Perioperative Division New Employee Orientation

1
Perioperative Division New Employee Orientation

• Sterilization

2
Reading Assignment

• Completion of this module requires reading the
  following
• UAB Hospital Nursing Standard Sterilization
• UAB Hospital Interdisciplinary Standard
  Creutzfeldt-Jakob Case, Management of a
• UAB Hospital Interdisciplinary Standard
• Steris Machine, Operation of

3
Objective 1

• Identify the 4 major methods for
• sterilization used in the OR CSS

4
Sterilization

• The process of killing micro-organisms by
  physical (exheat) or chemical (exparacetic
  acid) means

5
Most Common Methods of Sterilization used in OR
CSS

• Steam
• Liquid paracetic acid (Steris)
• Ethylene Oxide gas
• Hydrogen peroxide plasma (Sterrad, Abtox)

6
Steam Sterilization

• Most common, cost-effective rapid means of
  sterilization
• Major factors in steam sterilization time,
  temperature moisture
• Steam sterilizers may be gravity displacement,
  pre-vacuum or both

7
Gravity Displacement Steam Sterilizer Cycles

1. Conditioning- Steam enters the chamber, pushing
   out the air chamber temperature pressure rise
2. Exposure- Items being sterilized are exposed to
   heat/steam
3. Exhaust Phase- Steam is removed from the chamber,
   and the pressure within the chamber returns to
   atmospheric pressure
4. Drying Phase

8
Prevacuum Sterilizers

• Conditioning phase- Air is mechanically pulled
  out, and steam is injected. This method is more
  efficient than gravity displacement

9
Flash Sterilization

• Refers to the sterilization of unwrapped
  instruments in the OR
• Not a preferred method of sterilization- is used
  only when there is not sufficient time to package
  and sterilize the item

10
Ethylene Oxide Gas (EtO)

• Suitable for heat and moisture sensitive items

11
EtO

• Use regulated by OSHA the EPA
• EtO is highly flammable
• Associated with several health hazards- EtO is a
  carcinogen mutagen
• EtO overdose is associated with skin irritation,
  respiratory irritation, headache nausea

12
Hydrogen Peroxide Plasma Sterilization

• Sterrad
• Low temperature sterilization that is appropriate
  for heat and moisture sensitive items
• Sterilization cycle approximately 1 hour
• Do not use muslin or cellulose-containing
  wrappers with this system (H2O2 plasma can be
  absorbed by these materials, interfering with the
  sterilization process

13
Paracetic Acid Sterilization

• Steris
• Suitable for heat-sensitive instruments that can
  be immersed (ex endoscopes)
• Total cycle approximately 30 minutes-
• Exposure to the sterilant for 10 minutes,
  followed by four rinses with sterile water

14
Paracetic Acid Sterilization

• Is also known as just-in-time sterilization
• Items are processed just before they are used,
  cannot be stored for later use

15
Objective 2

• Identify the parameters for
• each type of sterilization

16
Steam Sterilization

• The exposure phase (or sterilization phase) does
  not begin until the chamber temperature reaches
  270F

17
Flash Sterilization

• Considered appropriate
• When an item is contaminated (ex dropped on
  floor) and is needed to continue a surgical
  procedure
• When there is no other sterilization
  alternativeshould not be used on a routine basis

18
Flash Sterilization

• Flash sterilization of multiple instruments or of
  full trays of instruments is not recommended
• Full trays of instruments should be flashed only
  if there is no other alternative AND the physical
  layout of the OR allows direct transport of the
  tray to the point of use

19
Powered Instruments

• Flashing of powered instruments is not
  recommended
• If a powered instrument must be flashed, follow
  the manufacturers recommendations

20
Implants

• The following agencies recommend that implants
  NEVER be flash sterilized
• CDC
• AORN
• AAMI

21
Implants

• If there is no alternative to flashing an
  implant
• Sterilize for 10 minutes at 270F

• A biological indicator must be included in the
  autoclave load when flashing implants!

22
Flash Sterilization

• For non-porous items (metal) that do not have a
  lumen
• flash at 270 degrees F for 4 minutes
• For porous items (instrument with a wooden
  handle) or an instrument with a lumen (suction
  tubes, cannulated drills, etc)
• Flash at 270 degrees F for 10 minutes

23
Steris (Paracetic Acid)

• Exposure time 12 minutes
• Temperature 50 - 56C

24
Objective 3

• Identify criteria for choosing the
• appropriate method of
• sterilization

25
Steam Sterilization

• Items must be able to tolerate combination of
  high heat (up to 275F) and moisture

26
EtO Gas Sterilization

• Suitable for items that are heat- and
  moisture-sensitive
• Disadvantages time required for sterilization
  aeration lengthy

27
Steris (Paracetic Acid)

• To be appropriate for paracetic acid
  sterilization items must
• Fit into Steris tray without crowding so that the
  sterilant comes into contact of all surfaces of
  items
• Must be immersible
• Must be able to withstand temperatures of up to
  56C (132.8F)

28
Hydrogen Peroxide Plasma (Sterrad)

• Good for heat-sensitive devices
• Cycle time approximately 1 hour
• Disadvantages Not compatible with all materials.
  Is not compatible with cloth or items containing
  cellulose

29
Objective 4

• State the difference between
• cleaning, disinfecting and
• sterilizing

30
Sterilization

• The process of killing micro-organisms by
  physical (exheat) or chemical (exparacetic
  acid) means
• Sterilization vs. Disinfection
• Sterilization destroys all microbial life,
  including bacterial spores
• Disinfection destroys almost all microbes, but
  might not destroy spores

31
Classifications of Patient Care Items

• CDC categorizes the level of decontamination
  items need according to risk of infection they
  present
• Critical
• Semi-critical
• Non-critical

32
Non-critical Items

• Only come into contact with intact skin and are
  unlikely to transmit disease (example B/P cuff)

33
Semi-critical

• Contact mucous membranes, but do not penetrate
  skin. More likely to transmit infection than
  non-critical devices.
• (example endoscopes)

34
Critical Devices

• Items that come into contact with non-intact
  skin. Present a high risk of transmitting
  infection.
• (example surgical instruments)
  

35
Levels of Disinfection

• Low-level kills most bacteria may not kill all
  spores or viruses
• Intermediate-level kills most bacteria, viruses
  and fungi. May not kill spores
• High-level kills all microorganisms, but may not
  kill all spores

36
Disinfection

• Recommended level of disinfection by device
  classification
• Critical items High-level disinfection
• Semi-critical itemsHigh-level disinfection
• Non-critical itemsLow-level disinfection

37
Objective 5

• Describe preparation of items
• for sterilization

38
Transport

• Contaminated instruments must be transported in
  closed, leak proof containers

39
Decontamination

• The process of cleaning contaminated items to
  make them safe for handling by people who are not
  wearing protective attire.
• Instruments must be clean for the sterilization
  process to be effective
• Dried blood, tissue or bone remaining on an
  instrument after decontamination will prevent the
  sterilant from making contact with the
  instruments surface

40
Nosocomial Infections

• Most cases of nosocomial (hospital-acquired)
  infection related to surgical instruments are
  caused by ineffective decontamination
• Surgical infections are very costly to treat,
  cause increased patient pain, and prolong the
  patients recovery

41
Cleaning

• Cleaning dirty instruments reduces bioburden,
  which refers to the microorganisms left on a
  contaminated object.
• Instruments must be properly cleaned in order for
  the sterilization process to be effective

42
Bioburden

• Bioburden left on instruments after cleaning
  interferes with sterilization by acting as a
  shield, preventing the sterilant from contacting
  every part of the instruments surface
• (Sterilant agent that destroys
  microorganisms, i.e. steam, EtO Gas)

43
Manual Cleaning

• For instruments which cannot be immersed in water
  or machine washed (ex orthopedic power drills
  saws)
• For instruments that are heat-sensitive (ex
  laparoscopic arthroscopic cameras)

44
Mechanical Cleaning

• Preferred method because it reduces exposure to
  potentially infectious materials
• Have several cycles, typically pre-rinse,
  enzymatic rinse, spray wash rinse, lubrication
  and dry cycles

45
Mechanical Cleaning

• Instruments that are heat, moisture, and
  pressure-sensitive should not be washed in
  mechanical washers
• Examples powered instruments, microsurgical
  instruments, cameras

46
Powered Instruments

• May be powered by compressed
• gas, battery, electricity
• Require special handling
• To clean wipe off the exterior by hand, NEVER
  immerse power tools in liquid!
• To lubricate follow manufacturers instructions

47
Objective 6

• Describe methods for evaluating sterilizer
  effectiveness for various sterilization methods

48
Sterilization Quality Control

• Documentation of each sterilization cycle
• Mechanical, biological chemical monitoring

49
Sterilizer Documentation

• Type of sterilizer cycle used
• Load number
• Contents of the load
• Exposure time temperature
• Results of biological chemical monitoring
• Patient sticker can be used on sterilizer log book

50
Sterilization Monitoring

• Mechanical
• Chemical
• Biological

51
Mechanical Indicators

• Measure time, temperature, pressure
• Examples autoclave readout, graphs

52
Chemical Indicators

• React to specific conditions, such as temperature
• Indicate that conditions for sterilization to
  occur have been met, but do not guarantee that
  sterilization has occurred
• Examples autoclave tape, indicator strips

53
Chemical Indicators

• It is important to have the
• correct mechanical indicator
• for the sterilization process being used
• Steam indicator for steam load, EtO indicator
  when processing items in ethylene oxide gas
  sterilizer, etc.

54
Biological Indicators

• Contain a concentration of organisms, usually
  live bacterial spores, that are resistant to
  being destroyed
• Used to indicate whether or not conditions needed
  for sterilization have been met

55
Biological Indicators

• Biological indicators should be used in autoclave
  loads at least weekly, but daily is preferred
• Biological indicators should be run in the first
  load after any major repairs to the autoclave.
• BIs should always be used in any load containing
  implants

56
Positive BI

• Check for defects in the BI vial- cracks, expired
  BI, incorrect BI (steam BI used for EtO load, EtO
  BI used for steam load), incorrect incubator
• Check sterilization parameters
• If BI truly positive remove sterilizer from
  service, notify supervisor, if items have already
  been delivered to the sterile field notify
  surgeon

57
Objective 7

• Demonstrate correct instrument tray assembly for
  sterilization
• To be completed during rotation in CSS

58
Objective 8

• Demonstrate correct, safe use of sterilization
  equipment
• To be completed in OR

59
Demonstrate correct use of

• Steam autoclave
• Steris

60
Objective 9

• Demonstrate proper technique for transporting
  articles after point of use sterilization
• To be completed in OR

61
Objective 10

• Identifies occupational hazards associated with
  various methods of sterilization

62
Steam Autoclave

• Occupational hazards of steam sterilizers- burns
• Open autoclave door carefully to avoid steam
  burns
• Use sterile towels to remove items from autoclave

63
Ethylene Oxide Gas Occupational Hazards

• EtO is highly flammable
• Associated with several health hazards- EtO is a
  carcinogen mutagen
• EtO overdose is associated with skin irritation,
  respiratory irritation, headache nausea

64
Safety Measures for EtO

• Items sterilized with EtO are aerated to remove
  residual gas before removal from sterilization
  chamber
• Sterilizer has an alarm which alerts staff to any
  accidental release of EtO
• Periodic monitoring for CSS employee exposure

65
Steris (Paracetic acid)

• Undiluted sterilant is corrosive- avoid exposure
• In case of contact to eyes or skin flush with
  copious amount of water for at least 15 minutes
• Store sterilant containers in well-ventilated
  area where temperature does not exceed 79F

66
Hydrogen Peroxide Plasma

• Sterrad
• Units located in CSS
• No special precautions are necessary for handling
  items sterilized by this method

67
Glutaryldehyde (Cidex)

• May be damaging to the eyes, may cause skin and
  respiratory tract irritation
• In event of Cidex splashing into eyes
  immediately flush eyes with water for 15 minutes,
  seek immediate medical care

68
Glutarldehyde

• Skin exposure remove contaminated clothing, wash
  affected area with soap and water, then flush
  with water for at least 15 minutes
• If skin irritation persists after rinsing area
  seek medical care

69
Glutaraldehyde

• If exposure causes respiratory irritation, move
  to a well-ventilated area.
• If respiratory difficulty develops, administer
  oxygen and seek immediate medical assistance

70
Objective 11

• Discusses concept of shelf life
• as it relates to handling,
• transport and storage of sterile
• supplies and equipment

71
Transport of Sterile Supplies

• Sterile items should be transported in a way that
  protects them from inadvertent contamination
• Avoid areas with excess amounts of moisture or
  dust
• Avoid dropping sterile supplies- a wrapped item
  that is dropped on the floor should be considered
  contaminated

72
StorageTime-related vs. Event-related

• Traditionally, sterilized items were given a
  time-related storage date. The item expired (was
  no longer considered sterile) after a specific
  time from the date of sterilization
• Current thought is that sterile storage time
  should be event-related, nottime-related

73
Event-related Storage

• A sterile package is considered to be sterile
  until something happens to make it un-sterile
• Contamination is caused by an event, not by the
  passage of time
• (Ex the package getting wet, a hole torn in
  the package)

74
Event-Related Storage

• Concept of event-related storage applies to items
  sterilized in the hospital, or manufacturer-steril
  ized items that have no labeled expiration date
• Expiration dates on manufacturer-sterilized items
  are observed

75
Storage of Sterilized Items

• Sterile storage areas should have controlled
  temperature humidity
• Temperature should be between 65 - 72 F
• Relative humidity should be 35 75

76
Open Shelf Storage

• Sterile items should be stored
• 2 inches away from outside walls
• 8 inches above the floor
• 18 inches from ceiling fixtures
• (closed shelf storage is preferable, as it offers
  more protection for sterile items, but is not
  always possible)

77
Sterile Items

• When sterile items are retrieved from storage
  they should be visually inspected before opening.
• Examine packages for holes, tears, water stains
  which indicate that the package is contaminated

78
References

• AORN (2003) Standards, Recommended Practices
  Guidelines
• Roth, R. (1995) Perioperative Nursing Core
  Curriculum
• Rothrock, J. (2003) Alexanders Care of the
  Patient in Surgery
• Steris (2002) The Hot Issues of Flash
  Sterilization Continuing Education Study Guide
• Steris (2002) The Liquid Chemical Sterilization
  Story Continuing Education Study Guide
• V. Mueller The Care and Handling of Surgical
  Instruments video study guide by Allegiance
  Healthcare Corporation