11/7/2016 Infection Prevention in the Outpatient Setting Lynn Skelton, BSN, RN, CIC Manager Epidemiology and Infection Prevention Advocate Medical Group and Advocate Dreyer Kelli Heisner, BSN, RN, CIC Infection Preventionist Advocate Medical Group and Advocate Dreyer Advocate Medical Group & Advocate Dreyer • Advocate Medical Group (AMG) – More than 350 locations throughout Chicagoland and Central Illinois • Including 56 Advocate Clinics at Walgreens – More than 1,500 physicians and advanced practice clinicians • Primary Care, Family Medicine, Immediate Care, and more than 50 medical and surgical specialties • Advocate Dreyer – 13 locations – More than 230 physicians and advanced practice clinicians • Primary Care, Family Medicine, Immediate Care, and more than 28 medical and surgical specialties Infection Prevention • No dedicated Infection Prevention Program prior to January 2015 • Currently 3.0 FTE – January 2015 - Manager of Infection Prevention and Epidemiology RN hired – July 2015 - Infection Preventionist RN hired – August 2016 - Infection Preventionist MT hired 1
11/7/2016 Cleaning, Sterilization, & High Level Disinfection (HLD) Objectives At the conclusion of this presentation, participants will be able to: • Explain the difference between cleaning, disinfection, and sterilization • Match the Spaulding Classification for Medical Devices with the required level of disinfection for medical equipment • Translate the process of cleaning, sterilization, and high level disinfection in your own setting • Develop an instrument Recall Procedure • Develop a cleaning, sterilization and high level disinfection competency Background • 2014 - Formal education completed • 2015 - Leadership and Infection Prevention audits identified inconsistent practices • Several new sites acquired since 2014 education • Several cleaning and sterilization products not on contract with the health system • Physician practice sites primarily staffed by medical assistance (MA) who are expected to perform sterile processing duties amongst their other duties – Variability in sterile processing education – High turn over • 9/11/15: CDC/FDA Health Advisory Issued – Immediate Need for Healthcare Facilities to Review Procedures for Cleaning, Disinfecting, and Sterilizing Reusable Medical Devices 2
11/7/2016 How did we start? • Identified the following: – Outpatient sites that have sterilizers – Types of sterilizers – Products being used for cleaning, high level disinfection, and sterilization – Procedures being performed – Instruments being used – Instructions For Use (IFU) of instruments, products, and autoclave • Completed education needs assessment • Standardized, educated, and audited our process What is the difference between cleaning, disinfection, and sterilization? • Cleaning – General removal of debris (dirt, food, feces, blood, saliva and other body secretions) – 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 • Low Level Disinfection (LLD) – kills some viruses and bacteria • Intermediate Level Disinfection (ILD) – kills mycobacteria, most viruses, and bacteria • High Level Disinfection (HLD) – kills all organisms, except high levels of bacterial spores • Sterilization – The killing or removal of all organisms, including bacteria, viruses, spores, and fungi Spaulding Classification for Medical Devices and Levels of Disinfection • Noncritical Items: Devices that do not ordinarily touch the patient or touch only intact skin. These devices should be cleaned by low-level disinfection. • Semi critical Items: A device that comes into contact with intact mucous membranes and does not ordinarily penetrate sterile tissue. These devices should receive at least high-level disinfection. • Critical Items: A device that enters normally sterile tissue, the vascular system, or through which blood flows. Such devices should be sterilized. 3
11/7/2016 Recommended Level of Device Processing Patient Contact Examples • Classification Low Level Disinfection (LLD) • High Level Disinfection (HLD) • Sterilization Intact Skin Noncritical Items LLD • At a minimum HLD Mucous • Sterilization membranes or Semi critical Items acceptable for non-intact skin surgical instruments Sterile areas of the body, Critical Items Sterilization including contact with Vascular System Cleaning, Disinfecting and Sterilizing… Easy Process?? Cleaning of Instruments 4
11/7/2016 Clean vs. Soiled Utility Rooms • Current State: All practice sites are space constrained – Many sites are performing cleaning of soiled instruments in the same room with sterilization and high level disinfection – Physician practice buildings were not built with infection prevention in mind • Ideal State: Each practice site has a separate clean and soiled utility room – Sterilization and HLD should take place in a clean room IF IT IS NOT CLEAN IT CAN NOT BE STERILE Transporting Soiled Instruments “ Approved container – a rigid container with a cover will be used if dirty instruments or equipment need to be transported to a soiled utility area for cleaning and sterilization” 5
11/7/2016 Instrument Transport Spray • Surfactant-based gel with corrosion inhibitors which allows instruments to stay moist so blood and body fluid don’t dry on • Spray on instruments at point of use prior to transferring to the soiled utility room Enzymatic Detergent • A detergent that removes soil and debris from instruments prior to sterilization. • Dual protease enzyme that attacks blood and fat • Excellent cleaning properties • Safe for surgical and endoscopic instruments • Follow manufacturer guidelines for: – Dilution – Soaking time Enzymatic Detergent PPE • Use PPE including fluid resistant gown, gloves, face shield or facemask with eye shield every time you use this product. – Enzymatic detergents can cause skin irritation and eye damage if they come in contact with your skin or eyes 6
11/7/2016 Brushes • Scrub instruments, as needed, below surface of enzymatic solution using a non-metal scrub brush • Brushes shall be changed when brush bristles are frayed • Follow manufacturer guidelines related to cleaning of brushes • Brushes should be available for all instruments including lumen instruments Instrument Lubrication • Instrument lubrication is used to: – Prevent rusting – Keep surgical instruments operating freely and easily • Follow lubricant manufacturer guidelines Instrument Cleaning Process • Don PPE • Place instruments in the enzymatic solution. – *Important* - Instruments must be in the open unlocked position while soaking – Take apart instruments that come apart for effective cleaning • Scrub instruments, as needed, below the surface of enzymatic solution using a non-metal scrub brush • Soak instruments in the enzymatic solution per manufacturer recommendations • Rinse instruments in warm tap water – Be aware of possible sharp objects in soaking solution – remove instruments with caution – Inspect instrument to be sure that all debris and blood or body fluids are removed • Dip hinged instruments in lubrication solution • Allow instruments to air dry *Important* - Instruments must be completely dry before you can package and place in sterilizer. 7
11/7/2016 Instrument Inspection Instrument Inspection • Instrument inspection is a key step in safety • Instruments will wear over time and if not inspected on a regular basis can cause harm to patients and/or frustration for your provider • Key things to look for when inspecting your instruments are: – Stains, rust, dried on blood or tissue debris – Cracks, wear, missing pieces, finish damage The larger the crack the Plating/metal finish can chip off longer it has been there Paper Test determines unstable finish - Rub with gloved hands 8
11/7/2016 Instrument Inspection Example Instrument Teeth Inspection This is what they should look like Examples of Damaged Teeth 9
11/7/2016 How to inspect an instrument • Inspect instrument for cleanliness: – If blood or debris still present, re-wash in enzymatic detergent utilizing scrub brush • Inspect instrument for damage and sharpness: – Remove from service any instruments with any defects – Place appropriate tag on instrument: • Red Tag = Repair of Instrument • Yellow Tag = Sharpening of Instrument – Schedule appointment with instrument repair company • Inspect instrument for wetness: – Visually inspect instrument for any signs of wetness – If wet, allow instrument to dry longer Instrument Pouching Pouching 101 Do not fold over to fit item Improper gap The fold line is in the wrong place Always fold at the perforation with no gaps 10
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