Cleaning and Disinfection in the Ambulatory Care Setting

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• Cleaning and Disinfection in the Ambulatory Care
  Setting
• Infection Prevention and Control
• Henry Ford Health System

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• This program is approved for 1.0 CE per
• Henry Ford Health System Nursing Development
  (Provider OH 312, 11/01/2015) is an approved
  provider of continuing nursing education by the
  Ohio Nurses Association (OBN-001-91), an
  accredited approver by the American Nurses
  Credentialing Centers Commission on
  Accreditation.
• The authors and planners of this program have
  declared no conflicts of interest.
• IN order to receive the CE you must complete a
  survey at the end of the program. The link is
  provided on the last slide.
• This program is available from October 1, 2013 to
  October 1 , 2014

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Objectives

• Describe basic principles of cleaning,
  disinfection and storage of patient care
  equipment in the clinic setting.
• Identify when to use cleaning, disinfection or
  sterilization with devices or the clinic
  environment.
• Understand how to complete an Infection Control
  Risk Assessment related to cleaning patient care
  equipment.

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Risk Factors For Cross Contamination in
Outpatient Clinics

1. Inadequate disinfection and sterilization of
   instruments and equipment
2. Improper use of barrier precautions by infected
   health care workers (or not taking sick leave)
3. Inadequate hand hygiene practices among health
   care personnel

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Infection Risks In The Healthcare Environment

• One of the easiest ways that pathogens are
  transferred in the healthcare environment is via
  hand carriage. Surfaces and equipment that are
  contaminated will colonize the hands of
  healthcare workers with pathogenic
  microorganisms.
• These pathogens are then transferred to the
  patient may cause infection.
• The importance of the environment as a source of
  infection is gaining more attention.

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CDC Recommends

• Training for all care providers on equipment
  cleaning and disinfection, specific to their job
  duties
• Training that focuses on worker safety and
  patient safety
• Training at orientation and repeated regularly
  (e.g., annually)
• Competencies in each workers personnel file that
  document their training.

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Healthcare Equipment Is Classified According To
Risk For Infection
Critical Enter tissue or vascular system Sterile
Semi- Critical Contact mucous membranes or non-intact skin Sterile or High Level Disinfected
Non-Critical Contact intact skin Medium or Low-Level Disinfected
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Terminology

• Cleaning
• General removal of debris (dirt, food, feces,
  blood, saliva, etc.)
• Reduces amount of organic matter that contributes
  to proliferation of bacteria and viruses
• Disinfection
• Removes most organisms present on surfaces that
  can cause infection or disease
• Sterilization
• Eliminates all living microorganisms, including
  bacterial spores

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More on Cleaning

• Accomplished with water, detergents and
  mechanical action (friction)
• The physical removal of foreign material such as
  dust, oil, secretions and micro-organisms.
• Reduces or eliminates the reservoirs of potential
  pathogenic organisms.

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Many Reservoirs For Infection
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Disinfection

• Eliminates or kills most bacteria, many virus
  types and some fungi
• Time-dependent process
• Cannot be accomplished without first cleaning

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Disinfection

• Follow manufacturers recommendations to achieve
  disinfection and to avoid medical device damage.
• Use correct dilution more is not better!
• Use correct contact time
• Use correct temperature
• Understand employee and environmental safely
  issues
• Do not exceed exposure limits
• Know permissible exposure levels
• Assess compatibility with gloves, basins, other
  products

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Sterilization

• Required for any items that enter tissue or
  vascular system.
• If item is reprocessed for use on another
  patient, it MUST be cleaned properly before
  sterilization.

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Non-critical Items

• Include items in contact with intact skin
• Therefore sterility is not critical
• Require intermediate-level or low-level
  disinfection products
• Examples include BP cuffs, stethoscopes, durable
  mobile patient equipment

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Medical Equipment

• Labeled by manufacturer as either reusable or
  single-use.
• Reusable equipment should have instructions for
  cleaning, disinfection or sterilization as
  appropriate. Must follow these instructions for
  cleaning maintenance.
• Single-use devices are labeled for only one use
  and do not have reprocessing instructions.

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Reusable Medical Equipment
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Disinfection of Supplies Equipment

• Certain reusable devices must be cleaned and
  reprocessed between uses with different patients,
  such as
• Ultrasound and X-ray equipment that touch a
  patient or are handled by the technician

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To Disinfect Noncritical Medical Devices

• Must use an EPA-registered hospital disinfectant
  using the labels safety precautions and
  directions for use.

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EPA Registration Of Disinfectants

• Labeled as high level vs. intermediate vs. low
  level
• May include degrees of approval
• Limited approval, e.g., kills Hepatitis B and HIV
  but not approved for spores.
• Select disinfectant based on what you are trying
  to accomplish
• Environmental vs. medical device disinfection
• Make certain product is compatible with device
• Can search EPA website by product name
• www.epa.gov/oppad001/chemregindex.htm

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Glucometers

• Multiple outbreaks have occurred associated with
  blood glucose monitoring
• Hepatitis B outbreak in an assisted-living
  facility in 2010 resulted in 6 deaths. Findings
• Finger stick devices used for gt 1 patient
• Did not clean and disinfect meters between
  patients

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Glucometer Recommendations From CDC

• A new single-use, auto-disabling lancing device
  is used for each patient
• The glucose meter is cleaned and disinfected
  after every use.

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Glucometers

• Must be cleaned between each patient or
• before going into storage.

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Glucometers

• Routine use After C.diff patient
• Use the proper wipe! After every use!

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Clostridium Difficile

• Also called C. diff
• Recurrent, severe diarrhea
• Abdominal cramping, vomiting
• Difficult to treat
• Sometimes results in patient death
• More often seen in community long-term care
  setting
• Increasing incidence.

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C. Difficile / Norovirus

• Suspect with any acute diarrhea
• Requires bleach cleaning of equipment and
  surfaces to eliminate spores.
• Hand hygiene must be with soap and water

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Environmental Cleaning

• Patient environment can facilitate transmission
  of bacteria and viruses
• By direct contact
• On hands of healthcare personnel
• Contaminated surfaces increase potential for
  transmission of bacteria and viruses between
  patients

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Infection Risks In The Healthcare Environment

• Bacteria may persist for long periods on dry
  surfaces
• MRSA 7 days to 7 months
• Acinetobacter 3 days to 5 months
• C. difficile (spores) 5 months
• Escherichia coli 1.5 hours to 16 months
• Influenza few days
• Source Kramer et al, BMC infectious
  Diseases, 2006

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• CDC has three recommendations for environmental
  cleaning and disinfection.

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• 1
• Have policies in place for routine cleaning
  and disinfection of environmental surfaces in
  ambulatory care settings
• Focus on those surfaces in proximity to the
  patient and those that are frequently touched.
• Example Once / day unless visibly dirty or risk
  assessment requires additional cleaning.

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• 2
• Select EPA-registered disinfectants or detergents
  with label for use in healthcare.

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• 3
• Follow the manufacturers recommendations for use
  of cleaners and EPA-registered disinfectants
  (e.g., amount, dilution, contact time, safe use
  and disposal)

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What Is Contact Time?

• Sometimes called dwell time
• Time necessary to kill disease causing organisms
• Varies with each product
• 1 minute 2 minutes 10 minutes

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Cant I Just Eyeball Dilution?

• Proper dilution is important
• Ability to kill disease causing organisms depends
  on strength of solution
• Developed / tested by manufacturer
• Recommended concentration is the only guarantee.
• Dont guess!

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Dilution Of Disinfectant

• Too weak ---- not effective in killing organisms
• Too strong --- corrosive to equipment or
  dangerous to the user.
• Proper PPE is important to protect the healthcare
  worker.

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High Touch Surfaces In Patient Rooms

• Considered non-critical
• Must be cleaned then disinfected on a regular
  basis.
• What are your clinics high touch surfaces?

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Sample Cleaning Schedule

• Each clinic needs a rational approach to
  cleaning.
• How often?
• Who? When? With what?

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Who Designated Staff

• Responsibilities for cleaning and disinfection of
  surfaces medical equipment are assigned to
  specific personnel.
• If Environmental Services are only available
  after hours, then designated facility staff are
  assigned cleaning/disinfection duties during
  clinic hours.
• All assigned personnel are trained in the
  appropriate cleaning/disinfection procedures and
  the proper use of PPE and cleaning products.

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Supplies Cleaning Products

• Designated staff regularly stock necessary
  supplies (e.g., gloves, gowns, facemasks) and
  replenish dispensers of hand sanitizer and soap.
• Follow manufacturers instructions, ensure that
  the cleaning product is compatible with the
  surface/device being cleaned.
• Follow safety precautions and instructions.

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Frequency Of Cleaning

• Patient-care areas, medication preparation areas
  and bathrooms are cleaned at least daily, with
  the following exceptions
• Promptly clean and decontaminate any location
  with spills of blood and other potentially
  infectious materials
• Disinfect environmental surfaces and noncritical
  patient-care devices when visibly soiled.

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Frequency Of Cleaning

• Clean medication preparation areas when visibly
  soiled if medication preparation takes place in
  the patient treatment area (outside a designated
  mediation room), clean this area after each
  patient encounter
• Ensure medication preparation area is free of any
  items contaminated with blood or body fluids
  (e.g., used equipment such as syringes, needles,
  IV tubing, blood collection tubes, and needle
  holders)

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Frequency Of Cleaning

• Disinfect environmental surfaces and noncritical
  patient-care devices in between patient use if
• There was direct contact to non-intact skin or
  mucous membrane or potential contamination with
  body fluids (e.g., blood, secretions)
• The patient-care device involves a blood glucose
  meter or other point of care testing device
  (e.g., PT/INR readers) that utilize blood samples

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Frequency Of Cleaning

• Disinfect bathrooms after use by a patient with
  known or suspected infectious diarrhea and before
  use by another person.

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Cleaning Decision Guide
Classification Contact Cleaning Level Cleaning Frequency
Critical Enters tissue or vascular system Sterile After Every Patient
Semi-Critical Contacts mucus membrane or non-intact skin Sterile or high level disinfect After Every Patient
Non-Critical Contacts intact skin Medium or low level disinfect Not visibly soiled Per schedule
Non-Critical Contacts intact skin Medium or low level disinfect Visibly soiled After Each Patient
To help determine how often to clean your
equipment use the above table. Start in the
contact column and ask what does this piece of
equipment come in contact with, then move to the
right to determine the type of cleaning and
frequency of cleaning. The exception is any
equipment that comes in contact with blood
(Glucometers). Must be medium level disinfected
after each patient.
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Cleaning Patient Care Areas

• General cleaning and disinfection measures that
  apply to any patient-care area
• Wear appropriate PPE
• In general, cleaning should be performed before
  disinfection unless a one-step detergent
  disinfectant is used.
• Concentrate on high-touch surfaces (frequently
  touched by patients or staff)

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PPE to Clean WHY its just cleaning?

• There are several reasons to wear gloves when
  cleaning equipment
• Hospital grade cleaning solutions are stronger
  than what you use at home
• Stronger solutions are more likely to cause skin
  irritation
• Your skin is a very porous organ and easily
  absorbs the chemicals in the cleaning solutions

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Items Requiring Only Cleaning

• Floors, walls and windows
• Chairs and other furniture used by individuals
  who are clothed
• Private offices and other non-public, non-patient
  care areas
• Unless an exposure to body fluids or other
  potentially infectious material has occurred.

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Cleaning Patient Care Areas

• Clean walls, blinds, and window curtains when
  they are visibly dirty
• Avoid dusting methods that disperse dust

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Exam Rooms

• Focus cleaning on high-touch surfaces (at least
  daily), e.g., exam bed, bedrails, blood pressure
  cuff, stethoscope, wall-mounted opthalmoscope and
  otoscope (per manufacturers instructions), chair
  and bedside stool, and door knob.
• Change the paper covering the exam table and
  pillows between patient use

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Exam Rooms

• Decontaminate high-touch surfaces using an
  EPA-registered disinfectant
• If patient has suspected infectious diarrhea and
  the infective agent is C. difficile or unknown,
  clean high-touch surfaces using a sodium
  hypochlorite (bleach)-based product (e.g., 110
  dilution prepared fresh)

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Can We Measure How Clean A Surface Is?

• Testing available, but not routinely used in
  outpatient setting
• ATP testing, Fluorescence, Bioluminescence
• Need special equipment, can be expensive
• Culturing should not be done sometimes used
  during outbreak investigation
• Visual inspection

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Risk Assessment in Your Clinic

• General Guidelines
• Do we need additional procedures as determined by
  our
• Patient population?
• Care / procedures provided?
• Type of equipment / devices used?

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Refrigerators

• Temperature/alarm control
• Signage
• Logs maintained for medication and specimen
  refrigerators
• Clean on a regular basis or when visibly dirty
• Always separate food from medication or specimens

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Myth Busters

• Common Misconceptions
• about Sterilization/Disinfection
• in the Office Setting

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Myth

• My patient is not in isolation, so I dont have
  to clean my equipment or wash my hands.

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A Patients Infection Status is Not Always Known!

• A patient may appear healthy but be colonized
  with an organism such as MRSA.
• Patients who are in the early stages of infection
  may not have symptoms but are still capable of
  spreading disease.
• The only way to keep your patients and yourself
  safe is to use good hand hygiene with every
  patient encounter.
• Standard Precautions gives a high level of
  protection to you as the healthcare worker and
  all of your patients.

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Myth

• Since I will be sterilizing these instruments, I
  can just rinse them off.

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Preparing Items For Sterilization

• In order for sterilization to occur, all surfaces
  must be cleaned.
• If organic material is still present on items
  that are placed into the sterilizer, processing
  cannot reach those surfaces and sterilization
  will be compromised.
• Thorough cleaning is critical to successful
  sterilization is the first step in the process.

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Myth

• I package instruments in the closed position so
  they will fit into a smaller package and take up
  less room in the drawer.

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Preparing Items for Sterilization

• Steam cannot properly contact instruments that
  are closed.
• Instruments should be packaged in the open
  position and disassembled.
• Tip protectors should be loosely applied and made
  of materials that do not interfere with steam
  contact.

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Myth

• We package multiple instruments in single peel
  packages.

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Peel Pouches

• Peel pouches are designed for lightweight items.
• Multiple items can be heavy and predispose the
  package to tearing.
• When a peel pouch containing multiple instrument
  is opened, instruments can go in various
  directions, contacting the outer edge of the
  package, which is non-sterile.
• The best option for multiple instruments is a
  tray designed for this purpose.

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Myth

• I often remove items from the sterilizer when
  they are hot and allow them to cool on the
  countertop.

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Proper Drying For Sterilized Items

• Hot metal items placed on cool surfaces may
  develop condensation.
• This moisture puts your sterile packages at risk
  for contamination.
• Bacteria can be wicked inward through the wet
  packaging material.

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Myth

• Three minutes in a flash sterilization cycle is
  good for anything that I need in a hurry.

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Flash Sterilization (IUSS)

• IUSS is performed on unwrapped items using time
  and temperature guidelines as per manufacturers
  recommendations.
• Chemical indicators must be included in each
  load.
• Porous items or those with lumens have different
  requirements.
• Taped instruments require 10 minutes.
• Flash sterilization should not be used for
  implantable devices.

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Myth

• We do not date our sterile packages since
  expiration dates are not longer required.

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Dating Of Sterile Supplies

• Expiration of supplies is event-relatedCan use
  unless the package is breached or damaged
• Dating helps with proper rotation of supplies
• Older packages are more likely to have a
  contamination event.
• Have a failed biological spore test? You can
  identify and isolate supplies processed since the
  last test.
• Dating is still important!

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Myth

• We store our sterile supplies in the cabinet
  under the sink or above the steam sterilizer.

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Sterile Storage

• Proper storage of supplies helps to prevent
  contamination and extends their shelf life.
• Sterile storage should never be located in the
  vicinity of water or water pipes due to the
  potential for moisture contamination (growth of
  mold and bacteria)

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Sterile Storage

• Optimally, closed cabinets or drawers should be
  used to protect and store sterile items.
• Shelving should elevate sterile items at least 8
  10 inches above the floor.
• If items are stored on open shelves or carts,
  they should be in low traffic areas and dust
  covers will help prevent dirt and dust from
  settling on packages.

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• Now that I know this, why do I need to repeat
  training and show a competency in my file?

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Need For Training

• Patient care equipment is always changing
• Cleaning products change every few years
• New pathogens emerge (e.g., MDROs)
• Every job has different cleaning / disinfectant
  duties
• Its a requirement by TJC and CMS

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For Additional Information

• Infection Prevention Specialist
• [phone]
• Office, Mon Fri
• [phone]
• On call, after hours

• Infection Control Manual Resources
• HENRY Main page
• Clinical Quality Safety
• Infection Control Resources

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References

• APIC Text of Infection Control Epidemiology,
  3rd Edition, Vol. 1, Essential Elements, 2009.
  Recommendations for Disinfection Sterilization
  in Health Care Facilities, Chapter 21.
• APIC Course, Basics of Infection Prevention,
  2012.
• Boyce, John M., Environmental contamination makes
  an important contribution to hospital infection,
  Journal of Hospital Infection (2007) 65 50-54.
• Centers for Disease Control and Prevention.
  Guide to Infection Prevention in Outpatient
  Settings Minimum Expectations for Safe Care,
  2011. www.cdc.gov/HAI/pdfs/guidelines/standatds-of
  -ambulatory-care-7-2011.
• CDC. Basic Infection Control and Prevention Plan
  for Outpatient Oncology Settings.
• Goodman, Richard A., et al., Transmission of
  Infectious Diseases in Outpatient Health Care
  Settings, JAMA, May 8, 1991, Vol. 265, No. 18
  2377-2381.

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• Thank you
• for your attention !
• Link to survey on the next slide.

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Survey link

• For Nurses and CMAs please follow this link to
  complete the
• Cleaning and Disinfecting in the Ambulatory Care
  Setting Survey