High Level Disinfection of Clinical Equipment and

Strategies for Endoscopes

Larissa Lewis, RN, BSN, CICInfection Preventionist

UW Harborview Medical Center

WHY IS IT IMPORTANT?

Reported Outbreaks from Duodenoscopes

• Florida 2008 • Pittsburg 2012• Chicago 2013• Los Angeles 2013-2015• Seattle 2012-2015

Who’s Interested?

…And anyone else who might accredit your facility

Who Offers Guidance

THE BASICS

A Perfect World

Spaulding Classification

• Earl Spaulding was a microbiologist at Temple University

• Over 30 years ago he proposed classification of patient care items and medical equipment and appropriate level of disinfection

Non-Critical

• Equipment/ instruments that contact intact skin

Semi-Critical

• Equipment/ instruments that contact mucous membranes or nonintact skin

Critical

• Equipment/ instruments that enter sterile tissue or the vascular system

Clean

• Removal of soil

Disinfection

• elimination of most pathogenic microorganisms(not spores)

Disinfection

• Low-level disinfection – • elimination of many pathogenic

microorganisms

• High-level disinfection – • elimination of all pathogenic

microorganisms except spores

Sterilization

• elimination of all pathogenic microorganisms, including spores

Back to Earl Spaulding…Critical Items Equipment/

instruments that enter sterile tissue or the vascular system

• Surgical equipment

• ImplantsSterilization

Semi-critical Items

Equipment/ instruments that contact mucous membranes or nonintact skin

• Many endoscopes

• Vaginal US probes

• Respiratory therapy equipment

High level disinfection

Noncritical Items Equipment/ instruments that contact intact skin

• Blood pressure cuff

• Patient environment

• Ambulation aids

Low level disinfection

DON’T FORGET TO CLEAN!

Cleaning is the fundament to disinfection regardless of the level!

Why?Biofilm!

FEMS Microbiol Rev 36 (2012) 972–989

Cleaning ultrasound probes vs scopes

Vs.

These are both semi-critical items

Sterilization

• Steam• Hydrogen peroxide gas plasma• 100% Ethylene oxide (ETO)• ETO mixtures• Vaporized hydrogen peroxide• Ozone

High Level Disinfection

• Peracetic acid/hydrogen peroxide• Gluteraldehyde• Hydrogen peroxide• Ortho-phthalaldehyde (OPA)• Peracetic acid

Manual High Level Disinfection

• Active times vary by product; 7-90 minutes• Chemicals are inactive below certain

temps, vary by product; 20-30°C• Expiration dates of chemicals– Overall expiration– Expiration of the product once open– Expiration of the product in use

• May also have to test solution for quality and keep track of test strip

Lots to Track!

Automated High Level Disinfection• Completes all steps of high

level disinfection following manual cleaning

• Often device specific• Most often used with

endoscopes• Device compatibility is

essential

High Level Disinfection is EVERYWHERE!

• Outpatient clinics/procedure areas• Inpatients ancillary departments• Inpatient procedure areas• Anywhere with– Scopes–Ultrasound probes– Respiratory equipment/ anesthesia

equipment

WHY IS IT SO IMPORTANT TO KNOW WHERE HIGH LEVEL DISINFECTION IS BEING DONE?

This!All staff must be trained and competency validated

And this…

Additional Monitoring for Endoscope Procedures

• ATP? – adenosine triphosphate monitoring–Measures “cleanliness”

• Culturing? – take cultures off scopes after procedures

• Surveillance? – track patients who’ve had the procedure and monitor for infection

Most important

• Know where you have high level disinfection• Ensure device/chemical compatibility• Ensure device/automated reprocessor

compatibility• Make sure your peeps are trained• Track EVERYTHING• Follow manufacturer’s directions– The scope– The chemicals/automated reprocessor

compatibility