IP IN THE OR: WHAT THE INFECTION PREVENTIONIST NEEDS TO KNOW

Heather Hohenberger, MSN, RN, CIC, CNOR, CPHQ, FAPIC Disclosure / Conflicts of Interest

 The presenter has no conflicts of interest to disclose. Objectives

 Upon completion of this session participants will be able to  Identify resources for guidance on best practices in the OR and sterile processing  Verbalize the various modalities for instrument sterilization  Gain baseline knowledge of processes in the OR and sterile processing How would you describe the relationship between sterile processing, perioperative services, and infection prevention at your facility?

Which would you rather see? How do we create great relationships?

 What do we have in common?  What makes us different?  What are the expectations?  How can we work together?  What can we learn from each other?  Do we have similar goals? Heather’s top 3 rules for working with perioperative services

 Wear scrubs  Do NOT wear a bunny suit

 Sterile processing is the backbone of the OR  The quickest way to shut down an OR is to stop providing sterile instruments

 Understand the concerns of staff and leadership  What keeps staff up at night?  What concerns does management have? The two biggest questions – aseptic technique & sterile processing Principles of aseptic practice – surgical attire

 Personnel working in the restricted area (operating room) must wear clean, hospital laundered surgical attire

 Covering and containing hair on the head and face is required

 Surgical masks should be donned when opening the sterile field and continue to be worn until the sterile field is broken down and removed from the surgical suite Principles of aseptic practice – hand hygiene

 Hand hygiene should be performed immediately prior to opening the sterile field

 Hand antisepsis products used in the operative area should be approved by infection prevention and noted within facility policy

 Hands and forearms must be dry before placing them into the sterile gown and gloves

 Hand antisepsis should be performed by all sterile members of the surgical team: i.e. surgeon, assistant, and scrub personnel Principles of aseptic practice – gowning and gloving

 Personnel should only touch the inside of the sterile gown when donning. A non-sterile member of the team will assist with securing the neck and back of the gown.

 Gloves are touched after the sterile gown is on the sterile team member

 Double gloving is the preferred method of glove use

 Once donned, sterile gowns remain sterile in the front from chest level to waist, excluding the collar, armpit area, and gown cuffs Principles of aseptic practice – sterility of instruments / disposables

 The integrity of the sterile packaging must be checked for each item

 When using event related sterility parameters, look for evidence of past exposure to moisture, dirt, or dust on packaging

 Wrapped sets must be checked for holes in the wrap before placing on the sterile field

 Instruments must have chemical indicators meeting sterilization parameters before delivery to the sterile field Principles of aseptic practice – the sterile field

 The sterile field should never be left unattended

 Tables are sterile at the top, flat level of the table only, not below

 Adjusting the drape once placed on the table is not recommended

 All members of the perioperative team are responsible for monitoring the sterile field Principles of aseptic practice – draping the patient

 Draping of the patient creates another sterile field

 The drape should not be used if it comes in contact with any non-sterile surface

 Staff should not lean over an unsterile area or unsterile equipment while placing the drape

 Any item or cord falling below this level is considered contaminated Principles of aseptic practice – tissue on instruments

 Any tissue (bone, hair, etc.) or debris found on reprocessed instruments should be considered contaminated and immediately removed from the sterile field

 Removing the tissue from the items on the sterile field is not recommended as this compromises sterility Principles of aseptic practice – maintaining the sterile field

 Movement around the sterile field should be kept to a minimum to avoid contaminating the sterile field

 Any member of the perioperative team who is non- sterile and within the periphery should face the sterile field

 AORN recommends non-sterile individuals maintain a 12 inch gap between themselves and the sterile field or scrubbed team members Principles of aseptic practice – medication delivery

 Medication delivery to the sterile field should be done in a manner to maintain both the sterility of the medication and the sterile field

 Ordered medications should be prepared and transferred to the sterile field as close as feasible to the time of use  Transfer devices Sterile Processing Resources

Instrument reprocessing flow

 Decontamination begins at the point of use

 Decontamination

 Assembly

 Sterilization

 Storage and handling

Decontam processes

 All soiled items should flow from dirty to clean

 3 bay sink is ideal  Wash sink with water and detergent  Intermediate rinse sink with plain or softened water  Final rinse sink with distilled, deionized, or reverse osmosis water Not all water is the same

 Deionized water (DI)  Water that has had all minerals removed through and ion exchange process  Distilled water  Water that is heated to steam, then allowed to cool and condense; removes impurities and some bacteria  Reverse osmosis (RO)  Water purification process where a solvent (water) is removed of impurities after being forced through a semipermeable membrane Manual cleaning

 Open hinged instruments  Disassemble multiple part instruments  Clean all surfaces  Brush under water surface to avoid splashing and aerosolization  Use correct sized brush for lumened instruments  Look for fat tissue, bone, and blood  Some items cannot be immersed  Power equipment, cameras Manual cleaning tools

 Brushes  Disposable or reprocessable  If using reprocessed brushes, decontaminate daily

 Sponges

 Syringes

 Instrument air  Compressed air with pollutants removed  Used to dry medical devices after cleaning and decontamination Solutions that damage surgical instruments

 Betadine

 Peroxide

 Soaking in water

 Soaking in saline

 Dish soap

 Iodine

 Bleach Mechanical cleaners

 Ultrasonic cleaner  Uses low pressure bubbles in a cleaning solution burst inward and dislodge soil from instruments  Instruments must be precleaned  Special trays used  Lumens must be filled with fluid  Complete submersion  Rinse is required after use  Irrigating sonic  Used for long, lumened instruments Mechanical cleaners

 Washer-Disinfector  a.k.a “the wall washer”  Uses impingement – spray force action of pressurized water against instruments to physically remove bioburden  Not used for batteries, electrical equipment, or pneumatic devices

 3 steps  Prerinse with cool water or enzymatic  Detergent cycle  Rinse Basic classification of instruments

 Graspers - forcepts

 Clamps & occluders for blood vessels and other organs

 Retractors

 Distractors, positioners, & stereotactic devices

 Mechanical cutters - scalpels, lancets, drill bits, rasps, trocars, Ligasure, Harmonic scalpel, surgical scissors, rongeurs

 Dilators & specula

 Suction tips Basic classification of instruments

 Sealing devices - surgical staplers  Irrigation and injection needles  Powered devices - drills  Scopes and probes  Carriers and appliers for optical, electronic, & mechanical devices  Ultrasound tissue disruptors, cryotomes, & cutting laser guides  Measurement devices - rulers & calipers Testing instruments

 Visual inspection

 Sharpness  Colored test materials  Index cards  Plastic dowel rods

 Integrity / Function  Hinges  Tips Chemical indicators (CI)

 Devices used to monitor for the presence or attainment of one or more of the parameters required for satisfactory sterilization process

 Placed inside the instrument pack in the area considered least accessible to the sterilant  Multiple layers have multiple CIs

 Class 5 integrating indicators are designed to react to all critical parameters over a range of cycles Biological indicators

 Sterilizer monitor used to determine if conditions have been met to kill live bacteria

 Requires incubation

 A test ampule is required at least daily

 Positive BI can be caused by sterilizer malfunction, user error, or utility malfunction

 BI should be run with each set with implantable devices Packing materials

 Single use  Peel packs  Flat wrap – “blue wraps”

 Multi use  Rigid containers / pans Package closure

 Tamper evident seals should be used  External indicator tape  Heat sealer – peel packs  Rigid container locks Preparing to sterilize

 Peel packs should be standing on edge in loading rack or placed in specialized baskets

 Peel pouches should not be placed inside wrapped trays or rigid containers Types of terminal sterilization

 High temperature sterilization  Steam  Gravity air displacement  Dynamic air removal  Prevacuum  Steam-flush pressure-pulse  Immediate use  Low temperature sterilization  Ethylene oxide  Hydrogen peroxide  Ozone

Unloading the steam sterilizer

 Packs need time to cool after sterilization  30 minutes – 2 hours

 Temperature and humidity in the sterilization space can impact sterility  Wet packs  Wet items are considered contaminated Ethylene oxide

 Highly effective means for alternative to steam sterilization on equipment that cannot withstand high temperatures

 Toxic gas

 Requires exposure monitoring (badges)

 Absorbable by many materials – requires aeration

Hydrogen peroxide gas plasma

 Multiple types / sizes

 Less toxic than EtO, but vapor can be irritating  Must wear gloves when unloading

 Exposure monitoring for the area around the sterilizer Vaporized hydrogen peroxide

 Similar to hydrogen peroxide gas plasma, but no monitoring requirements Ozone

 Newest type of low temperature sterilization

 Requires well vented room The most difficult to navigate…

Association for the Advancement of Medical Instrumentation AAMI documents

 ANSI/AAMI ST79:2010/(R)2014  Comprehensive guide to steam sterilization and sterility assurance in health care facilities  ANSI/AAMI ST91:2015  Flexible and semi-rigid endoscope processing in health care facilities  AAMI TIR63:2014  Management of loaned critical and semi-critical medical devices that require sterilization or high level disinfection AAMI documents

 AAMI TIR34:2014  Water for the reprocessing of medical devices

 ANSI/AAMI ST65:2008/(R)2013  Processing of reusable surgical textiles for use in health care facilities

 ANSI/AAMI ST58:2013  Chemical sterilization and high-level disinfection in health care facilities AAMI documents

 ANSI/AAMI ST41:2008/(R)2012  Ethylene oxide sterilization in health care facilities: Safety and effectiveness  AAMI TIR30:2011  A compendium of processes, materials, test methods, and acceptance criteria for cleaning reusable medical devices  ANSI/AAMI ISO 11607-1:2006/A1:2014  Packaging for terminally sterilized medical devices - Part 1: Requirements for materials, sterile barrier systems, and packaging AAMI documents

 ANSI/AAMI ISO11140-1:2014  Sterilization of health care products - Chemical indicators - Part 1: General requirements

 ANSI/AAMI ISO14161:2009/(R)2014  Sterilization of health care products - Biological indicators - Guidance for the selection, use, and interpretation of results

 ANSI/AAMI ST77:2013  Containment devices for reusable medical device sterilization Association of Surgical Technologists (AST)

 Guidelines & position statements for CSTs  AST Guidelines for the Decontamination of Surgical Instruments  AST Guidelines for Packaging Material and Preparing Items for Sterilization  Position Statement on the Backtable and Mayo Stand Remaining Sterile Until Patient is Transported from Operating Room  Position Statement on CST Working in Central Sterile Supply AORN Guidelines AORN Guidelines linked with sterile processing

 High-Level Disinfection

 Flexible Endoscopes

 Instrument Cleaning

 Packaging Systems

 Sterilization  Environmental Cleaning

 Hand Hygiene

 Surgical Attire

 Safe Environment of Care, part 1

 Safe Environment of Care, part 2

 Sharps Safety

 Transmissible Infections

 Information Management

Questions? Contact information

Heather Hohenberger, MSN, RN, CIC, CNOR, CPHQ, FAPIC Director of Surgical Services IU Health Arnett Hospital (765) 838-5869 [email protected]