High Level Disinfection of Clinical Equipment and Strategies for Endoscopes Larissa Lewis, RN, BSN, CIC Infection Preventionist UW Harborview Medical Center

Why is it important?

Reported Outbreaks from Duodenoscopes Florida 2008 Pittsburg 2012 Chicago 2013 Los Angeles 2013-2015 Seattle 2012-2015

Who’s Interested? …And anyone else who might accredit your facility

Who Offers Guidance They don’t always agree!

The basics

A Perfect World Single Use or Single Patient Use Reasons why this is not possible: Expense Waste Practicality

Spaulding Classification Earl Spaulding was a microbiologist at Temple University Over 30 years ago he proposed classification of patient care items and medical equipment and appropriate level of disinfection Earl Spauling wrote a paper on disinfection in 1939 using these:

Non-Critical Equipment/ instruments that contact intact skin

Semi-Critical Equipment/ instruments that contact mucous membranes or nonintact skin

Critical Equipment/ instruments that enter sterile tissue or the vascular system

Clean Removal of soil

Disinfection elimination of most pathogenic microorganisms(not spores)

Disinfection Low-level disinfection – High-level disinfection – elimination of many pathogenic microorganisms High-level disinfection – elimination of all pathogenic microorganisms except spores

Sterilization elimination of all pathogenic microorganisms, including spores

Back to Earl Spaulding… Critical Items Equipment/ instruments that enter sterile tissue or the vascular system Surgical equipment Implants Sterilization Semi-critical Items Equipment/ instruments that contact mucous membranes or nonintact skin Many endoscopes Vaginal US probes Respiratory therapy equipment High level disinfection Noncritical Items Equipment/ instruments that contact intact skin Blood pressure cuff Patient environment Ambulation aids Low level disinfection

DON’T FORGET TO CLEAN! Cleaning is the fundament to disinfection regardless of the level!

Why? Biofilm! FEMS Microbiol Rev 36 (2012) 972–989

Cleaning ultrasound probes vs scopes These are both semi-critical items Vs.

Sterilization Steam Hydrogen peroxide gas plasma 100% Ethylene oxide (ETO) ETO mixtures Vaporized hydrogen peroxide Ozone

High Level Disinfection Peracetic acid/hydrogen peroxide Gluteraldehyde Hydrogen peroxide Ortho-phthalaldehyde (OPA) Peracetic acid

Manual High Level Disinfection Active times vary by product; 7-90 minutes Chemicals are inactive below certain temps, vary by product; 20-30°C Expiration dates of chemicals Overall expiration Expiration of the product once open Expiration of the product in use May also have to test solution for quality and keep track of test strip Lots of subtly and variation between products

Lots to Track!

Automated High Level Disinfection Completes all steps of high level disinfection following manual cleaning Often device specific Most often used with endoscopes Device compatibility is essential

High Level Disinfection is EVERYWHERE! Outpatient clinics/procedure areas Inpatients ancillary departments Inpatient procedure areas Anywhere with Scopes Ultrasound probes Respiratory equipment/ anesthesia equipment

Why is it so important to know where high level disinfection is being done?

This! All staff must be trained and competency validated All staff must be trained and competency assured.

And this…

Additional Monitoring for Endoscope Procedures ATP? – adenosine triphosphate monitoring Measures “cleanliness” Culturing? – take cultures off scopes after procedures Surveillance? – track patients who’ve had the procedure and monitor for infection

Most important Know where you have high level disinfection Ensure device/chemical compatibility Ensure device/automated reprocessor compatibility Make sure your peeps are trained Track EVERYTHING Follow manufacturer’s directions The scope The chemicals/automated reprocessor compatibility