For years, the hospitals have been purchasing equipment to increase the safety of patient handling and movement in the effort to reduce injury to employees. Many healthcare workers have not been using the equipment for various reasons like time, difficult to use, inadequate training, weight limitations, availability of equipment and feeling the equipment is inappropriate for the task.
A variety of medical tools are been used varying from simple ones like disposable tongue depressor to complicated ones like flexible endoscope. As the disposable items are meant to be used only once, mre focus needs to be drawn towards the care and handling of medical devices that must be reprocessed to use repeatedly. And so they must be reprocessed correctly as there are peak chances of passing infection from patient to patient, from patient to staff and from the patient to community at large. Also, the medical devices are costly and thus it is in the pursuit of the sterile processing department to handle them with care to reduce the peril of breakage or chemical damage.
Minimize the Transmission of Infection to Patients
Dr. Earl Spalding in the mid 1960s made a framework to escort eprocessing decision making. The system is established n the patient’s risk of infection from contact with instruments and equipment.
The risk of transmitting infection is low in these tools which includes but not be limited to stethoscopes, BP cuffs, ECG machines, baby scales, electric thermometers, and environmental surfaces. These do not touch the patient directly or come into contact with normal and intact skin. Here, cleaning with a detergent and drying is usually sufficient. However, further disinfection may also be needed.
These do come into contact with non intact skin or mucous membranes but do not impale them like endotrachial tubes, specula, laryngoscopes, anaesthesia equipment, ultrasound probes, ear cleaning equipment and breast pump accessories. Cleaning with High Level Disinfection or sterilization is needed. This disinfection is further three types : boiling, moist heat at 70-100 C and chemical disinfection.
These penetrate sterile tissues like body cavities and the vascular system. Thus, here there is severe risk of passing on infection from one patient to another. It becomes madatory that devices are cleaned and sterilized properly. These include: intrauterine devices, vascular catheters, surgical instruments and implants.
Cleaning is the basic first step of the decontamination process. After the surgery, the OR staff should wipe down instruments to get rid of gross soil and then keep the instruments in a multi-enzymatic solution or spray them with an enzyme product prior to transport to the decontamination area. The solution should be emptied prior to transport to prevent spills if a soak is used. The instruments should be kept moist during transportation. Closed system should be used to transport instruments from the OR or point of use to the Sterile Processing Department (SPD) for cleaning and further sterilization or disinfection, as required.
They may be washed manually or mechanically in sonic cleaners and automated washers, when instruments reach the SPD. In manually washing, brushes with nylon bristles are recommended and the brush should be of the correct size to fit the lumen of the instrument. All medical devices should be disassembled so all surfaces can be cleaned. High quality pH neutral water should be used with pH balanced detergent. The cleaning should be in acordance with the instructions provided in the manual by the medical device manufacturer. The label of the package encompass correct use of parameters like temperature, dilution ratio and soak time, as well as rinsing and drying requirements. The devices must be dried completely before sterilization or disinfection.
After cleaning, high Level Disinfection may be used if the device falls under the semicritical category which will impair all vegetative microorganisms, tubercle bacilli, most fungi, non-lipid and small viruses with exception of high numbers of bacterial spores. Chemicals for the same comprises Glutaraldehyde, Ortho-Phthalaldehyde, Peracetic acid and Hydrogen peroxide. When heat is applied to the device and accomplished with machines such as automatic washersanitizers/disinfectors, pasteurisation equipment and automatic endoscope reprocessors, it is said to be thermal disinfection.
Sterilization is the process by which all forms of microbial life like bacteria, viruses, spores and fungi are completely destroyed. Many types of sterilization tecniques are being used with steam sterlization being the most prevalent among the all. In this process, there is adequate contact of the steam to objects being sterilized, for correct amount of time with temperature and moisture content set correctly. Low temperature methods of sterilization have Ethylene Oxide, Hydrogen Peroxide (or Plasma) and Ozone. The manufacturer test and validate the sterilization systems and include Instructions for Use with the sale of the unit. Specially, the devices MUST be clean before they can be sterilized.
Minimize the Risk of Breakage and Chemical Damage to Medical Devices
Improper reprocessing may cause surface damage to medical devices. If such damage occurs, a logical series of steps needs to be employed:
Determine the origin and cause of the surface change.
Assess the risks like- Will the surface change affect the care of the patient or is it only aesthetic
Process and treat items in accordance with manufacturer’s recommendations.
Take appropriate measures to prevent recurrence.
Sometimes, damage can be avoided by employing small changes like performing a final rinse with demineralised water.
Rusty instruments should be removed to avoid contamination of non affected devices. Rust looks orange or red and has a flaky appearance.
Stainless steel devices or anodized aluminum are resistant to wear and have maximum corrosion resistance. More chromium in stainless steel, higher resistance to corrosion. Pitting can occur when the organic residue (blood has chloride ions) left on medical devices causing discoloration and formation of biofilm, which becomes difficult to remove. Soil should never be allowed to dry on instruments.
The misuse of disinfectants can also lead to damage. The staff should follow the manufacturer’s instructions for use so correct concentration and exposure times of disinfectants are followed. The saline solutions and chlorine compounds such as bleach can harm stainless steel instruments and instruments should never be allowed to soak in these solutions. An ultimate option for instrument sterilization which is lighter than stainless steel and greater thermo conductivity is anodized aluminium. This must be washed with pH balanced detergents to prevent corrosion and preserve the useful life of the device. Also, the medical devices subjected to corrosion should be withdrawn from service as an affected item will subject other devices to corrosion and may be harmful to patients during surgery.
It is a crucial that the SPD staff should have the training to know how to protect the medical instruments as they are already costly. The friction of moving parts can erode the passive layer of the metal. Thus, a water soluble lubricant is recommended and lubrication is performed after cleaning. To avoid stress corrosion cracking, clean instruments in the open position and sterilize them with the ratchet locked in the first tooth at the earliest. Remove the item from use if the crack is found.
Physical damage to medical devices can happen when instruments are packed in loaded baskets and advance against each other during cleaning and sterilization process. Delicate instruments should be cramped in small perforated baskets with lids. Visual inspection should be done to check the instances of damage.
Minimize the risk of Staff Handling Medical Devices
The wearable equipment that is intended to protect HCP from exposure to or contact with infectious agents are called as the Personal Protective Equipment (PPE) which includes the gowns, respirators, gloves, face masks, face shields and goggles. The PPE is selected on the basis of the nature of the patient interaction and potential for exposure to blood, body fluids or infectious agents.
Instances of appropriate use of PPE for adherence to Standard Precautions comprise:
Application of gloves in situations involving possible contact with blood or body fluid, mucous membranes, non-intact skin or potentially infectious material
Application of a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated
Application of mouth, nose and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids
Also, after removing and disposing of PPE, the final step is the hand hygiene.
Key recommendations for use of PPE in ambulatory care settings:
Educate the healthcare staff on proper selection and use of PPE
Sufficient and appropriate PPE should be available and readily accessible to staff by the facilities
Before leaving the patient’s room or area PPE should be removed and discarded.
Wear gloves for potential contact with blood, body fluids, mucous membranes, non-intact skin or contaminated equipment:
1. Do not wear the same pair of gloves for the care of more than one patient
2. Do not wash gloves for the reuse purpose
3. Hand hygiene should be employed immediately after removing the gloves
Where contact with blood or body fluids is anticipated, wear a gown to protect skin and clothing during procedures or activities:
4. Do not wear the same gown for the care of more than one patient
During the procedures that are likely to generate splashes or sprays of blood or other body fluids, mouth, nose and eye protection should be worn
When placing a catheter or injecting material into epidural or subdural space, a surgical mask should be worn
Safe handling of needles and injections
The main purpose of injection safety is to avert transmission of infectious diseases between one patient and another, or between a patient and healthcare provider during preparation and administration of parenteral medications. Needle-stick injuries can lead to considerable anxiety because of the fear of contracting blood-borne diseases such as HIV, hepatitis B and hepatitis C as well as other diseases such as tetanus. The risk of having a disease from a needle-stick injury in a hospital is extremely high, thus it is crucial that they are disposed of promptly and safely to ensure staff, students and others are not harmed. Also, the unsafe disposal of needles and syringes is illegal.
According to the Environmental Protection (Waste Management) Regulation 2000, the needles and syringes should be disposed of in a rigid-walled, puncture-resistant, sealed container. Execution of the OSHA Bloodborne Pathogens Standard has helped increase the protection of HCP from blood exposure and sharps injuries, but there is room for improvement in ambulatory care milieu.
Unsafe practices that have led to patient harm are:
Utilization of a single syringe, with or without the same needle, to administer medication to multiple patients,
Reinsertion of a used syringe, with or without the same needle, into a medication vial or solution container (e.g., saline bag) to procure additional medication for a single patient and then using that vial or solution container for following patients,
Preparation of medications in close proximity to contaminated supplies or equipment.
Key recommendations for safe injection practices in ambulatory care settings:
When preparing and administering medications, use aseptic technique
Before inserting a device into the vial, cleanse the access diaphragms of medication vials with 70% alcohol
Never dispense medications from the same syringe to multiple patients, even if the needle is changed or the injection is administered through an intervening length of intravenous tubing
Don't reuse syringe to enter a medication vial or solution
Don't administer medications from single-dose or single-use vials, ampoules, bags or bottles of intravenous solution to more than one patient
Don't use fluid infusion or administration sets (e.g., intravenous tubing) for more than one patients
Whenever feasible, dedicate multidose vials to a single patient whenever possible. If multidose vials will be used for more than one patient, they should be limited to a centralized medication area and should not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle)
Cling to federal and state requirements for protection of HCP from exposure to bloodborne pathogens