Recommended practices for high-level disinfection

AORN Journal,  Feb, 2005  

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These recommended practices are intended be achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings or clinical situations that determine the degree to which recommended practices can be implemented.

AORN recognizes the various settings in which perioperative nurses practice. These recommended practices are intended to guide practice in these settings, including traditional ORs, ambulatory surgical units, physicians' offices, cardiac catheterization suites, endoscopy units, radiology departments, and all other areas where surgical and other invasive procedures may be performed.

PURPOSE. These recommended practices provide guidance for achieving high-level disinfection of instruments and equipment.

RECOMMENDED PRACTICE I

Items to be disinfected should be categorized as critical, semicritical, and noncritical.

1. The Spaulding classification system, developed by Earle Spaulding in 1968, has withstood the passage of time and continues to be used today by infection control practitioners and others to determine the correct processing methods for preparing instruments and other items for patient use. According to the Spaulding system, the level of processing required is based on the nature of the item and the manner in which it is to be used. (1)

2. Items that enter sterile tissue or the vascular system are categorized as critical and should be sterile when used. Examples of critical items include

* surgical instruments,

* cutting endoscopic accessories that break the mucosal barrier and the endoscopes through which they are used,

* cardiac and urinary catheters,

* implants,

* needles, and

* ultrasound probes used in sterile body cavities.

If critical items are contaminated with microorganisms, including bacterial spores, the risk of infection is substantial. (1-3)

The Spaulding system does not consider problems with processing equipment that may be heat labile (eg, arthroscopic and laparoscopic endoscopes). New technologies make it easier to sterilize heat-labile items. Although sterilization of these endoscopes is preferred, there is no conclusive evidence that sterilization reduces patient infection risk more than high-level disinfection. (3-6) Practitioners affected by this controversy should consult and follow recommendations and guidelines developed by AORN, the Association for Professionals in Infection Control and Epidemiology, Inc (APIC), and the American Society for Gastrointestinal Endoscopy. (7-9) Telescopes are constructed of smooth, easily cleanable surfaces with no internal channels and few irregularities. Cleaning rather than the specific disinfection or sterilization procedure is the major factor determining the success or failure of reprocessing. Unless packaged and sterilized, critical items should be reprocessed immediately before use.

3. Items that come in contact with nonintact skin or mucous membranes are considered semicritical and should receive a minimum of high-level disinfection immediately before use. Examples of semicritical items include

* respiratory therapy equipment,

* anesthesia equipment,

* bronchoscopes, and

* gastrointestinal endoscopes.

Unless packaged and sterilized, semicritical items (eg, endoscopes) should be reprocessed immediately before use. These items also may be sterilized. Intact mucous membranes generally provide a barrier to common bacterial spores but not to organisms, such as tubercle bacilli and viruses. (1,2) Semicritical devices contaminated with hepatitis B virus (HBV), hepatitis C virus (HCV), HIV, or Mycobacterium tuberculosis (TB) should receive a minimum of high-level disinfection. (1) Research has demonstrated that high-level disinfectants inactivate these and other pathogens that may contaminate semicritical devices. (1) This practice is consistent with standard precautions, which presume that all patients potentially are infected. (1)

4. Items that come in contact only with intact skin are categorized as noncritical items and should receive intermediate-level disinfection, low-level disinfection, or cleaning. Examples of noncritical items include

* tourniquets and blood pressure cuffs,

* linens, and

* Mayo stands and other OR furnishings.

Intact skin acts as an effective barrier to most organisms. (1)

5. Guidelines from APIC for inactivation of the Creutzfeldt-Jakob disease (CJD) agent should be observed. (10) When possible, disposable supplies should be used if a patient is thought to be infected with the CJD agent) Critical and semicritical items or surfaces contaminated with the CJD agent require unique decontamination procedures because of an extremely resistant subpopulation of prions. (8) Although some discrepancies exist between studies, all studies show that these prions resist normal inactivation methods. Noncritical patient care items and surfaces have not been implicated in disease transmission. (1)

RECOMMENDED PRACTICE II