Recommended Practices for High-Level Disinfection

AORN Journal, March, 1999

The following recommended practices were developed by the AORN Recommended Practices Committee and have been approved by the AORN Board of Directors. They were presented as proposed recommended practices for comments by members and others. They are effective Jan 1, 1999.

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

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

Purpose: These recommended practices provide guidelines for achieving high-level disinfection of instrumentation and durable equipment.

RECOMMENDED PRACTICE I

Items to be disinfected should be categorized as one of the following:

* critical,

* semicritical, and

* noncritical.

Discussion:

The Spaulding classification system, named for its developer, Earle Spaulding, was developed many years ago. It 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 disinfection required is based on the nature of the item and the manner in which it is to be used.(1)

Interpretive statement 1:

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

* surgical instruments,

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

* cardiac and urinary catheters,

* implants, and

* needles.

Rationale:

If critical items are contaminated with microorganisms, including bacterial spores, the risk of infection is substantial.(2)

Discussion:

One problem associated with the Spaulding system is that it does not consider problems with processing complicated equipment that may be heat labile (eg, arthroscopes, laparoscopes). In some arenas there is controversy regarding whether such instruments should be sterilized or receive high-level disinfection. Sterilization would not be a problem if these items could be steam sterilized, but most are heat labile and require other sterilization methods. Whereas new technologies make it easier to sterilize these heat-labile items, there is no conclusive evidence that the preferred sterilization of these endoscopes reduces patient infection risk.(3) Practitioners who are affected by this controversy should consult and follow guidelines developed by the Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention.(4) Critical items that are not sterilized should be processed immediately before use.

Interpretive statement 2:

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,

* gastrointestinal endoscopes, and

* cystoscopes.

These items also may be sterilized.

Rationale:

Intact mucous membranes generally resist infection by common bacterial spores but are susceptible to other organisms.(5)

Interpretive statement 3:

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

* bedpans,

* blood pressure cuffs,

* crutches,

* linens,

* bedside tables, and

* furniture.

Rationale:

Intact skin acts as an effective barrier to most microorganisms.(6)

Interpretive statement 4:

Semicritical devices contaminated with hepatitis B virus, HIV, or Mycobacterium tuberculosis should receive a minimum of high-level disinfection.(7)

Rationale:

Research has demonstrated the effectiveness of high-level disinfectants to inactivate these and other pathogens that may contaminate semicritical devices.(8) This practice is consistent with standard precautions, which presume that all patients potentially are infected.(9)

Interpretive statement 5:

The APIC guidelines for inactivation of the Creutzfeldt-Jakob disease (CJD) agent should be followed.(10) Disposables are recommended and, when practical, should be used if the patient is thought to be infected with the CJD agent.(11)

Rationale:

Critical and semicritical items or surfaces contained with the CJD agent require unique decontamination procedures. The need for special recommendations is due to an extremely resistant subpopulation of prions. Although some discrepancies exist between different studies, all studies show that these prions resist normal inactivation methods. Noncritical patient care items or surfaces have not been involved in disease transmission.(12)