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

2. Why is it important?

4. Reported Outbreaks from Duodenoscopes
Florida 2008
Pittsburg 2012
Chicago 2013
Los Angeles
Seattle

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

6. Who Offers Guidance
They don’t always agree!

7. The basics

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

9. 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:

10. Non-Critical
Equipment/ instruments that contact intact skin

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

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

13. Clean
Removal of soil

14. Disinfection
elimination of most pathogenic microorganisms(not spores)

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

16. Sterilization
elimination of all pathogenic microorganisms, including spores

17. 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

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

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

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

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

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

23. 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

24. Lots to Track!

25. 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

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

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

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

29. And this…

30. 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

31. 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