Spaulding Classification
Category Critical Semi-critical Description Enters sterile body cavity Contacts mucous membranes, non-intact skin Contacts intact skin Requirement Sterile High level disinfection
Non-critical
Non-lipid (small) viruses (polio) Fungi Vegetative bacteria (Salmonella) Lipid viruses (Herpes, HepB, HIV)
Sterilization
Steam Ethylene oxide Peracetic acid (.2%) Hydrogen peroxide gas plasma Vapourized hydrogen peroxide Ozone
Sterilization process
Clean items Package items Load sterilizer Monitor
Physical (time/temp/pressure) Chemical Biological
Biological Monitors
Steam: Geobacillus stearothermophilus Dry heat: B. atrophaeus (formerly B. subtilis) ETO: B. atropheus Peracetic acid: G. stearothermophilus Plasma (Sterrad): G. stearothermophilus
Ontario guidelines:
Steam: monitor daily, every load with implantables ETO: monitor every load
Sterilization process
Clean items Package items Load sterilizer Monitor
Physical (time/temp/pressure) Chemical Biological
Flash Sterilization
Unwrapped objects, 132C, 3mins, 27-28lbs pressure in gravity Acceptable for processing items that cannot be sterilized and stored before use
Inactivation of Prions
Steam sterilization with NaOH Alkaline cleaner (pH 2.2, 1 hr 23C) Copper plus peracetic acid Vapourized hydrogen peroxide (Sterrad NX)
Yan ICHE 2004;25:280, Fichet Lancet 2004;384:251, Baier JHI 2004;57:80, Lemmer J Gen Virol 2004;85:3805; Roger-Kreuz, ICHE 2009;30(8):769-77 Lehman Hosp Infect. 2009;72(4):342-50;
Semi-critical items
Endoscopes/bronchoscopes Laryngoscopes Respiratory therapy and anaesthesia equipment Tonometers Endocavitary probes Vaginal specula, diaphram fitting rings
Endocavitary probes
Prostate & vaginal ultrasounds, TEE Trans-rectal biopsies Transvaginal probes for IVF Infrared coagulation for hemmorhoids
Laryngoscopes - blades are semi-critical - handles are non-critical (but still need to be disinfected)
Disinfection of tonometers
Solutions
Centralization of disinfection & sterilization wherever possible Standards: PIDAC, CSA
Processes, monitoring, training
New technology
Endoscopes that can be steam sterilized Better sterilization technology
Outbreaks (1999-2007
Failure to clean/disinfect/sterilize adequately
Manual balloons for ventilation (B. cereus) Pasteurizer failure (x2) Thermometers (E. cloacae, NICU) x3 Temperature sensors for ventilators (S. maltophilia) x 2 Ophthalmology equipment (adenovirus) Endoscopes (TB x3, P.aeruginosa x2, pseudo outbreaks x5) OR sterilization/high-level disinfection failure Forceps in cystoscopy (P. aeruginosa) Rigid laryngoscopes in NICU (P. aeruginosa, M. tuberculosis) Transrectal prostate needle biopsies (P. aeruginosa x2) Transesophageal echocardiography probes (E. cloace) Bite blocks (P. aeruginosa, Group A streptococci) Laparoscopy ports (Mycobacterium chelonae)
Outbreaks (2)
Contaminated disinfectants.
Non-antimicrobial soap x2 Benzalkonium chloride and other quaternary ammonium compounds 0.5% chlorhexidine Chlorhexidine without alcohol Improperly diluted disinfectants (disinfectant spray, environmental cleaning solutions) Open containers with soaked cotton balls
Outbreaks (3)
Other
Incompetent waste drain ports on hemodialysis machines x2 Inadequately maintained endoscopy washer/disinfector Incorrect hook-up for endoscopes to sterilizer Environmental contamination with Acinetobacter
Non-critical items
Contaminated Surfaces
VRE
Bed Rails Bed Table Door Knobs Doors Call Button Chair Tray Table Toilet Surface Sink Surface Bedpan Cleaner +++++++ ++++++ ++ +++ +++ ++ +++ + + -
MRSA
+ + ++ + + + ++ + -
Speck et al., Abstract, (2007) SHEA 17th Annual Scientific Meeting, Baltimore, MD
Problems
How important is environmental transmission overall? What do we mean by environment? What is the right standard for clean? How do we measure adherence?
80
% Objects Cleaned
60
40
20
Tray Table
Hand Side Toilet Call BR hold rails door box light Toilet Bedpan Chair Room Telephone handle cleaner door
Seymour S. Block: Disinfection, sterilization and preservation Williams &Wilkins (ISBN 0812113640) PIDAC best practices for cleaning, sterilization and disinfection
http://www.health.gov.on.ca/english/providers/program/infectious/diseas es/best_prac/bp_cds_2.pdf