Chemical selection it may seem likea tedious, even trivial topic in this day and age, but choosing the rightchemical for the job is crucial to proper cleaning and disinfection.
Don Gordon, CRCST, FCS, network director for central serviceat North Bronx Healthcare Network, observes, Although I do not haveday-to-day interaction with this topic, I do receive important feedback shouldproblems arise, both from my managerial staff and central sterile (CS)technicians. We also have tested products throughout the years, searching forthe best quality at the lowest costs.
Gordon points out that even though manufacturersrecommendations are at-hand, they have examined different detergents anddisinfectants over the years, attempting to identify the best quality product atthe lowest cost. My best answers come from my staff members who work in boththe decontamination and tray assembly areas, he says. They are my expertcritics. By working with these products, they can advise how well the productsclean our instruments. (With some products, you can view the removal of bloodwith little brushing.) We also check for smell, spotting and color/foam (makingsure instruments can be observed in the sinks).
If its not specified by the manufacturer, it is left tothe facility to determine the appropriate detergent and these are notregulated by the Environmental Protection Agency (EPA), which does not registerproducts that claim only to clean, says Michael Hardy, ombudsman and enforcementteam leader for the antimicrobials division at the EPA. As a matter of fact,the agency does not regulate cleaners, deodorizers, or bleach products that donot make pesticide claims. Disinfection is a claim that carries the burden ofachieving a 99.999 percent log reduction for selected microorganisms. Thefollowing Web site lists the testing requirements for public healthantimicrobial products: http://www.epa.gov/oppad001/sciencepolicy.htm.
Gordon says, Because water quality can affect a productsperformance, we frequently call the vendor in for their suggestions. At times, we have changed the concentration ratio, and we evenhad one vendor that went back to the plant, made adjustments in their detergentand returned with a better product. Beyond that, he says, We use a washertest weekly to make sure our washers are working correctly using these products.
Each of those items is critical. So too is handling of theproducts, which can be dangerous for staff if they do not observe properprotective 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 nowin the construction stage, we will have a detergent room feeding our washersutilizing large drums to reduce the handling of detergents and to save time andmoney.
When asked if he had encountered facilities who had improperlyused chemicals in the past, Gordon replies that he has not, but that thereare often mistakes made when disinfectants are applied to surfaces when cleaningportable equipment. In these cases, it is a matter of carefully reading themanufacturers instructions and educating the staff to make sure that thedisinfectant remains on the surfaces for the prescribed time to disinfectproperly.
When choosing a disinfectant or detergent, it is essential tobase your decisions on what the device manufacturer recommends, says NancyChobin, RN, CSPDM, SPD/CS educator for Saint Barnabas Health Care System. Sometimestheyre getting very specific because there could be materialnon-compatibility with some detergents, specifically silicone. If they dontselect a chemical, then I would look to a good enzymatic detergent. We knowtoday that enzymes do a superior job loosening a lot of the protein soils wehave.
However, it is also necessary to research if the product isjust an enzyme, or if it is both enzyme and detergent. An enzyme is onlygoing to loosen the soil, cautions Chobin. You still need a detergent toremove soils that the enzymes dont get off. So unless its an enzymaticdetergent, you need two products.
Water quality is another issue; it is a previously unexploredarea that is now being tackled by the Association for the Advancement of MedicalInstrumentation (AAMI). When asked about the quality of water, Chobin says, theonly answer was tap water. It must be potable, but little more is knownabout its makeup.
Second, temperature is also problematic, as some enzymaticsare inactivated in certain temperatures, such as above 140 degrees Fahrenheit.How do you know your waters too hot? Ask everybody in CS When itburns my hands. Who has a thermometer at their sink? Nobody, Chobin protests. Were using a lot of thesechemicals, and I dont think were getting the desired result, because wedont control the process. Theyve got to know the temperature of water, andif 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 justkind of pour it from the bottle, thinking if it doesnt have suds, it doesntwork. If the manufacturer says one ounce per gallon, and Im putting it inthe sink, even if I take the time to measure the ounce, how many gallons are inmy sink? What youre supposed to do is take an empty jug, fi ll it with waterrepeatedly 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 indeliblemarker or a piece of instrument marking tape and then post it on the wall: Lineequals 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 tomeasuring laundry detergent at home, she adds. Chobin encourages students in herCS course to go home and place a washcloth in a bowl of tap water. If you getsuds out of it, two things: number one, youre using too much detergent, whichmeans youre wasting money. Two, your clothes arent clean, because youveleft all the suds behind.
Cleaning in a hospital is the same principle as washingdishes 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 youhave a really greasy pot? Dont you put it in hot detergent and water and letit soak? Well, thats the enzyme presoak. When you load a dishwasher, on aholiday when you stack stuff on top and the next morning say, nothing cameout clean, you overloaded it. In a hospital, people want to put bowls and basins on top oftheir instruments to keep everything together, but theyre not going to comeout clean, she adds.
She observes that in CS, when chemicals are not mixedcorrectly, its not just wasting money or having an instrument that isntentirely clean. This could adversely affect the overall outcome.
Chobin offers the example of high-pH detergents not beingdiluted properly and then damaging instruments. Getinge provides you with anautomated detergent dispenser. It can actually hook up to your water faucet indecontam, so when you turn on the water, it will automatically dispense theappropriate amount of detergent so you dont even have to measure it. AndSTERIS has the little pumps, where each pump equals an ounce, she says.
Beyond measuring, she has another grievance the choice ofcleaning solution being determined by the purchasing department. I donthave a problem with trials, but the final outcome should not be cost, Chobinstates. The fi nal outcome should be, Are my instruments clean? If yourepaying $5 less a gallon, and Ive got dirty instruments, what good is it? Yourelooking good and my patient is suffering.
Knowing what causes problems ahead of time is a necessity, nota bonus -- many washers must use neutral pH detergents, because high pHdetergents will damage the anodized aluminum rigid containers many facilitiesare 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. Yourcart washer always uses a high pH detergent because theres much less washingaction there, so the high pH makes up for that. If you put your containersthrough your cart washer without switching your detergent, youre going toruin a couple hundred thousand dollars worth of containers. And the manufacturerof the containers knows it immediately and will null and void the warranty.
Each of those containers might cost up to $900; Chobin recallsone hospital with more than $100,000 in containers ruined by a high-pH detergent. They expected the manufacturer of thecontainer to do something about it. I said, Why? This was your problem, nottheirs. We cant plead ignorance anymore. People are saying, This isntfair; the manufacturers should come up with one set of instructions that we canall follow. We shouldnt have to change all these times and temperatures.But the manufacturer of the device has determined how to process it. Hes notgoing to turn around and say, Well, Im going to have to be able tosterilize it in four minutes, or the people in Central cant do it. Wevegot to stop treating people like theyre idiots. People say, I cantpossibly have my staff change the times; theyre going to make a mistake andwere going to have a problem. Thats why you train people. If you havethat problem, you probably have that problem in everything you do in yourdepartment, not just with changing the sterilizer.
Keep in mind that disinfection solutions and detergents arevery 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 manufacturerusually recommends that you make two solutions. The first one you would use toclean with, and the second one you would use to disinfect it. Everybody wants aquick fix, but there is no quick fi x when it comes to cleaning.
She offers the example of standing in the shower and lettingwater run over her -- not an effective means of cleaning. But soap, water andscrubbing give a much more effective result. You get what you pay for, shesays. You cant blame the manufacturers, because were constantly buggingthem for something faster, smarter. Youve got to take the time to do itright, period.
Cleaning is vital, but is the one thing that is oftenoverlooked. Even people in CS dont always appreciate thedecontamination process. Youre covered with all this protective attire;youre in the back and nobody can come in there and youre not where itshappening. But I tell my staff that I want my superstars in decontam, because ifthey dont do their job, were wasting our time in the rest of thedepartment. The mentality is, thats not an important job -- its importantto know the instrument and put it on the tray correctly -- and nothing could befurther from the truth, Chobin emphasizes. Weve got to make peoplerealize how important it is. When I first started in CS, I went to a seminar andPeggy Ryan said, If we cant clean something, we disinfect it. If we cantdisinfect it, we sterilize it. And if we cant sterilize it, Lord have mercy,we pray a lot. Theres a lot of praying going on.