A patient, dehydrated and needing fluids STAT, enters the emergency department. But wait, there are no IV pumps. The central sterile department (CSD) is paged, the call is returned to the ER, and an infusion pump is requested. The CSD responds with the dreaded answer, “We don’t have any pumps to give you.” The ER responds with, “Where are all the pumps, we need one STAT, you have to find one!” Then, off goes the CSD professional, running on a pump-hunt, searching every unit, cabinet, closet and bathroom. The CSD professional stops briefly to ask a passing healthcare worker (HCW) if there are any pumps on the unit, and oddly, nobody has seen any. Then, the CSD professional passes an empty patient room, the one where the curtains are pulled around the bed so it looks like there is a patient inside. The CSD professional ventures into the room and voila, six pumps, on one pole, not plugged in and filthy. The pole is smeared with blood, hair, urine and that other colorful biofilm that you ask your co-workers to look at because you have no idea what it is. How many of us in the CSD have encountered this scenario?
These issues, among many other equipment-related issues, do happen, have happened and will continue to happen if facilities and healthcare workers continue to allow this to happen. What part of “single-patient use” or “clean-and-disinfect-between-patient-use” do HCWs not understand? Many HCWs shrug their shoulders and wonder why there are so many surgical site infections (SSIs). It’s not their fault, of course. Is it the patient's fault? Perhaps it’s the insurance companies’ fault? Perhaps it’s the family of the sick or elderly?
First, let’s make sure we have a clear and concise understanding of what the concept of “clean-between-patients” entails. All patient-care equipment must undergo a very detailed and accurate process of cleaning, disinfection or sterilization, depending on the manufacturers’ recommendations. Not once have I seen the recommendation of “use on several patients without cleaning,” nor have I seen the recommendation of “let’s hide the equipment from the CSD so we have it for later.” After each patient use or patient discharge, the CSD must be notified of any patient-care equipment left on the unit, or make the units responsible for the return of this equipment. Absolutely no exceptions should be allowed or tolerated, especially when it comes to patient care.
Upon contaminated equipment being received in the CSD decontamination area, the CSD professional must don appropriate personal protective equipment (PPE), and then the equipment must be thoroughly cleaned and or disinfected, depending upon the manufacturers’ recommendations. Every nook, cranny, handle, crevice and crack must be inspected and cleaned properly. Is the cord frayed? Does the equipment work? Is the PM expired? Are you using the correct spray or cleanser? Are we rinsing if necessary? Are we air drying? These are all important factors that must be considered.
After all of the equipment is properly cleaned in the CSD, a bag should be placed on each piece and a “clean” sticker with the CSD professional’s initials and the date should be attached to the bag. The equipment should then be placed in the clean storage area, plugged in until the floor sends a requisition. Once the requisition is sent to the CSD, the CSD professional should document the equipment requested, the serial number and what unit and the room number to which the equipment has been issued. An equipment or device-tracking system, if used correctly, can be an excellent resource. However, many facilities do not have this kind of luxury. A manual system can work just as well if done correctly and if there is participation from all users.
Upon patient discharge, a requisition is sent to the CSD and then the CSD professional can retrieve the equipment from the unit during the designated equipment rounds. If this is not done via requisition, the units can call CSD or send a fax. The CSD professional can still make rounds and collect equipment. It is important that all HCWs make the patient’s stay a healthy stay. Discontinue hoarding equipment and communicate with the CSD staff, as they are there to support the hospital. They are there for the positive outcome of the patient. Units will get the equipment they need if they cooperate and allow CSD professionals to perform their jobs correctly.
There is no room for shortcuts, especially when another human life is at the mercy of the HCW. There are so many different hospital-acquired infections (HAIs) that can be transmitted, and most inanimate objects are one of many culprits in the process of disease transmission. An HAI, defined as an infection which was contracted in a hospital, can be caused by bacteria, viruses, parasites, fungi and many other infectious agents. Examples of some of these kinds of bacteria are Pseudomonas aeuruginosa, Staphylococcus aureus, strep, enterococci, Clostridium difficile and Esherichia coli, to name just a few. Infections can begin within surgical wounds, be transmitted by careless HCWs, or may even spread through the air and breathed in by patients who are immuno-compromised. These infections cause serious illness and even death.
It can be challenging for the patient to avoid contracting an HAI, however, they can insist that HCWs wash their hands properly before having any contact with them and demand clean, bagged equipment. The HCW is responsible in ensuring that patients also have proper access to their own handwashing facilities, especially before and after eating or using the toilet. In addition to handwashing, hospitals can help prevent infections from spreading among patients by always cleaning medical devices after each patient use and always isolating patients with any communicable infectious diseases. Facilities must demand that HCWs not only wash their hands, but utilize appropriate PPE as necessary. Keep in mind that HCWs and CSD professionals are patients’ advocates and are ultimately responsible for their recovery.
So why do so many HCWs insist on re-using patient-care equipment? Why is it so difficult for the CSD professional to obtain and clean these contaminated items? Amazingly enough, however, when it's time for a visit from the Joint Commission or a mock survey, the equipment is piled up to the ceiling in the CSD. Is the issue really not enough equipment to go around on the unit? Is it due to lack of staff, caring or concern? If this is an ongoing issue in any facility, one option is to conduct an equipment assessment. The CSD manager or director, along with materials managers or purchasing personnel can review how much and what type of patient-care equipment has been purchased, leased or rented. There must be an appropriate patient-to-equipment ratio before any decisions are made to purchase, lease or rent in the past. How many beds does the facility have and what is the usual admissions data? If the facility really does not have enough patient-care equipment, there are many options to explore, and the facility’s finance department can assist with this task. Some facilities that have had to rent equipment will charge the individual unit’s budget, as well as counsel the HCWs assigned to the specific patient. Lack of staff is not an excuse for not doing the expected job correctly, especially when the CSD professional makes rounds to collect these items.
There must never be an excuse for inappropriate patient care. It is unacceptable, immoral, unethical and wrong. Ask yourself, would you ever admit publicly to doing your job incorrectly and taking shortcuts? The best policy is doing the job correctly the first time, even when nobody is watching. Remember why we all became involved in healthcare in the first place. Remember the feeling of going home after a hard day’s work and saying to yourself, “Today I made someone’s life so much better!” And always remember the six P’s: Proper Prior Planning Prevents Poor Performance!ICT
Kristina Pirollo, CRCST, CHL, is a consultant with New York City-based Nexera Consulting Inc.
Eliminating Reservoirs of Microorganisms
Patient-care equipment and medical devices — as well as environmental surfaces — can serve as reservoirs for pathogenic microorganisms. Transmission of disease-causing bacteria and viruses occurs when gloved or ungloved hands of healthcare workers (HCWs) come in contact with a contaminated surface and/ or there is patient contact with contaminated surfaces or medical equipment. Various studies show that contamination of the environment has likely contributed to the spread of multidrug-resistant organisms (MDROs).1-2
Fleming3 emphasizes that the use of friction is the key to cleaning and disinfecting environmental surfaces and non-critical patient-care equipment, as this mechanical scrubbing action removes visible dirt, organic material, and debris — thereby also removing microorganisms. Fleming notes, “Items must be cleaned before disinfection can take place. It is important to note that many disinfectants contain detergents that aid in cleaning. Healthcare facilities should have established protocols and procedures for cleaning environmental surfaces and patient care equipment. One of the biggest challenges in healthcare is assigning who is responsible for items to be cleaned. Healthcare workers (HCWs) are frequently unaware of who is responsible for specific cleaning protocols. Routines for cleaning surfaces and medical equipment in all clinical and non clinical areas need to be established based on the need to frequently clean (e.g., after patient use or at end of the day or shift, and degree of contamination).”
Items and surfaces that are frequently touched are at a greater risk for cross-contamination. Fleming says that examples of high-touch surfaces include bed rails, light switches, doorknobs, blood pressure cuffs, stethoscopes, portable X-ray machine handles, cardiac monitor knobs, stretchers, wheelchairs, telephones, IV poles and pumps, utility carts, rehabilitation equipment, and computer keyboards. Fleming observes, “Disinfection of environmental surfaces may be the responsibility of the housekeeping department, but cleaning and disinfection of patient care items and some clinical department-specific surfaces are usually the responsibility of the clinical department staff. Protocols and procedures should outline who is responsible for disinfection of surfaces and patient care equipment, the frequency of disinfection and product used for disinfection. Infection prevention and control departments should be involved in reviewing cleaning and disinfection practices and protocols and work with housekeeping department and the clinical unit/department management in establishing protocols to ensure best practices. Consistent monitoring of cleaning and disinfection practices should be conducted on a regular basis by department and unit management teams.”3
1. Muto CA, Jernigan JA et.al. SHEA Guideline for Preventing Nosocomial Transmission of Multidrugresistant Strains of Staphylococcus aureus and Enterococcus. ICHE. 2003; 24: 362-386.
2. Zachary K, et. al. Contamination of gowns, gloves, and stethoscopes with vancomycin-resistant enterococcus. ICHE 2001; 22: 560-564.
3. Fleming J. Environmental surface disinfection: Meeting best practices for infection prevention. Infection Control Today. 2007.