gloves, apron and a facemask) should be worn.

Chemical disinfectants Chemical disinfectants may be supplied ready to use or may need accurate dilution to provide an appropriate solution. disinfectants can decay and lose activity Decay is more rapid at high temperatures and can be accelerated by the presence of impurities. All disinfectants take time to work.

Range of Activity of Disinfectants Gram positive bacteria. E.G. Staphylococci, are more sensitive than gram negative bacteria e.G. Pseudomonas. Mycobacteria and spores are relatively resistant. Enveloped viruses e.G. HIV are killed by most disinfectants but non-enveloped viruses e.G. Coxsackie tend to be more resistant.

Spores Fungal spores are easily killed by disinfectants. Other bacterial spores e.g. Clostridia are resistant to most disinfectants in common use. Tubercle bacteria are more resistant to chemical disinfectants than other bacteria. They can be killed by exposure to 2% alkaline Glutaraldehyde solution (Cidex) for 60 minutes.

Viruses. Hepatitis B virus (HBV) and Human Immunodeficiency Virus (HIV) are inactivated by Cidex in minutes. to ensure adequate penetration, soiled items should be placed in a 2% glutaraldehyde solution for 30 minutes. Exposure to 70% alcohol solution for 10 minutes is also effective. Viruses causing Rabies, Lassa fever and other haemorrhagic fevers are also killed by Cidex.

Heat In order to kill microbial agents, heat can be applied in dry or wet form. The advantage of wet heat is a better heat transfer to and into the cell resulting in overall shorter exposure time and lower temperature.

Steam sterilization Steam sterilization uses pressurized steam at C ( F) for 30 or 40 minutes. This type of heat kills all microbial cells including spores, which are normally heat resistant. In order to accomplish the same effect with dry heat in an oven, the temperature needs to be increased to C ( F) for periods of 2 to 4 hours.

Liquid Chemicals Used as Disinfectants Liquid disinfectants are preferably used for solid surfaces and equipment. They vary greatly in their efficiency, depending on the chemical constituents and the agents involved.

Variables to remember when disinfecting: Nature of surface being disinfected - Porous or smooth the more porous and rough the surface, the longer a disinfectant will need to be effective.

Number of microorganism present Higher concentrations require a longer application time and/or higher concentration of disinfectant.

Resistance of microorganisms - Microbial agents can be classified according to increasing resistance to disinfectants and heat

Presence of organic material - The proteins in organic materials such as blood, bodily fluids, and tissue can prevent or slow the activity of certain disinfectants.

Duration of exposure and temperature Increased exposure time increases the effectiveness of disinfectants. Low temperatures may slow down the activity requiring more exposure time.

Surface Disinfectants and Microbial Activity Disinfectants work by absorbing onto any microbial cell. such absorption increases the permeability of the cell membrane, ultimately leading to rupture and leakage of the contents of the cell. The cell dies. There is no chance for mutation.

Chemical disinfectant solutions

concentrations 5% to 10 %. Unpleasant odor Toxic. protective equipment used for disinfection of walls, floors, bench tops. They effectively kill bacteria including Mycobacterium tuberculosis, fungi and lipid- containing viruses. They are not active against spores Phenol and Phenol Derivatives:

Halogens (Chlorine and Iodine): Sodium hypochlorite is the most common Common household bleach (5% available chlorine) can be diluted 1/10 to 1/100 with water Always use personal protective equipment At high concentrations and extended contact time, considered cold sterilants Iodine has similar properties to chlorine. They are most often used as antiseptics and in surgical soaps and are relatively nontoxic to humans.

Alcohols Ethyl or isopropyl alcohol in concentration of 70% to 90% are good general-use disinfectants. they evaporate fast and therefore have limited exposure time. They are less active against non-lipid viruses and ineffective against bacterial spores. Concentrations above 90% are less effective. (eg methanol, ethanol & isopropanolol) have good activity against bacteria & viruses. They should only be used after all the visible surface dirt has been removed from the area to be disinfected.

Aldehydes Formalin: Formalin is 37% solution of formaldehyde in water. Dilution of formalin to 5% results in an effective disinfectant. Formaldehyde is a human carcinogen and creates respiratory problems at low levels of concentration.

Glutaraldehyde: chemically related to formaldehyde, is more effective against all types of bacteria, fungi, and viruses. Vapors of glutaraldehydes are irritating to the eyes, nasal passages and upper respiratory tract.

Quaternary Ammonium Compounds (Quats): detergents with strong surface activity. They are active against Gram-positive bacteria They are less active against Gram-negative bacteria. Quats are relatively nontoxic and can be used for decontamination of food equipment and for general cleaning.

Sterilization This can be achieved by steam, steam & formaldehyde, hot air, ethylene oxide or irradiation. Autoclaving is the commonest method. It uses steam under pressure and is the most reliable way to sterilize instruments. A temperature of 134°C for 3 minutes or 121°C for 15 minutes is recommended.

Formaldehyde Formaldehyde is irritant to the eyes, respiratory tract and skin. It can also be absorbed by some materials and subsequently slowly released with potentially hazardous results. Hot air sterilization takes a long time and items must be able to withstand temperatures of at least 160°C for periods of 2 hours or more.

Formaldehyde gas Formaldehyde gas is primarily used in the decontamination of spaces or biological containment equipment like biological safety cabinets. Formaldehyde is a toxic substance and a suspected human carcinogen. Considerable caution must be exercised in handling, storing, and using formaldehyde

Ethylene oxide Ethylene oxide is a colorless gas which is toxic to inhale. It is effective against all organisms and does not damage equipment. The operating cycle ranges from hours so the turnaround time is prolonged and it is a relatively expensive process. A variety of vapors and gases possess germicidal properties. The most commonly used are formaldehyde and ethylene oxide.

Applied in closed systems under controlled conditions (e.g., humidity) these gases achieve sterility. Ethylene oxide is used in gas sterilizers under controlled conditions. Ethylene oxide is also a human carcinogen and monitoring is necessary during its use.

Sterilisation by irradiation Sterilisation by irradiation is an industrial process and particularly suited to the sterilization of large batches of products. Irradiation can cause serious deterioration of materials and is therefore not a suitable method for the resterilisation of equipment items

Radiation Gamma and X-ray are two principal types of ionizing radiation used in sterilization. Their application is mainly centered on the sterilization of prepackaged medical devices. Ultraviolet (UV) radiation is a practical method for inactivating viruses, mycoplasma, bacteria and fungi. UV radiation is successfully used in the destruction of airborne microorganisms. UV light sterilizing capabilities are limited on surfaces because of its lack of penetrating power.