Infection Control: New York State Mandatory Training

Element V: The creation and maintenance of a safe environment for patient care through application of infection control principles and practices for cleaning, disinfection, and sterilization.


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This 2005 colorized scanning electron micrograph (SEM) depicted numerous clumps of methicillin-resistant Staphylococcus aureus bacteria, commonly referred to by the acronym, MRSA; Magnified 4780.Courtesy of CDC/ Janice Carr; Jeff Hageman. Photo courtesy of Janice Carr.

The CDC released, in 2008, Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008 (Rutala, et al., 2008). The following information is largely taken from that document.

Contamination involves the presence of microorganisms on an item or surface.

Cleaning is the removal of visible soil and foreign materials (e.g., organic and inorganic material such as dirt, body fluids, lubricants) from objects and surfaces and normally is accomplished manually or mechanically using water with soaps, detergents or enzymatic products, through washing or scrubbing the object or surface. Thorough cleaning is essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.

Decontamination involves the use of physical or chemical means to remove, inactive or destroy pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles. Decontamination removes pathogenic microorganisms from items so they are safe to handle, use, or discard.

Sterilization involves the removal or destruction of all microorganisms and their spores. Sterilization describes a process that destroys or eliminates all forms of microbial life and is carried out in health-care facilities by physical or chemical methods. Steam under pressure, dry heat, EtO gas, hydrogen peroxide gas plasma, and liquid chemicals are the principal sterilizing agents used in health-care facilities. Sterilization is intended to convey an absolute meaning; unfortunately, however, some health professionals and the technical and commercial literature refer to "disinfection" as "sterilization" and items as "partially sterile." When chemicals are used to destroy all forms of microbiologic life, they can be called chemical sterilants. These same germicides used for shorter exposure periods also can be part of the disinfection process (i.e., high-level disinfection).

Disinfection describes a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. In healthcare settings, objects usually are disinfected by liquid chemicals or wet pasteurization. Each of the various factors that affect the efficacy of disinfection can nullify or limit the efficacy of the process. Factors that affect the efficacy of both disinfection and sterilization include prior cleaning of the object; organic and inorganic load present; type and level of microbial contamination; concentration of and exposure time to the germicide; physical nature of the object (e.g., crevices, hinges, and lumens); presence of biofilms; temperature and pH of the disinfection process; and in some cases, relative humidity of the sterilization process (e.g., ethylene oxide).

  • High-level disinfection is capable of killing all organisms, except high levels of bacterial spores, and is effected with a chemical germicide cleaned for marketing as a sterilant by the FDA.
  • Intermediate level agent destroys all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. These agents are registered as "tuberculocidal" by the US Environmental Protection Agency (EPA).
  • Low-level agent is one that destroys all vegetative bacteria (except tubercle bacilli), lipid viruses, some nonlipid viruses, and some fungi, but not bacterial spores. These agents are registered as a hospital disinfectant by the EPA.

The CDC Guidelines utilize the Spaulding classification, which divides instruments and items for patient care into critical, semicritical or non-critical items. Depending on the category, planning for disinfection or sterilization can be determined for the most part.

  • Non-critical items are those that come in contact with intact skin but not mucous membranes. Intact skin acts as an effective barrier to most microorganisms; therefore, the sterility of items coming in contact with intact skin is "not critical." In the CDC Guideline, noncritical items are divided into noncritical patient care items and noncritical environmental surfaces. Examples of noncritical patient-care items are bedpans, blood pressure cuffs, crutches and computers. In contrast to critical and some semicritical items, most noncritical reusable items may be decontaminated where they are used and do not need to be transported to a central processing area. Virtually no risk has been documented for transmission of infectious agents to patients through noncritical items when they are used as noncritical items and do not contact non-intact skin and/or mucous membranes. Most Environmental Protection Agency (EPA)-registered disinfectants have a 10-minute label claim. Federal law requires all applicable label instructions on EPA-registered products to be followed: use-dilution, shelf life, storage, material compatibility, safe use, and disposal. Noncritical environmental surfaces include bed rails, some food utensils, bedside tables, patient furniture and floors.

    Noncritical environmental surfaces frequently touched by hand (e.g., bedside tables, bed rails) potentially could contribute to secondary transmission by contaminating hands of healthcare workers or by contacting medical equipment that subsequently contacts patients. Mops and reusable cleaning cloths are regularly used to achieve low-level disinfection on environmental surfaces. However, they often are not adequately cleaned and disinfected, and if the water-disinfectant mixture is not changed regularly (e.g., after every three to four rooms, at no longer than 60-minute intervals), the mopping procedure actually can spread heavy microbial contamination throughout the healthcare facility. In one study, standard laundering provided acceptable decontamination of heavily contaminated mopheads but chemical disinfection with a phenolic was less effective. Frequent laundering of mops (e.g., daily), therefore, is recommended. Single-use disposable towels impregnated with a disinfectant also can be used for low-level disinfection when spot-cleaning of noncritical surfaces is needed.

  • Semicritical items contact mucous membranes or nonintact skin. This category includes respiratory therapy and anesthesia equipment, some endoscopes, laryngoscope blades, esophageal manometry probes, cystoscopes, anorectal manometry catheters, and diaphragm fitting rings. These medical devices should be free from all microorganisms; however, small numbers of bacterial spores are permissible. Intact mucous membranes, such as those of the lung and the gastrointestinal tract, generally are resistant to infection by common bacterial spores but susceptible to other organisms, such as bacteria, mycobacteria, and viruses.

    Semicritical items minimally require high-level disinfection using chemical disinfectants. Glutaraldehyde, hydrogen peroxide, ortho-phthataldehyde, and peracetic acid with hydrogen peroxide are cleared by the Food and Drug Administration (FDA) and are dependable high-level disinfectants provided the factors influencing germicidal procedures are met. When a disinfectant is selected for use with certain patient-care items, the chemical compatibility after extended use with the items to be disinfected also must be considered. Semicritical items minimally require high-level disinfection using chemical disinfectants.

  • Critical items are those that enter sterile tissue or the vascular system and must be sterile. Critical items have a high risk for infection if they are contaminated with any microorganism. This category includes surgical instruments, cardiac and urinary catheters, implants, and ultrasound probes used in sterile body cavities.

    Most of the items in this category should be purchased as sterile or be sterilized with steam if possible. Heat-sensitive objects can be treated with ethylene oxide (EtO), hydrogen peroxide gas plasma; or if other methods are unsuitable, by liquid chemical sterilants. Germicides categorized as chemical sterilants include >/=2.4% glutaraldehyde-based formulations, 0.95% glutarldehyde with 1.54% phenol/phenate. 7.5% stabilized hydrogen peroxide, 7.35% hydrogen peroxide with 0.23% peracetic acid, 0.2% peracetic acid, and 0.08% peracetic acid with 1.0% hydrogen peroxide. Liquid chemical sterilants reliably produce sterility only if cleaning precedes treatment and if proper guidelines are followed regarding concentration, contact time, temperature, and pH.

The CDC, in the Guidelines, identifies the limitation of the Spaulding classification system with complicated medical equipment, particularly with complicated medical equipment and those that are in the semi-critical category. Choosing the best method for disinfection/sterilization can be difficult. According to the Guidelines (2008, p. 13):

This is true particularly for a few medical devices (e.g., arthroscopes, laparoscopes) in the critical category because of controversy about whether they should be sterilized or high-level disinfected. Heat-stable scopes (e.g., many rigid scopes) should be steam sterilized. Some of these items cannot be steam sterilized because they are heat-sensitive; additionally, sterilization using ethylene oxide (EtO) can be too time-consuming for routine use between patients (new technologies, such as hydrogen peroxide gas plasma and peracetic acid reprocessors, provide faster cycle times). However, evidence that sterilization of these items improves patient care by reducing the infection risk is lacking. Many newer models of these instruments can withstand steam sterilization, which for critical items is the preferred method.

Another problem with implementing the Spaulding scheme is processing of an instrument in the semicritical category (e.g., endoscope) that would be used in conjunction with a critical instrument that contacts sterile body tissues. For example, is an endoscope used for upper gastrointestinal tract investigation still a semicritical item when used with sterile biopsy forceps or in a patient who is bleeding heavily from esophageal varices? Provided that high-level disinfection is achieved, and all microorganisms except bacterial spores have been removed from the endoscope, the device should not represent an infection risk and should remain in the semicritical category . Infection with spore-forming bacteria has not been reported from appropriately high-level disinfected endoscopes.

An additional problem with implementation of the Spaulding system is that the optimal contact time for high-level disinfection has not been defined or varies among professional organizations, resulting in different strategies for disinfecting different types of semicritical items (e.g., endoscopes, applanation tonometers, endocavitary transducers, cryosurgical instruments, and diaphragm fitting rings). Until simpler and effective alternatives are identified for device disinfection in clinical settings, following this guideline, other CDC guidelines and FDA-cleared instructions for the liquid chemical sterilants/high-level disinfectants would be prudent.

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