Chemical Selection for Cleaning and Disinfection
By Kathy Dix
Chemical selection it may seem like a tedious, even trivial topic in this day and age, but choosing the right chemical for the job is crucial to proper cleaning and disinfection.
Don Gordon, CRCST, FCS, network director for central service at North Bronx Healthcare Network, observes, Although I do not have day-to-day interaction with this topic, I do receive important feedback should problems arise, both from my managerial staff and central sterile (CS) technicians. We also have tested products throughout the years, searching for the best quality at the lowest costs.
Gordon points out that even though manufacturers recommendations are at-hand, they have examined different detergents and disinfectants over the years, attempting to identify the best quality product at the lowest cost. My best answers come from my staff members who work in both the decontamination and tray assembly areas, he says. They are my expert critics. By working with these products, they can advise how well the products clean our instruments. (With some products, you can view the removal of blood with little brushing.) We also check for smell, spotting and color/foam (making sure instruments can be observed in the sinks).
If its not specified by the manufacturer, it is left to the facility to determine the appropriate detergent and these are not regulated by the Environmental Protection Agency (EPA), which does not register products that claim only to clean, says Michael Hardy, ombudsman and enforcement team leader for the antimicrobials division at the EPA. As a matter of fact, the agency does not regulate cleaners, deodorizers, or bleach products that do not make pesticide claims. Disinfection is a claim that carries the burden of achieving a 99.999 percent log reduction for selected microorganisms. The following Web site lists the testing requirements for public health antimicrobial products: http://www.epa.gov/oppad001/sciencepolicy.htm.
Gordon says, Because water quality can affect a products performance, we frequently call the vendor in for their suggestions. At times, we have changed the concentration ratio, and we even had one vendor that went back to the plant, made adjustments in their detergent and returned with a better product. Beyond that, he says, We use a washer test weekly to make sure our washers are working correctly using these products.
Each of those items is critical. So too is handling of the products, which can be dangerous for staff if they do not observe proper protective protocol. I am of the opinion that the less handling of products, the safer it is for staff, Gordon says. In my new department that is now in the construction stage, we will have a detergent room feeding our washers utilizing large drums to reduce the handling of detergents and to save time and money.
When asked if he had encountered facilities who had improperly used chemicals in the past, Gordon replies that he has not, but that there are often mistakes made when disinfectants are applied to surfaces when cleaning portable equipment. In these cases, it is a matter of carefully reading the manufacturers instructions and educating the staff to make sure that the disinfectant remains on the surfaces for the prescribed time to disinfect properly.
When choosing a disinfectant or detergent, it is essential to base your decisions on what the device manufacturer recommends, says Nancy Chobin, RN, CSPDM, SPD/CS educator for Saint Barnabas Health Care System. Sometimes theyre getting very specific because there could be material non-compatibility with some detergents, specifically silicone. If they dont select a chemical, then I would look to a good enzymatic detergent. We know today that enzymes do a superior job loosening a lot of the protein soils we have.
However, it is also necessary to research if the product is just an enzyme, or if it is both enzyme and detergent. An enzyme is only going to loosen the soil, cautions Chobin. You still need a detergent to remove soils that the enzymes dont get off. So unless its an enzymatic detergent, you need two products.
Water quality is another issue; it is a previously unexplored area that is now being tackled by the Association for the Advancement of Medical Instrumentation (AAMI). When asked about the quality of water, Chobin says, the only answer was tap water. It must be potable, but little more is known about its makeup.
Second, temperature is also problematic, as some enzymatics are inactivated in certain temperatures, such as above 140 degrees Fahrenheit. How do you know your waters too hot? Ask everybody in CS When it burns my hands. Who has a thermometer at their sink? Nobody, Chobin protests. Were using a lot of these chemicals, and I dont think were getting the desired result, because we dont control the process. Theyve got to know the temperature of water, and if their particular product is inactivated at a certain temperature.
Third, measuring the actual amount of detergent is necessary. That is one thing virtually nobody does, Chobin points out. We just kind of pour it from the bottle, thinking if it doesnt have suds, it doesnt work. If the manufacturer says one ounce per gallon, and Im putting it in the sink, even if I take the time to measure the ounce, how many gallons are in my sink? What youre supposed to do is take an empty jug, fi ll it with water repeatedly until you get the water level in the sink you normally would use, say, three-quarters full, and if thats 10 gallons, mark it with an indelible marker or a piece of instrument marking tape and then post it on the wall: Line equals 10 gallons. Now its a no-brainer; I need 10 ounces of detergent when I fill it to that line.
Measuring detergent for decontamination is similar to measuring laundry detergent at home, she adds. Chobin encourages students in her CS course to go home and place a washcloth in a bowl of tap water. If you get suds out of it, two things: number one, youre using too much detergent, which means youre wasting money. Two, your clothes arent clean, because youve left all the suds behind.
Cleaning in a hospital is the same principle as washing dishes at home. Your mother always told you to sort glasses, silverware, dishes, then pots and pans. Well, we sort things in CS. What happens when you have a really greasy pot? Dont you put it in hot detergent and water and let it soak? Well, thats the enzyme presoak. When you load a dishwasher, on a holiday when you stack stuff on top and the next morning say, nothing came out clean, you overloaded it. In a hospital, people want to put bowls and basins on top of their instruments to keep everything together, but theyre not going to come out clean, she adds.
She observes that in CS, when chemicals are not mixed correctly, its not just wasting money or having an instrument that isnt entirely clean. This could adversely affect the overall outcome.
Chobin offers the example of high-pH detergents not being diluted properly and then damaging instruments. Getinge provides you with an automated detergent dispenser. It can actually hook up to your water faucet in decontam, so when you turn on the water, it will automatically dispense the appropriate amount of detergent so you dont even have to measure it. And STERIS has the little pumps, where each pump equals an ounce, she says.
Beyond measuring, she has another grievance the choice of cleaning solution being determined by the purchasing department. I dont have a problem with trials, but the final outcome should not be cost, Chobin states. The fi nal outcome should be, Are my instruments clean? If youre paying $5 less a gallon, and Ive got dirty instruments, what good is it? Youre looking good and my patient is suffering.
Knowing what causes problems ahead of time is a necessity, not a bonus -- many washers must use neutral pH detergents, because high pH detergents will damage the anodized aluminum rigid containers many facilities are now using. The problem is, because were at capacity in our washers, many of us will put our containers through our cart washer, she explains. Your cart washer always uses a high pH detergent because theres much less washing action there, so the high pH makes up for that. If you put your containers through your cart washer without switching your detergent, youre going to ruin a couple hundred thousand dollars worth of containers. And the manufacturer of the containers knows it immediately and will null and void the warranty.
Each of those containers might cost up to $900; Chobin recalls one hospital with more than $100,000 in containers ruined by a high-pH detergent. They expected the manufacturer of the container to do something about it. I said, Why? This was your problem, not theirs. We cant plead ignorance anymore. People are saying, This isnt fair; the manufacturers should come up with one set of instructions that we can all follow. We shouldnt have to change all these times and temperatures. But the manufacturer of the device has determined how to process it. Hes not going to turn around and say, Well, Im going to have to be able to sterilize it in four minutes, or the people in Central cant do it. Weve got to stop treating people like theyre idiots. People say, I cant possibly have my staff change the times; theyre going to make a mistake and were going to have a problem. Thats why you train people. If you have that problem, you probably have that problem in everything you do in your department, not just with changing the sterilizer.
Keep in mind that disinfection solutions and detergents are very different beasts. One is intended for cleaning, the other for disinfection. Some products are detergent germicides, but, Chobin says, Basically, theyre only half as good as if you use them separately, so the manufacturer usually recommends that you make two solutions. The first one you would use to clean with, and the second one you would use to disinfect it. Everybody wants a quick fix, but there is no quick fi x when it comes to cleaning.
She offers the example of standing in the shower and letting water run over her -- not an effective means of cleaning. But soap, water and scrubbing give a much more effective result. You get what you pay for, she says. You cant blame the manufacturers, because were constantly bugging them for something faster, smarter. Youve got to take the time to do it right, period.
Cleaning is vital, but is the one thing that is often overlooked. Even people in CS dont always appreciate the decontamination process. Youre covered with all this protective attire; youre in the back and nobody can come in there and youre not where its happening. But I tell my staff that I want my superstars in decontam, because if they dont do their job, were wasting our time in the rest of the department. The mentality is, thats not an important job -- its important to know the instrument and put it on the tray correctly -- and nothing could be further from the truth, Chobin emphasizes. Weve got to make people realize how important it is. When I first started in CS, I went to a seminar and Peggy Ryan said, If we cant clean something, we disinfect it. If we cant disinfect it, we sterilize it. And if we cant sterilize it, Lord have mercy, we pray a lot. Theres a lot of praying going on.