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October 21, 2014   Download print version

CDC tightened guidance for U.S. healthcare workers on personal protective equipment for Ebola

Study shows exit screening vital to halting global Ebola spread

Ebola and the epidemics of the past

Australian scientists prove link between viral infection and autoimmune disease

Texas hospital apologizes for Ebola mistakes

Hospital hand hygiene reporting discrepancies continue

Canada leads the way on Ebola experimental drugs: ZMapp, TKM-Ebola and VSV-EBOV

Pure Processing launches new dedicated eye sink


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CDC tightened guidance for U.S. healthcare workers on personal protective equipment for Ebola

The Centers for Disease Control and Prevention is tightening previous infection control guidance for healthcare workers caring for patients with Ebola, to ensure there is no ambiguity. The guidance focuses on specific personal protective equipment (PPE) healthcare workers should use and offers detailed step by step instructions for how to put the equipment on and take it off safely. 

Recent experience from safely treating patients with Ebola at Emory University Hospital, Nebraska Medical Center and National Institutes of Health Clinical Center are reflected in the guidance.

The enhanced guidance is centered on three principles:

·         All healthcare workers undergo rigorous training and are practiced and competent with PPE, including taking it on and off in a systemic manner

·         No skin exposure when PPE is worn

·         All workers are supervised by a trained monitor who watches each worker taking PPE on and off

All patients treated at Emory University Hospital, Nebraska Medical Center and the NIH Clinical Center have followed the three principles. None of the workers at these facilities have contracted the illness.

Principle #1: Rigorous and repeated training: Focusing only on PPE gives a false sense of security of safe care and worker safety. Training is a critical aspect of ensuring infection control. Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment, especially in the step by step donning and doffing of PPE. CDC and partners will ramp up training offerings for healthcare personnel across the country to reiterate all the aspects of safe care recommendations.  

Principle #2: No skin exposure when PPE is worn: Given the intensive and invasive care that US hospitals provide for Ebola patients, the tightened guidelines are more directive in recommending no skin exposure when PPE is worn. 

CDC is recommending all of the same PPE included in the August 1, 2014 guidance, with the addition of coveralls and single-use, disposable hoods. Goggles are no longer recommended as they may not provide complete skin coverage in comparison to a single use disposable full face shield. Additionally, goggles are not disposable, may fog after extended use, and healthcare workers may be tempted to manipulate them with contaminated gloved hands.  PPE recommended for U.S. healthcare workers caring for patients with Ebola includes:

·         Double gloves

·         Boot covers that are waterproof and go to at least mid-calf or leg covers

·         Single use fluid resistant or imperable gown that extends to at least mid-calf or coverall without intergraded hood.

·         Respirators, including either N95 respirators or powered air purifying respirator(PAPR)

·         Single-use, full-face shield that is disposable

·         Surgical hoods to ensure complete coverage of the head and neck

·         Apron that is waterproof and covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea

The guidance describes different options for combining PPE to allow a facility to select PPE for their protocols based on availability, healthcare personnel familiarity, comfort and preference while continuing to provide a standardized, high level of protection for healthcare personnel. 

The guidance includes having:

·         Two specific, recommended PPE options for facilities to choose from. Both options provide equivalent protection if worn, donned and doffed correctly.

·         Designated areas for putting on and taking off PPE. Facilities should ensure that space and lay-out allows for clear separation between clean and potentially contaminated areas

·         Trained observer to monitor PPE use and safe removal

·         Step-by-step PPE removal instructions that include:

·         Disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment

·         Disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE.

Principle #3: Trained monitor: CDC is recommending a trained monitor actively observe and supervise each worker taking PPE on and off. This is to ensure each worker follows the step by step processes, especially to disinfect visibly contaminated PPE. The trained monitor can spot any missteps in real-time and immediately address.

The CDC reminds health workers to "Think Ebola" and to "Care Carefully." Healthcare workers should take a detailed travel and exposure history with patients who exhibit fever, severe headache, muscle pain, weakness, diarrhea, vomiting, stomach pain, unexplained hemorrhage. If the patient is under investigation for Ebola, healthcare workers should activate the hospital preparedness plan for Ebola, isolate the patient in a separate room with a private bathroom, and to ensure standardized protocols are in place for PPE use and disposal. Healthcare workers should not have physical contact with the patient without putting on appropriate PPE.     

CDC's guidance for U.S. healthcare settings is similar to MSF's (Doctors Without Borders) guidance 

Both CDC's and MSF's guidance focuses on: Protecting skin and mucous membranes from all exposures to blood and body fluids during patient care; Meticulous, systematic strategy for putting on and taking off PPE to avoid contamination and to ensure correct usage of PPE; Use of oversight and observers to ensure processes are followed.

Disinfection of PPE prior to taking off: CDC recommends disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment. Additionally, CDC recommends disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE. Due to differences in the U.S. healthcare system and West African healthcare settings, MSF's guidance recommends spraying as a method for PPE disinfection rather than disinfectant wipes. 

CDC reminds all employers and healthcare workers that PPE is only one aspect of infection control and providing safe care to patients with Ebola. Other aspects include five pillars of safety:

·         Facility leadership has responsibility to provide resources and support for implementation of effective prevention precautions. Management should maintain a culture of worker safety in which appropriate PPE is available and correctly maintained, and workers are provided with appropriate training. 

·         Designated on-site Ebola site manager responsible for oversight of implementing precautions for healthcare personnel and patient safety in the healthcare facility.

·         Clear, standardized procedures where facilities choose one of two options and have a back-up plan in case supplies are not available.

·         Trained healthcare personnel: facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment.

·         Oversight of practices are critical to ensuring that implementation protocols are done accurately, and any error in putting on or taking off PPE is identified in real-time, corrected and addressed, in case  potential exposure occurred.

Visit CDC for the guidance.



Study shows exit screening vital to halting global Ebola spread

Three Ebola-infected travelers a month would be expected to get on international flights from the West African countries suffering epidemics of the deadly virus if there were no effective exit screening, scientists said on Tuesday.

The three countries, Guinea, Liberia and Sierra Leone, do all check departing air passengers for fever, although the test cannot spot sufferers in the period before they show symptoms, which can be up to 21 days.

The researchers, whose work was published in The Lancet medical journal on Tuesday, said exit screening was nevertheless one of the most effective ways of limiting Ebola's spread.

Using modeling based on 2014 global flight schedules and 2013 passenger itineraries, as well as current epidemic conditions and flight restrictions, the analysis showed that, on average, just under three (2.8) Ebola-infected travelers are projected to travel on an international flight every month.

Dr. Kamran Khan of St Michael's Hospital in Toronto, Canada, who led the research, said the study showed it was far more effective and less disruptive to screen travelers from the affected countries in West Africa as they leave, rather than when they land, as the United States, Britain, France and some other countries have begun to do.

"While screening travelers arriving at airports outside of West Africa may offer a sense of security, this would have at best marginal benefits, and could draw valuable resources away from more effective public health interventions," Khan said.

Ebola is known to have killed more than 4,500 people in Liberia, Sierra Leone and Guinea. But with at least half the cases going unreported and a 70 percent fatality rate, by World Health Organization (WHO) estimates, the true toll in what is by far the worst outbreak on record is probably more than 12,000.

Cases of the hemorrhagic fever have already been imported into Nigeria, Senegal, Spain and the United States, and WHO officials have said it is "unavoidable" that Ebola cases will be seen in more countries.

Many medical experts have argued that the best place to prevent the spread of Ebola is at its source.

Khan said excessive constraints on air travel could have "severe economic consequences that could destabilize the region and possibly disrupt critical supplies of essential health and humanitarian services".

The study found that, of the almost 500,000 travelers who flew on commercial flights out of Conakry, Monrovia and Freetown international airports in 2013, more than half were destined for one of five countries: Ghana (17.5 percent), Senegal (14.4 percent), Britain (8.7 percent), France (7.1 percent) or Gambia (6.8 percent).

It also found that more than 60 percent of travelers in 2014 were likely to be heading for poor or middle-income countries, where the medical and public health resources to prevent a wider outbreak are likely to be more limited.

Visit Reuters for the story.



Ebola and the epidemics of the past

In the winter of 1947, an American tourist arrived in New York City on a bus from Mexico, feeling feverish and stiff. He checked into a hotel and did some sightseeing before his condition worsened. A red rash now covered his body. He went to a local hospital, which monitored his vital signs and transferred him to a contagious disease facility, where he was incorrectly diagnosed with a mild drug reaction. He died a few days later of smallpox. By this point, the man had infected at least a dozen New Yorkers, one of whom died. Taking no chances, city officials began a massive but voluntary vaccination campaign against a disease that had killed more people than any other in history.

Sound familiar? Parts of the 1947 smallpox scare - the sick traveler harboring a deadly disease, the missed hospital diagnosis, the quickly spreading infection - strike a disturbing chord. A key difference between that crisis and our current one with Ebola is, of course, the absence of an effective vaccine - and the fact that Ebola is usually transmitted through close, direct physical contact with the bodily fluids of someone infected.

But Americans in the 1940s had a different mind-set as well. Today many Americans doubt that health authorities can handle the crisis. Back then, by contrast, there was a growing confidence in the power of medical research to solve any problem, tame any epidemic, conquer any disease. It was a confidence grounded in the miracle drugs and vaccines beginning to emerge from university and pharmaceutical laboratories, and in the public health apparatus that had served the nation and its troops so well during World War II.

The great medical breakthroughs in the mid-19th century came mainly from Europe. Among these was the concept of germ theory proposed by Louis Pasteur, Robert Koch and Joseph Lister. Germ theory linked specific germs to specific diseases, like rabies, cholera and tuberculosis. It taught people to accept the peculiar idea that humans shared their communities, their homes, even their bodies with invisible, often dangerous microorganisms. Put simply, what you didn't see could make you very ill.

Germ theory spurred the development of modern laboratory research. Its impact on pathology and bacteriology can hardly be overstated. In 1900, the life expectancy for an American man was 46, and for an American woman 48. By 1950, the figures had jumped to 65 and 72 respectively.

Some of this increase can be explained by factors such as better nutrition, cleaner water and the passage of pure food and drug laws. But much of it was due to the vaccines, sulfa drugs and antibiotics aimed at the deadly infections that put children at special risk.

In terms of public confidence, America's golden age of medicine reached its peak in the 1950s. It was here that the miracle of the laboratory routed the terror of infectious disease in the most dramatic imaginable way. The disease was polio—also known as infantile paralysis—which descended like a plague upon Americans each summer, killing thousands of children and leaving thousands more in leg braces, wheelchairs and iron lungs. Polio in the 1950s, like Ebola today, put everyone at risk.

But Americans channeled these fears into a common purpose, much like the smallpox episode of 1947. Uniting behind Franklin D. Roosevelt's March of Dimes, they raised hundreds of millions of dollars to find an effective polio vaccine. In a move probably incomprehensible to most parents today, they volunteered their children - almost two million of them - for the massive public trials in 1954 that tested Dr. Jonas Salk's killed-virus injected polio vaccine.

Salk's triumph was followed, in short order, by Albert Sabin's equally effective live-virus oral polio vaccine (given on a sugar cube or in a medicine dropper) as well as vaccines for measles, mumps, chickenpox and whooping cough. Meanwhile, the remarkable success of penicillin and other antibiotics in destroying harmful bacteria led some researchers to declare victory in the war against infectious disease.

Medical students in the 1960s were warned away from the field and encouraged to study chronic disorders like cancer and heart disease, where the real action—and the research money—would be found. Rarely has a scientific prediction been so thoroughly shredded. The hubris of that era collapsed under the combined weight of HIV/AIDS, SARS, Ebola, Avian flu and deadly drug-resistant bacterial infections. And let's not forget Enterovirus D68, a pathogen that has sickened more than 1,000 American children this year and likely killed at least six. In the so-called war between “man and microbes,” there is never a truce.

The first outbreaks of Ebola occurred in rural African villages, but rarely traveled far. Unlike bacteria, viruses cannot live long on their own. They depend on the cells of the host they invade to reproduce. When the host dies, the virus does, too. Having killed off so many villagers, Ebola simply burned itself out.

The difference in 2014 is that Ebola no longer haunts just the rural countryside. Its reach now extends into densely populated cities, where there is no shortage of human hosts. There already have been 10 times more deaths from Ebola than in any previous outbreak, and that number is climbing fast. Now it has reached the U.S. - disease, in our interconnected world, being an easy plane ride away.

History assures us that Ebola will be conquered. It also tells us that the next "fatal strain" is likely bubbling up somewhere right now - in a bat cave, a pig farm or an open-air poultry market. That's the nature of these microbial beasts, and we may not be spending enough now to understand these threats. But public trust in dealing with future crises is perhaps the dearest resource of all. Visit the Wall Street Journal for the full story



Australian scientists prove link between viral infection and autoimmune disease

Common viral infections can pave the way to autoimmune disease, Australian scientists have revealed in breakthrough research published internationally. Professor Mariapia Degli-Esposti, from The University of Western Australia and the Lions Eye Institute, said the research proved a link between chronic viral infection and autoimmune disease.

Published in the leading journal Immunity, the Australian research found that chronic cytomegalovirus (CMV) infection could lead to the development of Sjogren's (SHOW-grins) syndrome. CMV - a member of the herpes family - is a common viral infection that causes mild flu-like symptoms in healthy people but can lead to more serious illness in those with compromised immune systems. Between 50 and 80 percent of people in developed countries are infected with CMV. Although normally innocuous, given the right genetic background, chronic viral infection with CMV can trigger autoimmunity.

"Sjogren's syndrome (SS) is the second most common autoimmune disease in humans, affecting up to three percent of the population or more than four million people in the United States alone," Professor Degli-Esposti said. "It affects the function of salivary and lacrimal glands and leads to a debilitating disease characterized by the loss of saliva and tear production."

Overwhelmingly, it is a disease suffered by women, with most symptoms of the disorder emerging in the 40 to 60 year age group. There are two forms - primary Sjogren's syndrome, defined as a dry eye and mouth that occurs by itself - and secondary Sjogren's syndrome, with the same symptoms occurring in those with a major underlying disease such as rheumatoid arthritis or systemic lupus.

Professor Degli-Esposti said this new research was highly significant because it had identified a cause of SS, and in doing so, demonstrated a novel, unknown function of an immune cell population.

Visit University of Western Australia for the study.



Texas hospital apologizes for Ebola mistakes

DALLAS — The head of the group that runs the Texas hospital under scrutiny for mishandling an Ebola scare apologized Sunday in full-page ads in local Dallas newspapers, saying the hospital "made mistakes in handling this very difficult challenge."

Barclay E. Berdan, chief executive of the Texas Health Resources, which operates a network of 25 hospitals here, said in an open letter that hospital officials were deeply sorry for having misdiagnosed symptoms shown by Thomas Eric Duncan, the Liberian man who was sent home after his first visit to the emergency room of Texas Health Presbyterian Hospital but was later readmitted and then died of Ebola two weeks later.

"The fact that Mr. Duncan had traveled to Africa was not communicated effectively among the care team, though it was in his medical chart," Berdan wrote. "On that visit to the Emergency Department, we did not correctly diagnose his symptoms as those of Ebola. For this we are deeply sorry."

The letter was the latest in an attempt to turn around a crippling public relations disaster for the hospital, which was criticized for making serious errors and then announcing incorrect information about those mistakes.

Last Thursday, Dr. Daniel Varga, the chief clinical officer for Texas Health Resources, apologized for the missteps in prepared remarks before members of the House Energy and Commerce Committee.

"Unfortunately, in our initial treatment of Mr. Duncan, despite our best intentions and a highly skilled medical team, we made mistakes," Varga said. "We did not correctly diagnose his symptoms as those of Ebola. We are deeply sorry."

"Based on what we already know, I can tell you many of the theories and allegations being presented in the media do not align with facts stated in the medical record and accounts of caregivers who were present at the scene," he said in the letter published in The Dallas Morning News and The Fort Worth Star-Telegram newspapers.

The nurses have been transferred to hospitals with specialized isolation units, including one at the National Institutes of Health.

Dr. Anthony S. Fauci, director of the NIH's National Institute of Allergy and Infectious Diseases, said the hospital had been following guidelines on protection gear from the Centers for Disease Control and Prevention, which were prepared by the World Health Organization for treating people in rustic conditions in Africa.

There have been reports that business had slowed considerably at the Dallas hospital, with a number of patients canceling appointments. The hospital has declined to say whether admissions were down or cancellations up.

County Judge Clay Jenkins, the county's chief executive and director of homeland security, said the hospital was safe and open for business.

"You cannot get Ebola from going into a building where someone is being treated on a different floor for Ebola, and currently there's no one being treated for Ebola here, and all of the medical waste has been thoroughly cleaned up," Jenkins told reporters Saturday as he stood outside Presbyterian. "There's no reason to not come here."

Jenkins said that about 25 Presbyterian employees had taken the hospital up on its offer to sleep at the hospital to avoid spreading any possible contamination to their homes. The hospital made rooms available for employees who treated Duncan to allow them to stay at the hospital throughout their monitoring periods. The agreements that the state and the county have asked the workers to sign voluntarily — which prohibit them from traveling on public transportation and from going to public places — state that the workers would be given the opportunity to stay at Presbyterian "on a non-admission status," in order to make the monitoring process easier.

In addition to the rooms available for workers being monitored, the hospital was also allowing any other employees to stay at the hospital rather than go home, "to avoid even the remote possibility of any potential exposure to family, friends and the broader public." (The New York Times) Visit the Boston Globe for the story



Hospital hand hygiene reporting discrepancies continue

DebMed announced the results of its third annual survey exploring methods used by hospitals to gather hand hygiene data, the reliability of that data and the commitment of healthcare facilities to improving hand hygiene. With responses from more than 400 infection preventionists, nurses and other healthcare leaders from U.S. hospitals, the survey reveals that despite the prevalence of available electronic technologies, manual methods are still predominately used for tracking hand hygiene, leading to a vast inconsistency in hand hygiene compliance reporting, and ultimately leaving patients and clinical staff at risk for infection.

Key findings include:

·         66 percent of respondents said their facility reports hand hygiene compliance to be 81 percent or greater, however,

·         59 percent believe that their true hand hygiene compliance is actually less than 70 percent

·         13 percent of those surveyed said they are "extremely satisfied" by the reliability of their facility's hand hygiene compliance data

In addition to the reporting discrepancies, the survey also found that there are significant inconsistencies between healthcare workers' beliefs, and the actual practices of hand hygiene compliance in their facilities.

·         78 percent believe electronic hand hygiene compliance monitoring is a more accurate option than direct observation yet

·         62 percent use manual direct observation by staff as the primary method used to measure and report hand hygiene compliance, with another 34 percent using manual direct observation by "secret shoppers"

·         With that said, 88 percent believe the Hawthorne effect, which states that people will change their behavior if they know they are being watched, impacts the accuracy of reported hand hygiene compliance rates

"The survey results are promising, yet accurately represent the challenges the industry faces in regard to clean hands and safer care for patients," said Heather McLarney, vice president of marketing, DebMed. "The numbers confirm what we hear firsthand from infection preventionists. They and other hospital staff want to implement the best hand hygiene practices for improved patient safety and health, but they face the reality of a host of other IT priorities competing for funding and focus like Meaningful Use, ICD-10 and EHR implementations."

Further, the survey findings cite the oft-used "in and out" method of only cleaning hands before and after patient interaction still reigns at most facilities, despite the fact that data shows additional hand cleaning – such as after touching a bed rail or medical chart – lowers infection rates.

·         94 percent believe the WHO Five Moments and Centers for Disease Control and Prevention Guidelines (CDC) are a higher clinical standard that help reduce the spread of infections better than cleaning hands before and after patient care, a four percent increase from 2013, and

·         63 percent teach staff to follow the WHO and CDC hand hygiene guidelines, but only 44 percent actually follow those standards, as the majority (54 percent) only clean hands when entering and exiting patient rooms

In looking back at the survey data collected the previous two years, there is a positive trend in not only the adoption of better technologies, but also the more imminent plans for purchase among those not yet using electronic monitoring.

·         There is a two percent increase in facilities using electronic monitoring since 2012

·         43 percent surveyed said they are currently considering implementing an electronic monitoring system, and 33 percent said their facility intends to purchase an electronic monitoring system within the next year

Visit PR Newswire for the study.



Canada leads the way on Ebola experimental drugs: ZMapp, TKM-Ebola and VSV-EBOV

As health workers and government officials scramble to make advancements in Ebola drug research, one country has emerged as a major player in the development of the world's top treatment options: Canada.

With the Ebola death toll topping 4,400 in West Africa and two Dallas health workers infected this week, all eyes are on TKM-Ebola and ZMapp, two front-runner drugs developed in Canada, that doctors are using to treat Ebola patients.

Although the United States helped to fund and produce the treatments, both medications were researched in Canada. And industry insiders say it's all thanks to a handful of innovative scientists at a small laboratory in Manitoba.

"The lab in Winnipeg certainly raised awareness in Canada," said Tom Geisbert, a virologist and Ebola expert currently researching vaccines and treatments at the University of Texas Medical Branch.

Why has Canada emerged as an important player in the race for Ebola drugs? Geisbert said, "I can tell you in two words: Heinz Feldmann."

Feldmann, a virologist who began his career researching influenza but later focused on Ebola and Marburg viruses in Germany, became the first special pathogens chief at Canada's National Microbiology Laboratory, NML, in Winnipeg. The lab first opened in 1999 and has since become part of the Infectious Disease Prevention and Control branch of the Public Health Agency of Canada. Though Feldmann later moved on to U.S. institutions, the lab continues to pursue cutting-edge research.

The idea began in the early 1990s, when infectious diseases were a hot topic among politicians. According to the Canadian Press, officials and high-level doctors were concerned at the time that Canada didn't have a lab equipped to handle highly dangerous, Level 4 diseases such as Ebola. If Canadian officials wanted to test these specimens, they had to be sent to the U.S. Centers for Disease Control and Prevention in Atlanta, GA. Today, the Winnipeg lab does have what it needs but also continues to work with its American counterparts.

Another promising drug candidate, TKM-Ebola, which has been used to treat American physician Rick Sacra and other patients, was developed by Tekmira Pharmaceuticals based in Vancouver, British Columbia. The company has been working on Ebola research for many years, thanks largely to funding from the U.S. Department of Defense, and has seen its stock jump during the recent outbreak. Visit IB Times for the story.



Pure Processing launches new dedicated eye sink

Pure Processing LLC, developer of ergonomic medical device pre-cleaning systems and accessories, is introducing a new pre-cleaning system specifically for eye instruments. The lightweight, movable Pure Station Dedicated Eye Sink can be installed on a countertop, inserted into a sink, or recessed into a mobile cart to create a dedicated pre-cleaning area for intraocular instruments. This reduces the potential for cross-contamination by material or residue from general surgical instruments, as recommended in ANSI/AAMI ST 79:2006:A1:2008/Annex N.

"Compliance to standards, especially to best practices that help prevent infection, is even more critical in today's emerging microbial landscape, and in light of the dangers and costs infections pose for patients and their healthcare providers," said Dan Gusanders, president of Pure Processing. "Our innovation focuses on enhancing ergonomics and pre-cleaning compliance. We identified the need for a safe, effective, efficient dedicated pre-cleaning capability for intraocular instruments and developed a new system, based on our proven technology, that meets that need. The Pure Station Dedicated Eye Sink has the potential to become an essential support tool for eye surgery."

The first compliance feature of the Pure Station Dedicated Eye Sink is its visual labeling. The upper edge of the system includes a permanent label that states: "EYE INSTRUMENTS ONLY." The same label also instructs users to "Discard water used to clean or rinse after each use," and to "Follow device manufacturer's instructions for use." In addition, there are two configurations available; one with the proven Pure Processing pump system for lumens and channels, and one without. For more information, please visit