Chapter 22 MA-100

Vaginal speculums

must be sterilized between patients but do not necessarily need to be stored sterilely unless used in a minor office surgery. Therefore, some offices autoclave their speculums unwrapped. All critical devices and instruments should be wrapped to maintain a sterile environment following autoclaving. 513

High-level disinfectant:

May be used on items on the semicritical list. Can kill all forms of microorganisms except high levels of bacterial spores. 509

Intermediate-level disinfectant

May be used on noncritical devices and some semicritical items. Inactivates vegetative bacteria, mycobacterium, and most fungi, but does not necessarily kill spores. . 509

Double wrap trays

The instrument is wrapped so that it can be opened without contaminating the pack. Many facilities double wrap trays to provide extra protection from environmental factors. 513

dilution

dilution ratios and submersion times play a role in determining how the solution is classified. 511

Process indicators

distinguish whether an item has been processed or autoclaved. These indicators change to a distinct color for confirmation purposes. Autoclave tape is an example of a process indicator. 515.

...Critical devices

enters non intact skin, sterile tissue or vascular tissue, examples include scalpels, hemostats, operating scissors

Establishing that a pack is sterile

establishing that a pack is sterile: 1. The expiration or sterilization date 2. The sterilization indicator to make certain it is the proper color 3. The general condition of the wrapping material to make certain that there are no signs of moisture, holes, or other defects 514

Dry heat

is not as effective as wet heat and requires a much longer time to completely sterilize items, but it may be used to sterilize articles that may be damaged by wet heat or steam. 512

Aseptic technique

is the effort that is employed to reduce the spread of microorganisms.

The term asepsis

means free of germs

The term sanitization

means to make sanitary or clean, usually by scrubbing the items with a special soap. Even though certain instruments may not have been used, non-visible body fluids or airborne pathogens may have adhered to the instrument. 507

There are two types of asepsis:

medical asepsis and surgical asepsis. 506

microorganisms

microorganisms in order from most resistant to least resistant: ❖ Bacterial spores ❖ Mycobacteria ❖ Nonlipid or small viruses ❖ Fungi ❖ Vegetative bacteria ❖ Lipid or medium-sized viruses 509

If any defects are found

the affected instruments should be removed from the current supply of instruments and either sent out for repair or discarded. 508

MEC

the minimum effective concentration (MEC) .

three key elements

three key elements on the pack or tape: 1. The name of the item 2. The date of expiration 3. The initials of the person who prepared the pack for sterilization 513

A common temperature

used for dry heat sterilization is 338°F (170°C) for 60 minutes. Dry heat is ineffective against spores. 512

Surgical soaps

used to sanitize instruments should have a pH relatively close to 7, because acidic or alkaline solutions may cause deposits to form, resulting in damage to the instrument. 507.

Another method

used to seal the open end is to seal it with a heat sealer. There are also continuous rolls of sterilization pouch material that come in a variety of different sizes and may be cut to desired lengths. Pouches made entirely or partially of plastic provide easy visibility of the contents within the pack. Each pouch includes a sterilization indicator and should be checked for a color change following the autoclaving cycle. 513

Boiling

water can only reach a maximum temperature of 212°F (100°C), which is not high enough to kill spores. The autoclave sterilizes items by displacing air with steam within the autoclave's chamber and exposing items to large amounts of heat over a specified time period. 512

Internal indicators and integrators:

will demonstrate that the ideal temperature was achieved both inside and outside the pack. A multi-parameter indicator or internal integrator will indicate that temperature, timing, and saturation of sterilant was achieved in order for proper sterilization to occur. Indicators may be in the form of a strip that changes color or a melting pellet. 515

Advantages of lubricating instruments include

❖ Dissolving organic debris on the box locks, which helps to prevent them from locking in one position ❖ Inhibiting the instrument from becoming discolored or rusted ❖ Providing a protective coating for the instruments.

High level of disinfectant

is effective against viruses mycobacteria fungi and some endospores

Sterilant

is effective against viruses, mycobacteria,fungi and endospores

Proper Operation of the Autoclave

1. Properly load the autoclave. 2. Check the water reservoir to make certain that it is at the desired level. Never use tap water in an autoclave; the minerals in the water will cause the chamber to rust. Always use distilled water. 3. Turn on the autoclave and follow the manufacturer's instructions. 4. Fill the chamber with water. 5 Allow the temperature to climb to a minimum of 250°F (121°C) and the pressure to reach a minimum of 15 psi before the timing of the load begins. 6. Allow the load to run the entire length of the sterilization cycle. the timing should not begin until the chamber has been preheated to a minimum of 250°F (121°C) and the pressure has risen to a minimum of 15 psi.) 7. Complete the ventilation cycle. ❖ In older units, the medical assistant must turn the knob to vent and allow the autoclave to completely depressurize. Once depressurized, the door should be opened slightly, between 1,2 and 1 inch. ❖ This step occurs automatically in newer units. 8. Allow the load to go through the drying cycle, if applicable. 515

...Shelf life

: The amount of time the solution may be stored unopened before losing its potency (the expiration date on the container). 511

Semicritical Devices

: touches non intact skin or mucous membranes. There are really two levels of semi critical devices: those that require an intermediate level disinfectant, and those that require a high level disinfectant. Devices that are at lower risk of spreading infection include thermometers, ear specula, and hydrotherapy tanks. These semi critical devices only require an intermediate level disinfectant.

Types of wraps

Autoclave or sterilization paper, Sterilization cloth wraps,Sterilization pouches:

Economical

Autoclaving is not only one of the most trusted forms of sterilization, but it is also very economical. 512

Autoclaving, or steam

Autoclaving, or steam under pressure, is one of the most dependable forms of sterilization. The physical makeup of an autoclave can be compared to that of a pressure cooker. It combines steam under pressure (15 pounds of pressure per square inch [psi]) to reach a heat of 250°F to 254°F (121°C to 123°C). 512

Autoclave or sterilization paper

Available in a variety of sizes and cut into squares, this paper is disposable but can be expensive. Autoclave paper is opaque, so the contents of the pack cannot be seen prior to opening. The different sizes of paper allow the person performing the wrapping the opportunity to wrap single items or large trays. 513

Interruption in the Sterilization

Chain of Events ,In order for proper sterilization to occur, there can be no interruptions in the chain of events that must occur in order for sterilization to take place 516

Storing Chemical Disinfectants

Chemical disinfectants may be hazardous in case of an accidental spill and may also be highly flammable.

Chemical indicator strips

Chemical indicator strips are strips that are used when sterilizing instruments through chemical means to confirm that the necessary environmental conditions needed to achieve complete sterilization have been met. 511

Preparing and Storing Disinfectant

Disinfectants may be caustic and cause irritation to skin and other mucous membranes; therefore, medical assistants should always wear gloves and other appropriate PPE (apron, goggles, a mask if splashing is anticipated) and work in well-ventilated areas when using disinfectants. 511

Disinfecting solutions

Disinfecting solutions come in either "ready to use" formulas or as concentrates. Once the solution has been prepared, a label is placed on the outside of thecontainer stating the name and strength of the solution, the date it was prepared, the date it will expire, and the initials of the person that prepared the solution. The solution should be covered with a lid to keep it from evaporating and to keep contaminants out of the solution.

Sterilization pouches:

Easy to prepare and made of plastic, paper, or both, these individual pouches usually feature a peel-apart seal on one end of the pouch for easy opening. The opposite end is open so that the instrument may be inserted into the pouch. Once the instrument is placed in the pouch, the medical assistant will peel off the adhesive strip protector located above the perforation and fold the perforated edge over the adhesive strip, pressing firmly to seal it. 513

Endospores

Endospores are very difficult to destroy because of their impermeable coating. This coating surrounds the spore, protecting it from many environmental factors including heat, ultraviolet radiation, chemicals, acids, and drying. 512

Ethylene oxide, or EtO

Facilities choose gas sterilization for products that may become easily damaged by other forms of sterilization. This method of sterilization is also used in manufacturing plants that package sterile needles, sutures, and catheters. Because of the dangers of working with EtO, staff must have specialized training before operating any EtO sterilizers. 512

Lubricating Instruments

Many manufacturers suggest placing instruments into a lubricating solution following the cleansing process. This is known as "milking" the instruments. Instruments are placed into the lubricating solution for 30 to 60 seconds following the cleansing process and dried according to the manufacturer's instructions. 508.

Heavy or sharp instrument

Heavy or sharp instruments should be separated from delicate instruments to avoid damage caused by the heavier instruments knocking up against the more delicate instruments. 507

the four "Rs

If there are any concerns that the pack may be contaminated, follow the four "Rs": Remove, resanitize, rewrap, and resterilize. 514.

Endoscope

Instrument to visually examine within (the body).

open position

Instruments should always be wrapped in an open position so that the steam can penetrate each surface of the instrument. 513

material safety data sheet (MSDS)

It is essential that the medical assistant store chemical disinfectants according to the manufacturer's instructions. All chemical disinfectants on the premises should have a material safety data sheet (MSDS) in the MSDS manual. 512

Levels of disinfectants

Levels of disinfectants that destroy various forms of microorganisms Low-level disinfectant,Intermediate-level disinfectant, High-level disinfectant,Sterilant: 509

Sterilization cloth wraps:

Made of woven or unwoven materials, these special cloths come in different sizes and colors and are thicker than autoclave paper. They are economical because they are reusable. They open easily and are easy to handle. The cloths should be inspected prior to use for any thinning of the material, holes, or tears. If any defects are found, the cloth will need to be disposed of. 513

Other semi critical devices:

Most semi critical divides require a high level disinfectant because of their higher risk of transmitting infection. These devices include cystoscopes, diaphragms used for fittings anesthesia equipment, ext.

Noncritical items

Noncritical items are instruments or devices that only touch intact skin; they do not come into contact with mucous membranes or nonintact skin. Noncritical items may be disinfected with a low-level disinfecting solution. 509

Offices

Offices should also perform weekly spore checks. If the spore test results are positive, another test should be immediately performed prior to the sterilization of any more instruments. If the second spore test comes back positive, the autoclave should not be used again until after it has been properly serviced and the problem resolved. 516

Weekly spore checks

Offices should run weekly spore checks by placing a biological indicator in the autoclave with a regular load. .

wrapping

Once instruments have been properly sanitized, inspected, and lubricated, they are ready for sterilization. In order to maintain sterility, items will need to be wrapped in an acceptable wrapping material; 512

Sterilization Indicators

Process indicators, Internal indicators and integrators,Biological indicators 515

Maintaining the Autoclave

Proper maintenance includes internal and external inspection of the unit, proper cleansing of the unit, and the implementation of a quality assurance program through the use of chemical and biological indicators. 516.

Sterilant:

Should be used on critical items. Refers to a high-level chemical disinfectant that has been cleared by the FDA as being capable of destroying all microorganisms, including large amounts of bacterial spores. Submersion times are usually much longer than required for use as a high-level disinfectant. . Sterilizing instruments through the use of sterilants is referred to as "cold sterilization." 510

Low-level disinfectant

Should only be used on noncritical devices. Kills most types of bacteria and some viruses. 509

Sterilization pouches

Six months to a year (follow manufacturer's instructions) 514

Solutions and submersion

Solutions and submersion times against low level disinfectant are Isopropyl alcohol 70% (5 mins exposure time), liquid sodium hypochlorite, household bleach 10% solution (5 mins exposure time), Iodophor germicidal: wescodyne

Gas Sterilization

Some larger health care facilities, such as hospitals and surgical centers, use gas to sterilize instruments. Ethylene oxide, or EtO, is one of the most common gases used for sterilization because of its ability to kill all forms of microorganisms including bacterial spores. 512

Soaking Instruments

Some manufacturers suggest submersing soiled instruments in distilled water immediately following the surgical procedure. 507

Sterilization Wraps

Sterilization wraps must be permeable to steam, yet must still provide an effective barrier against the penetration of microbes and contamination from persons handling the packs prior to use. 513

Strips

Strips impregnated with heat-resistant endospores are placed in the center of a wrapped article and placed into a full autoclave. Once the cycle is completed, the spore strip is removed and sent to a monitoring lab where it is cultured. If the autoclave is working properly, there should be no growth. Results are usually faxed or e-mailed back to the provider's office where they are kept in a log for reference purposes. Spore checks should be performed at a minimum of once per week. 516

The active ingredients

The active ingredients in the disinfectant should be included on the MSDS form. All hazardous spills must be reported to a supervisor immediately. 512

...Opened-container life:

The amount of time the disinfecting solution may be used once the bottle has been opened. 511

Reuse life:

The amount of time the solution may be used once it has been prepared or activated. 511

Vertical position

The autoclave must be loaded properly in order for steam to circulate both through and between the packs. To avoid air pockets, packs should not be stacked on top of each other or shoved directly beside each other. Packs should be placed in a vertical position and separated by at least 1 to 3 inches. 514

Methods

The only methods that can eliminate endospores altogether are steam under pressure (autoclaving), certain gases such as ethyl oxide, sterilants, and prolonged exposure to radiation. Complete sterilization is essential when preparing critical care instruments and items. 512

disinfection.

The process of using special liquids or pasteurization techniques to destroy or inhibit the growth of most microorganisms is referred to as disinfection. Disinfecting solutions are typically used to clean inanimate objects, or structures that are nonliving, such as countertop surfaces, flooring, and examination tables. Disinfectants may also be used to further clean instruments or items that cannot be autoclaved. 509

fanfold" or "envelope"

The proper method used to wrap instruments when using autoclave paper or cloth is referred to as the "fanfold" or "envelope" method of wrapping . 513

The initials

The purpose of placing the initials of the preparer on the peel-apart pack or autoclave tape is to identify who prepared the pack in case there are any problems with the pack such as missing items or debris on the instruments. 514

sterilization

The term sterilization means the complete destruction of all microorganisms including endospores, which can form within particular types of bacterial cells. 512

There are three major levels of disinfecting solutions.

There are three major levels of disinfecting solutions. The level or strength of a disinfecting solution is based on both the solution's ability to kill particular types of microorganisms and the numbers of microorganisms that the solution can destroy. 509

Biological indicators

These indicators are used to check that all parameters including temperature, timing, sterilant, and humidity were met for the unit's ability to kill endospores. 516

Three dates

Three dates that medical assistants must familiarize themselves with when working with disinfecting solutions include:Shelf life,Reuse life,Opened-container life 511

sealed containers

To avoid explosion, never place sealed containers in an autoclave. 514

CARE AND MAINTENANCE OF SURGICAL INSTRUMENTS

To obtain the longest life possible for a surgical instrument, great care must be instituted while preparing and processing instruments for sterilization. Chemicals, heat, and steam can be quite harsh on instruments, so medical assistants must learn techniques that will promote sterilization while maintaining the integrity and quality of the instrument. 507

General Length of Time Items Should Be Sterilized

Unwrapped Items 20 minutes Single wrapped items or items that are loosely wrapped30 minutes Double wrapped items or items that are tightly wrapped40 minutes 515

Use surgical soaps

Use surgical soaps with a pH close to 7 and adjust the water temperature to meet the manufacturer's recommendations. Avoid placing specially plated instruments into the ultrasonic cleaner. The vibrations from the unit may knock instruments into each other, causing damage to the finish. Using ultrasonic cleaners eliminates the need for manual cleansing of instruments. 508

Weekly maintenance of Autoclave

Weekly maintenance may include a thorough cleansing of the autoclave by running a commercially approved cleanser through the autoclave, such as Omni Cleaner. 516

Wet load.

When venting one of the older models of autoclaves, never open the door more than 1⁄2 to 1 inch. The cold air from the outside can rush into the hot chamber and cause condensation to occur, resulting in wet packs. This is commonly referred to as a wet load. Because the integrity of the wrap is now in question, the whole process must be repeated. 515

...Low level disinfectant

is effective against viruses and fungi,

Six months

Wrapped after autoclaving with sterility maintenance covers Six months 514

30 days

Wrapped with sterilization paper or cloth30 days 514

The sterilization chain of events should not be confused with the chain of infection

a. The instrument must be properly sanitized. b. The instrument must be wrapped properly. c. The instrument must be loaded properly. d. The instrument must be sterilized properly. e. The instrument must be stored correctly. 517

Proper dilution ratios

and submersion lengths are factors that contribute to the solution's ability to chemically change from the status of a disinfectant to that of a sterilant.

Intermediate-level disinfectant

are effective against viruses, mycobacteria,and most fungi.

Event factors

are factors that occur as a result of poor wrapping, poor sealing, poor storage, and poor handling of the packs. 514

Chemical sterilants

are high-level disinfecting solutions that have the capability to become a sterilant under the right conditions. 512

Surgical asepsis efforts

are instituted to prevent the transfer of microorganisms to the patient during surgical procedures. Examples of practices or procedures used when performing surgical asepsis include the careful sterilization of surgical instruments, the donning of surgical attire, and the placement of surgical drapes around the surgery site. 507

Semicritical items

are instruments or devices that may come into contact with non-intact skin or mucous membranes, but do not penetrate them. Endoscopes are common pieces of equipment that fall under the category of semicritical devices. Many semicritical devices require the use of a high-level disinfectant, but a few semicritical items may be disinfected with an intermediate-level disinfectant

Some types of microorganisms

are more resistant to particular disinfectants and may require stronger dilutions and longer submersion times. 509

SOLUTIONS AND SUBMERSION

associated with intermediate level of disinfectant are ethyl or isopropyl alcohol 70% to 90% (exposure time less than 10 mins). THE MAJORITY OF LOW LEVEL Disinfectants may be used as intermediate level disinfectants at higher concentrations and with longer submersion times

Inspect all instruments

for discoloration, defects, and maneuverability prior to sterilizing. Test the sharpness of scissors by cutting into tissue or latex. When cleaning clamps and hemostats, check their serrations, jaw alignment, and box locks for any defects and ascertain that the ratchets are secure when closed at each interval. 508

...exposures to high level

glutaraldehyde based formulas exposure time will vary, check the label for use as a high level disinfectant, cidex plus, wavicide, omnicide banicide, matricide, provide, household bleach 1:50 dilution (exposure time more than 20 mins)

opaque

impossible to see through; preventing the passage of light

Surgical asepsis

includes procedures and practices used to destroy and eliminate all microorganisms from instruments and other objects before they have a chance to enter an individual. 507

Medical asepsis

includes procedures that are used to greatly decrease the number of microorganisms and prevent them from being passed from one person to another. In a surgical environment, this would include the gathering and cleaning of all instruments and the disinfection of all counter surfaces, trays, and flooring following the surgical procedure. 506

Daily maintenance of Autoclave

includes the inspection and cleaning of the autoclave's interior and exterior with a damp cloth. The medical assistant should look for any concerns such as frayed electrical cords and problems with the rubber gasket. 516

the milk bath

instrument should not be rinsed following the milk bath because rinsing could also remove the lubricant. 508

instruments

instruments should be in an open position and all visible debris and blood should be removed before placing them into an ultrasonic cleaner. Place only like metals together to avoid 508

An ultrasonic cleaner

is a device that cleans instruments by transmitting sound waves through a cleaning fluid. This creates a bubbling effect, loosening debris from the instrument. 507

The level of disinfectant

is based on the type of instrument and its function. 509

Distilled water

is chemically pure, which helps prevent instruments from rusting. The instruments should be thoroughly dried following the last rinse with a non-lint producing material such as muslin cloth. 507

All parts

of each instrument should be cleansed with a nylon bristle brush or soft toothbrush and cleaned while in an open position to assure thorough cleansing. Once instruments have been properly scrubbed, they should be rinsed once again using deionized or distilled water. 507

The immediate soaking

of instruments helps to keep debris from drying on them. Minerals in tap water, especially hard tap water, may deposit crystals onto instruments, causing them to become discolored and aesthetically unappealing. Pits and crevices may also form on the instruments, making it easier for microorganisms to hide. All of these factors together may inhibit the sterilization process, thus compromising the patient's safety. 507

Temperature, timing, and saturation

of sterilant are three critical parameters that are used to determine that conditions are ideal for complete sterilization

Noncritical Devices:

only touches intact skin. Does not come into contact with mucus membranes. Examples are stethoscoped, blood pressure cuffs, bed rails doorknobs, exam tables, iv poles, wheelchairs, and basins,

The shelf life

or length of time that packs are considered sterile following autoclaving will vary depending on the type of wrapping material used. One must also inspect the pack for any defects, such as moisture, holes, bubbles, or tears. These defects may be caused by event factors. 513

Soaking containers

should be made of plastic; alternatively, metal pans may be used as long as a towel is placed in the bottom of the container. The towel will keep the instrument tips and other delicate structures from knocking against the metal surfaces of the container. 507

Jars

should be placed on their sides with their lids ajar or removed altogether to facilitate complete sterilization of the contents within the jar. Avoid overloading the autoclave, and make certain that there is a minimum of 1 inch between each tray. 514

Medical assistants

should wear utility gloves to decrease their risk of becoming infected during the sanitization process 207

Critical items

❖ are instruments or devices that will penetrate or enter sterile tissue. These items require complete sterilization and are usually cleaned by autoclaving or through gas sterilization. Items that are either heat sensitive or will not fit into an autoclave or gas oven may be sterilized through cold sterilization using an FDA-approved sterilant.