Disinfecting in dangerous times

The efficient application of disinfectants in hospital settings is integral to both the health of the facility and, likewise, to all of the persons who work or reside therein. Along with the processes of cleaning and sterilization, disinfection is a chief means of ensuring safety from the pathogens that spread sickness, disease, and hospital acquired infections (HAIs).

When healthcare facilities are developing their protocols and policies for carrying out effective methods of disinfection, their chief concern is the consideration of the microorganisms which can be potentially present according to the device and/or environment.

Each and every day, instrument disinfection efforts are undertaken with extreme precision and care by the professionals in the CS/SPD. Considering the broad range of items that require reprocessing, as well as the varieties of disinfectants (and combinations of disinfectants) that are needed to achieve the intended level of disinfection, the processes are highly specialized, with high reliance on time and precision.

The question is how

So, how exactly are disinfectants utilized in healthcare facilities and hospitals today to ensure the safety of both staff and patients? How do we determine which are the best to use according to the specificities of the place and situation? What are some of the factors that need to be taken into consideration?

“Proper cleaning and disinfection of instruments is vital to ensure our patients receive the highest quality care that can be provided,” said Janet Pate, JD, MHA, BSN, RN, Nurse Consultant/Educator at The Ruhof Corporation. “Evidence-based guidelines should be followed at all times when processing instruments. If instruments are not cleaned appropriately, biofilm and debris can remain on them, ultimately putting the patient at risk for a healthcare acquired infection which could cause negative outcomes.”

Know your device, follow the rules

Natalie Lind, an Education Director at HSPA, speaks to the importance of understanding how a device will be used when selecting the level of disinfection:

“Not all disinfectants are alike, and the word ‘disinfectant’ is a general term. Different chemical disinfectants provide different levels of disinfection, so knowing how the device will be used can help determine the level of disinfection required. That information, along with the device’s IFU, can provide solid information. I believe that Sterile Processing professionals have always had a good understanding of the importance of the disinfection process. It’s what we do!”

Determining the right type of disinfectant can often be determined by paying heed to a device’s instructions for use (IFU), as all such documentation should provide succinct instructions on cleaning and disinfecting the apparatus. The IFU must be referenced and strictly followed throughout the process (of using said instrument).

“There may be situations where certain disinfectants may not be appropriate for all environments and instruments,” Pate commented. “Determine the ease of use and compatibility with the instruments/devices. The duration of exposure and type of microorganisms should be evaluated to ensure the appropriate disinfectant is used. The IFUs for the devices and disinfectants should be followed. Each scenario should be evaluated to ensure the selection of the product is appropriate for the intended use and adjustments are made accordingly.”

Classify with Spaulding

HPN asked Randalyn Walters, Clinical Educator/Manager at BeliMed, for her thoughts concerning the selection of appropriate disinfectants depending on the circumstances. She referenced the Spaulding classification system, the disinfectant’s safety data sheet (SDS), and the device’s IFU as critical tools for decision making.

“When it comes to selecting the right chemistry for your healthcare’s reprocessing department there are many factors to consider. First, identify what is the purpose and level of disinfectant you require. Start by utilizing the Spaulding classification to determine this level during the selection process. It is critical for healthcare professionals to understand what pathogenic microorganisms they are working to eliminate. Various forms of disinfectants are available, including solutions with a variety of chemical makeup.”

“Personnel should consult the SDS (safety data sheet) and intended IFU to determine what particular chemical is safe to use and what it is comprised of,” she added. “Disinfectants have specific approvals from the EPA and contact times, so that should always be a consideration if looking for agents to disinfect surfaces.”

When selecting a disinfectant, Walters advises to pay close attention to the following attributes and/or ask related questions:

• Non-abrasive or toxic product, which is safe for your team and patients
• Free rinsing product that can disinfect the inventory in suitable time
• Cost effective and fits into your budget, making sure to consider the dosing amounts and concentration so you can forecast how much your team will utilize or require
• Provides a rapid kill rate, and is approved to eliminate the types of microorganisms you are facing
• Is the product environmentally friendly, or does it require special disposal, or storage conditions? Do you have a safety spill kit for this chemical?
• Does it require specific handling instructions, PPE, and respiratory ventilation?
• Does the chemical provide your department with safe, efficient and effective disinfection or does it require a mixture of other costly tools or neutralizing agents?

Pate notes the importance of aligning the disinfectant to the device and the environment:

“To ensure the appropriate detergents are selected, determine the compatibility with the instruments to be cleaned, the type of microorganisms that potentially may be on the instruments, the exposure time to the organism, and the physical environment where the chemicals/detergents will be used. IFUs for the devices and detergents selected should be followed. Ensure there is compliance with the parameters given for water hardness, pH, and temperature for each disinfectant, and that it is appropriate for use for that particular instrument.”

Follow best practice standards

HPN asked Nancy Fellows, MSN MPA RN CNOR Sr. Clinical Education Consultant, at Advanced Sterilization Products (ASP) to comment on some of the main points of disinfection concern. She emphasized adherence to best practice standards.

“Factors that come to mind are safety and knowing best practices to minimize exposure for healthcare workers and patients. Best practices are the safest and most effective means of providing care. Implementing best practice standards and procedures ensures patient and staff safety. Performance characteristics should be considered when selecting an appropriate disinfectant solution for any item, and applied it in the most efficient way.”

Fellows proceeded to list the following key questions that should always be answered by the CS/SPD teams in selecting and utilizing a disinfectant:

• What devices are to be high level disinfected?
• Do they adhere to Spaulding Classification for clinical application?
• Are the devices material compatible with the HLD solution being considered?
• What are the air exchanges needed depending on the physical environment where HLD is to be performed?
• Is there manufacturer support for education of staff?
• Is it easy to use?
• Is PPE required?

Close adherence to standards is not only imperative for health of the patients, but the staff as well. Improper use of disinfectants is often inclined to physically damage a device; likewise, the usage of disinfectants without proper ventilation for the staff can have both instantaneous and long-lasting negative side effects.

Best means isn’t a clear-cut decision

Damien Berg, BS, BA, CRCST, AAMIF, VP of Strategic Initiatives for the Healthcare Sterile Processing Association (HSPA), was adamant in his statement that the so called ‘best means’ for choosing an appropriate disinfectant is a difficult question to answer.

“This question is vast because the variety of product depends on some factors that the end user must take into account.” He suggests asking the following questions when evaluating disinfectants:

• What level of disinfection are you wanting/needing to achieve?
• What are the disinfectants and device’s IFU and are they compatible with one another?
• What are staff safety considerations with other chemicals in the department?
• Does use of the product work with the flow of the department?
• Is the product approved for use in the healthcare facility?

“All of these are important factors that can determine the appropriate disinfectant and when and how to use it,” said Berg.

Limit your options

With all the disinfectant products on the market today, Lind suggests standardizing as much as possible to help drive safe and effective use and minimize the risk for errors:

“If there are disinfectant options and an approved disinfectant is already in use in the SPD, keeping the number of chemicals to choose from to a minimum reduces the chance for confusion and user error. Again, selecting the effective disinfectant that poses the lowest risk of exposure or injury to the staff should always be a consideration.”

How COVID raised questions, and the bar on staff education

“Early in the COVID-19 pandemic, there were questions about which disinfectants would kill the virus. Once there was guidance on that, we moved to a business-as-usual mode. SP has always dealt with killing microorganisms; therefore, SP professionals already knew what to do to protect themselves and provide safe devices for patient use,” added Lind.

Berg was quick to highlight the impact of the COVID-19 pandemic and the resulting boom in the application of countless disinfectants.

“Working in a frontline hospital before and during the pandemic I saw that the use of disinfectants was really highlighted. It was interesting having conversations with my clinical counterparts, as well as our hospital leaders, purchasing department and infection prevention teams on how to best “kill” COVID-19 — and how to train technicians to use disinfectants and other products appropriately and safely. We did have some shortages of certain types of disinfectants, but overall, we still always had something to use. We did see that the long-term use of disinfectants on surfaces of certain devices (phones, computers, countertops) had a negative effect on the lifespan of that surface or device, depending on the type of disinfectant used and how often. Overall, I feel that many SP professionals ‘backed into’ education and sought more information and knowledge around terms such as concentration, dwell time, IFU, and compatibility. These words were known before the pandemic, but they really became everyday words as they related to disinfectants.”

The most noticeable and troubling impact of COVID-19 was related, of course, to the hindrance and disruption of the supply chain. As the pandemic was an unknown entity with undetermined causes and effects, it required time and effort to effectively determine the types of disinfectants that would kill the virus.

Many organizations stockpiled some of the wider known brands of disinfectants, thereby resulting in other organizations having to alternate from their preferred brands. Likewise, staff had to be trained on these new products to ensure that they worked effectively.

All things considered, the critical factor in determining the efficacy of a disinfectant lies in the ‘dwell’ time needed for the chemical to stay wet and in contact with the surface, and long enough to eliminate the targeted microorganisms.

Berg went on to stress that there continues to be an increased demand for understanding of disinfectant use in our health facilities today.

“In my working in the hospital and also working on a national and global scale in the world of disinfection and sterilization, I am seeing a positive trend to focus on the basics, which we know work but may not always give the attention needed. I see people in Sterile Processing really wanting to know more about what the right thing is to use and how to use it safely as opposed to the mentality of “spray and pray.”