Cleaning and Disinfection in the Ambulatory Care Setting Infection Prevention and Control

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

2. 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 Center’s 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

3. 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.

5. Risk Factors For Cross Contamination in Outpatient Clinics • Inadequate disinfection and sterilization of instruments and equipment • Improper use of barrier precautions by infected health care workers (or not taking sick leave) • Inadequate hand hygiene practices among health care personnel

6. 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.

7. 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 worker’s personnel file that document their training.

8. Healthcare Equipment Is Classified According To Risk For Infection

9. 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

10. 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.

11. Many Reservoirs For Infection

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

13. Disinfection • Follow manufacturer’s 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

14. 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.

15. 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

16. 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.

17. Reusable Medical Equipment

18. 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

19. To Disinfect Noncritical Medical Devices: • Must use an EPA-registered hospital disinfectant using the label’s safety precautions and directions for use.

20. 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

21. 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 > 1 patient • Did not clean and disinfect meters between patients

22. 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.

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

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

25. 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.

26. 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

27. 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

28. 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

29. CDC has three recommendations for environmental cleaning and disinfection.

30. #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.

31. #2 Select EPA-registered disinfectants or detergents with label for use in healthcare.

32. #3 Follow the manufacturer’s recommendations for use of cleaners and EPA-registered disinfectants (e.g., amount, dilution, contact time, safe use and disposal)

33. 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

34. Can’t 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. • Don’t guess!

35. 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.

36. High Touch Surfaces In Patient Rooms • Considered non-critical • Must be cleaned then disinfected on a regular basis. • What are your clinic’s high touch surfaces?

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

38. 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.

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

40. 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.

41. 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)

42. 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

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

44. Cleaning Decision Guide 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.

45. 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)

46. PPE to Clean … WHY it’s 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

47. 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.

48. Cleaning Patient Care Areas • Clean walls, blinds, and window curtains when they are visibly dirty • Avoid dusting methods that disperse dust

49. 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 manufacturer’s instructions), chair and bedside stool, and door knob. • Change the paper covering the exam table and pillows between patient use

50. 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., 1:10 dilution prepared fresh)