Chapter 7 Surgical Tech

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1

Mutualism

Both organisms benefit from and depend on one another to a certain extent.

2

Examples of Mutualism

  • Escherichia coli, which colonizes within the human intestine, obtains nutrients from the food that humans eat.
  • E. coli produces vitamin K, which is essential to the blood-clotting process in humans.
3

Synergism: Subcategory of mutualism

  • Two organisms work together to achieve a result neither could obtain alone.
  • Example: Fusobacteria and spirochetes work together to cause a disease known as trench mouth.
4

Commensalism

One organism benefits but second organism neither benefits nor is harmed.

5

Examples of Commensalism

Indigenous microflora on the skin of humans obtain nutrients, but do not affect the skin or human body. To a certain extent they benefit humans by occupying space and preventing other potentially harmful microbes from colonizing, a process referred to as competitive exclusion.

6

Neutralism: Subcategory of commensalism

Two organisms occupy the same area with no effect on each other.

7

Antagonism: Second subcategory of commensalism

  • One microorganism inhibits or interferes with the growth of another.
  • Example: A microbe produces waste products that are toxic to the neighboring microbes.
8

Parasitism

One organism benefits and the host is harmed. Commensal microbes that become opportunistic by entering through a surgical skin incision. Nosocomial infections (infections acquired in a hospital) such as urinary tract infections. Airborne viruses, such as the virus that causes the common cold.

9

Examples of Parasitism

Endoparasites, such as intestinal worms, cause an infection and deplete the body of nutrition.

10

Symbiosis

. The relationship between human hosts and indigenous flora

refers to both organisms. The relationship may be harmless, harmful, or beneficial to one or both

11

CDC study on nosocomial infections

compiled recent data estimating that HAIs accounted for 1.7 million infections and 99,000 associated deaths per year. Of these:

  • 32% of all HAIs are urinary tract infections
  • 22% are surgical site infections (SSIs)(SSIs)See surgical site infection (SSIs) See surgical site infection
  • 15% are pneumonia (lung infections)
  • 14% are bloodstream infections
12

Bacteria

prokaryotes

are less complex organisms whose organelles are not membrane bound like those of the eukaryotes. All bacteria are this. Bacteria divide by the process of binary fission, which is a simple division that results in two identical cells.

13

Bacteria

cellular structure is complex, and this classification includes protozoa; fungi; green, brown and red algae; and all plant and animal cells.

14

Morphology: size, shape, and arrangements of bacteria

Coccoid:

round-shaped bacteria (coccus, singular form; cocci, plural form)

15

Morphology: size, shape, and arrangements of bacteria

Diplococci:

paired bacteria

16

Morphology: size, shape, and arrangements of bacteria

Streptococci

chain of bacteria

17

Morphology: size, shape, and arrangements of bacteria

Staphylococci:

cluster of bacteria

18

Morphology: size, shape, and arrangements of bacteria

Bacillus

rod-shaped bacteria (bacillus, singular form; bacilli, plural)

19

Morphology: size, shape, and arrangements of bacteria

Spirilla

spiral-shaped bacteria

20

Motility: ability of a microbe to move by itself

  • Flagella

long thin structure attached to the outside of the cell; uses whipping motion to provide motility to the cell

21

Motility: ability of a microbe to move by itself

Cilia

fine, short, hairlike extensions located on the surface of the cell; their coordinated, rhythmic movement allows the cell to move

22

Oxygen requirements: bacterial species classified according to oxygen and carbon dioxide needs

  • Obligate aerobes: require level of oxygen found in a typical room
  • Microaerophiles: require oxygen but at level lower than that found in room air (about 5% oxygen)
  • Obligate anaerobes: will not grow if there is any amount of oxygen present in the environment
  • Facultative anaerobes: able to survive in an environment that contains oxygen or no oxygen
  • Aerotolerant anaerobes: grow best in environment without oxygen, but can survive in atmosphere that contains up to 15% oxygen
  • Capnophiles: grow best in high concentrations of carbon dioxide
23

Gram Stain

cells are stained with crystal violet; washed with ethanol that removes purple stain from bacteria that don’t retain the stain; red dye safranin is applied; specimen is rinsed with water. Gram-positive bacteria retain the crystal violet and therefore are a purple color; gram-negative bacteria do not retain the crystal violet and are red from the safranin stain. Gram-variable bacteria, such as Mycobacterium tuberculosis, do not consistently stain red or purple.

24

Spore forming (sporulation): bacterial species capable of forming spores* Clostridium

  • When environmental conditions are unfavorable, including extremes in temperature, dry environment, and a total lack of a source of food, the genetic material of the cell is enclosed in a protein capsule.
  • Spores can survive for a long time until favorable conditions are reestablished; the bacteria returns to its vegetative state and is able to grow and reproduce again.
  • Not to be confused with reproduction, sporulation is a method of bacterial survival.
  • Spores are difficult to destroy; therefore sterilization processes must also be able to kill spores.
25

Staphylococcus

most common in the o.r

26

Types of Staphylococcus

S. aureus

Toxic shock syndrome

Osteomyelitis

Endocarditis

Postoperative SSI

27

Types of Staphylococcus

S. epidermis

IV catheter infections

UTIs

Prosthetic device infections

Subacute bacterial infections

Endocarditis

28

S. pyogenes

Rheumatic fever: If you have had this you will be put on an antibiotic before surgery

Necrotizing fasciitis: Flesh eating disease

29

Aerobic Gram-Negative Cocci, Coccobacilli

Neisseria gonorrhoeae

Pelvic inflammatory disease leading to salpingitis

30

Aerobic Gram-Negative Cocci, Coccobacilli

Moraxella catarrhalis

Otitis media in children

31

Aerobic, Microaerophile Gram-Negative Bacilli, Spirochetes

Pseudomonas

Deep-tissue health care-associated

32

Aerobic, Microaerophile Gram-Negative Bacilli, Spirochetes

Helicobacter pylori

Chronic gastritis

Stomach ulcers

Peptic ulcers

33

Vanomycin

VRE

Family of penicillin

used so much people have become resistant to it

34

Facultative Anaerobic Gram-Negative Bacilli

influenzae

Respiratory tract infections

Bacterial pneumonia (elderly)

Otitis media

Eye infections

Septic arthritis

Cellulitis

35

Facultative Anaerobic Gram-Negative Bacilli

Klebsiella pneumoniae

Health care–associated UTIs

Wound and burn infections

Ankylosing spondylitis (sequelae of a Klebsiella infection)

36

Anaerobic Gram-Positive Bacteria

Clostridium

Gas gangrene infection

37

Mycobacteria

Mycobacterium tuberculosis

Tuberculosis

38

Mycobacteria

Chlamydia

39

Tuberculosis

caused by Mycobacterium tuberculosis and transmitted through airborne droplet nuclei, usually infects the lungs but may also infect the kidneys, bone, joints, or skin. Surgical procedures performed on known TB carriers require implementing isolation precautions, including the wearing of gloves, protective eyewear, gown, and National Institute of Occupational Safety and Health (NIOSH)–approved respirators.

40

Viruses

are nonliving particles that are completely reliant on the host cell for survival.

contain either DNA or RNA and a protein coat that encases the nucleic acid.

41

Viral Pathogens Common to the OR

Hepatitis B (HBV)

Transmission:Percutaneous or permucous in blood, serum, and other body fluids

Description:Causes inflammation of the liver, jaundice, cirrhosis, and, in some cases, liver cancer

42

Viral Pathogens Common to the OR

Hepatitis C

Transmission: Blood-borne RNA; transmitted through blood and blood products

Description: Asymptomatic when acute; may be carried for 25 years; causes chronic hepatitis, cirrhosis, liver cancer

43

Viral Pathogens Common to the OR

Human immunodeficiency virus (HIV)

Transmission: Blood or other body fluids

Description: Compromises immune system

44

Viral Pathogens Common to the OR

Herpes simplex virus (HSV)

Transmission: Contact with fluid from lesions

Description: Causes localized blisterlike eruptions; can also cause keratoconjunctivitis, acute retinal necrosis, meningoencephalitis

45

Viral Pathogens Common to the OR

Papillomavirus

Transmission: Direct contact with another person

Description: Warts

46

Viral Pathogens Common to the OR

Cytomegalovirus (CMV)

Transmission: Direct contact with body fluids

Description: Infects salivary glands or viscera; opportunistic infection in patients with HIV or hepatitis

47

Viral Pathogens Common to the OR

Creutzfeldt-Jakob Disease (CJD)

Transmission: Exact mode of transmission unknown; thought to be by percutaneous inoculation with brain tissue or cerebral spinal fluid from infected persons; transmission has been associated with use of contaminated instruments; longer sterilization times required.

Description: Rapidly progressive fatal central nervous disease characterized by dementia, myoclonus

48

Prions

is short for “proteinaceous infectious particle.” , built of proteins and do not contain DNA or RNA. attack the brain, which is why the diseases they cause are called subacute spongiform encephalopathies

49

two common forms of prions

scrapie (a disease that infects sheep and goats) and bovine spongiform encephalopathy (commonly called mad cow disease).

50

Sample Guidelines for Suspected or Known CJD Patients

Preoperative Preparation

  • Notify all units that will be involved, including nursing, pharmacy, central sterile processing department, infection control, environmental services, laboratory, surgical services, and pathology.
  • Remove all unnecessary equipment and supplies from the OR as possible. Move everything else as far from the OR table as possible.
  • Cover all surfaces in the OR, including anesthetic equipment and OR table, with impervious sheets.
  • Cover electrical cords with sterile plastic sleeves.
51

Sample Guidelines for Suspected or Known CJD Patients

Intraoperative Case Management

  • Use disposable equipment and instruments as much as possible.
  • Try to avoid use of power instruments to prevent aerosolization of contaminates.
  • Use neutral zone when passing sharps.
  • Sterile attire should include double gloves, face shields, and knee-high impervious shoe covers.
  • Clean blood and body fluid spills with sodium hydroxide (household bleach).
  • Change gowns, gloves, suction tip(s), and ESU tip.
  • Place tissue specimens into a specimen container, then place in a biohazard specimen bag (marked with the biohazard symbol) and labeled “CJD precautions.”
  • Per surgeon’s order, clean the patient’s head with 1 molar sodium hydroxide at the end of the procedure.
52

Sample Guidelines for Suspected or Known CJD Patients

Postoperative Case Management

  • Reusable instruments: Place in impervious container, place in biohazard bags, label as “possible CJD,” and handle according to hospital policy, which may include disposal.
  • Body fluids and liquid waste: Collect, label, and bag in biohazard bags labeled “possible CJD”; keep separate from other waste bags and notify environmental services personnel to immediately collect and incinerate the bags.
  • Disposable supplies: Place surgical attire, drapes, sponges, suction tip(s), etc. in biohazard bags labeled “possible CJD” and keep them separate from other red bags; notify environmental services personnel to immediately collect and incinerate the bags.
  • Sharps: Place in separate sharps container labeled “possible CJD”; notify environmental services personnel to immediately collect and incinerate the container.
53

Sample Guidelines for Suspected or Known CJD Patients

Environmental Cleaning

  • Decontaminate all OR surfaces at the end of the procedure by wetting all exposed surfaces with 1 molar sodium hypochlorite for 60 minutes. Rinse with water and then clean in routine fashion.
  • Surfaces contaminated with visible tissue or body fluids should be decontaminated with 1:10 dilution of 5.25% sodium hypochlorite, followed by routine cleansing with disinfectant according to hospital policy.
54

Parasites

two categories : unicellular protozoans and multicellular protozoans.

55

Parasites

Helminths

are popularly known as worms. Those that are most common in the human population are tapeworms, flukes, and roundworms.

The chances of a surgical technologist encountering a this type of infection have increased due to the mobility of the world population and immigration from Third World countries. Worms can damage body tissues and organs to the point that they require surgery.

56

Cysticeri

(Taenia solium)

are pork tapeworms that can migrate out of the intestinal tract and travel to muscle and brain tissue, and the eyes. can cause palpable lumps in soft tissues, blurred vision and retinal detachment, and when located in the brain tissue cause seizures, ataxia, headaches, and possibly death.

57

Fungi

Mycology is the study of this

are eukaryotic organisms that are either unicellular yeasts or multicellular molds and mushrooms. reproduce either sexually or asexually by producing spores; a true spore is formed by either asexual cleavage or sexual meiosis. diseases are called mycoses (the plural of mycosis).

58

Common Fungal Infections

Candida albicans

Vaginal yeast infection Trench mouth (thrush) Immunocompromised patients prone to serious infections of the brain, meninges, and heart valves Patients intubated or who have indwelling venous catheter or other type long-term indwelling catheter should be monitored for infection

59

Common Fungal Infections

Pneumocystis jiroveci

Pneumocystis pneumonia

60

zygomycosis,

caused by a common bread mold

If the organism enters the bloodstream and destroys the cranial bones, the brain tissue will be invaded.

61

Precautions (Modes of Transmission)

are separate guidelines for infection control and prevention of cross-contamination of patients when the disease process has been diagnosed

disposable cover gowns and unsterile gloves should be worn by transporters of patients with known contact-transmissible diseases.

62

Personnel (Methods of Transmission)

The skin, hair, and nares of surgical personnel are reservoirs of bacteria, which may be discharged in particle form into the air and therefore pose a risk of SSI to the patient.

Gowns and drapes cover the skin on areas of the body other than the hands.

63

Basic Hand washing

  1. Turn on the faucet and adjust the water temperature.
  2. Inspect hands and wrists.
  3. Wet hands and wrists.
  4. Apply soap; lather.
  5. Use moderate friction and circular motions.
  6. Interlace fingers to facilitate cleaning of the web spaces.
  7. Continue washing for 30 seconds to 1 minute.
  8. Rinse.
  9. Turn off the water.
  10. Dry hands and wrists.
  11. Discard the towels.
64

Environmental (Methods of Transmission)

Fomites are inanimate objects that may contain infectious microorganisms including walls, floors, cabinets, furniture and equipment.

65

The Patient (Methods of Transmission)

The two primary sources of SSI risk to the patient are the endogenous flora encountered in contaminated procedures and the resident flora of the skin.

66

Factors That increase the risk of surgical site infections

  • Age: Geriatric and pediatric patients have lower immunological defenses.
  • Obesity: Diminished blood flow, larger wound sizes, and the difficulty of handling adipose tissue make these patients more susceptible to infection.
  • General health: Patients in poor health or who have an inadequate nutritional intake generally have a predisposition to infection.
  • Carriers of S. aureus or MRSA: These patients are at greater risk of infection from their own endogenous flora.
  • Remote infections: Infections at other body sites increase the chance of SSI. Bacteria in the bloodstream enter and infect the surgical site.
  • Preoperative hospitalization: Infection rates increase parallel to the duration of preoperative stay. Patients are exposed to higher numbers of antibiotic-resistant strains of bacteria within the hospital.
  • Preexisting illness and related treatment: Infection rates are higher in patients with compromised immune systems from preexisting illness; patients who have been treated with certain medications, including steroids or chemotherapy agents; and patients who have recently undergone radiation therapy.
67

Procedure-related risk factors that increase the danger of SSI include:

  • Preoperative hair removal: Although hair removal has been a standard, studies have shown that hair removal is a risk factor for the development of SSI. The risk is greater when the preoperative shave is performed the day before surgery, and the use of razors carries a greater risk than the use of clippers. Razor blades leave many small cuts, nicks, and scrapes on the skin, allowing bacteria easier access for colonization. If the patient is not allergic, use of depilatory cream is less traumatic and is therefore a safer alternative. Hair removal by use of surgical clippers with disposable heads has replaced use of razors in most facilities.
  • Type of procedure: Clean-contaminated (Class II), contaminated (Class III), and dirty (Class IV) cases carry a higher risk of infection (refer to Chapter 11), as do cases that compromise blood flow to a particular area, such as coronary artery bypass procedures, where one or both internal mammary arteries are used.
  • Duration of procedure: Longer anesthetic and operative times have an accompanying increase in time for bacterial contamination to occur, increased tissue damage, and greater immunosuppression. Surgical team members become more fatigued, which may lead to breaks in sterile technique.
68

colonization

The growth and collection of microbes into a group that lives in a particular area

69

Asepsis

Absence of Microorganisms

70

Bacteriocidal

Substance that destroys/kills bacteria

71

Bacteriostatic

Substance that inhibits the growth and reproduction of bacteria

72

Bioburden

The number of microbes or amount of organic debris on an object at any given time

73

Contamination

The presence of pathogenic materials

74

Cross-contamination

The contamination of a person or object by another

75

Decontamination

To reduce to an irreducible minimum the presence of pathogenic material

76

Event-related sterility

Sterility determined by how a package is handled rather than time elapsed; a package is considered sterile until opened or the integrity of packaging material is damaged

77

Fomite

Inanimate object that harbors microorganisms

78

Fungicide

Agent that destroys fungus

79

Infection

Invasion of the human body or tissue by pathogenic microorganisms that reproduce and multiply, causing disease

80

Nosocomial

Infection acquired within a health care facility

81

Pathogen

Any microbe capable of causing disease

82

Resident flora

Microbes that normally reside below the skin surface or within the body

83

Sepsis

Infection, usually accompanied by fever, that results from the presence of pathogenic microorganisms

84

Spore

A resistant form of certain types of bacteria that are able to survive in adverse conditions

85

Sporicide

Substance that kills/destroys bacteria in the spore stage

86

Sterile

Having been rendered free of all living microorganisms, including spores

87

Sterile technique

Techniques of creating a sterile field and performing within the sterile field to keep microbes at an irreducible minimum

88

Sterile field

Specified area, usually the area immediately around the patient, that is considered free of microorganisms

89

Strike-through contamination

Contamination of a sterile field that occurs through the passage of fluid through, or a puncture in, a microbial barrier

90

Surgically clean

Mechanically cleaned and chemically disinfected but not sterile

91

Terminal disinfection

To render items safe to handle by high-level disinfection

92

Terminal sterilization

To render items safe to handle by sterilization

93

Transient flora

Microbes that reside on the skin surface and are easily removed

94

Vector

Living carrier that transmits disease

95

Virucide

Agent that destroys viruses

96

Antisepsis

is a process in which most but not all microorganisms located on animate surfaces, such as the skin, are destroyed.

97

Antiseptic:

name used to describe the solutions that are used by the sterile surgical team members to perform the surgical scrub and are used on the patient for skin preparation of the surgical site.

98

Classification of Patient Care Items

Critical

Items that will be used for invasive procedures or vascular access and carry a high potential for causing SSIs include: surgical instruments, devices that enter the vascular or urinary systems (needles, catheters), implantable items (wires, screws, joint replacements, mesh, sutures), and any monitors or probes that enter deep tissue layers or cavities. These items should be sterilized.

99

Classification of Patient Care Items

SEMI-CRITICAL

Items that come into contact with mucous membranes or non-intact skin carry a lesser risk of infection due to the properties of resistance of intact mucosal linings to many commonly encountered bacterial spores. Examples include: laryngoscopes, anesthesia and respiratory equipment, and some endoscopes. High-level disinfection should be used for items in this category.

100

Classification of Patient Care Items

NON-CRITICAL:

Items that come into contact with a patient’s intact skin and clean environmental equipment items pose the least risk of infection. Examples include blood pressure cuffs, pulse oximeters, OR transport stretchers, and other furniture. These items require either intermediate-level or low-level disinfection.

101

Disinfection Principles and Disinfecting Agents

Cleaning

The physical removal of blood, body fluids, and/or gross debris (bioburdenbioburdenAmount of gross organic debris or the number of microorganisms on an object at any given time bioburden Amount of gross organic debris or the number of microorganisms on an object at any given time ) from an inanimate object.

102

Disinfection Principles and Disinfecting Agents

Disinfection

Destruction of pathogenic microorganisms or their toxins or vectors by direct exposure to chemical or physical agents. Disinfection is discussed on three levels.

103

Disinfection Principles and Disinfecting Agents

High-level disinfection

Kills all microorganisms except spores and prions (CJD).

104

Disinfection Principles and Disinfecting Agents

Intermediate-level disinfection Intermediate-level disinfection Level of disinfection in which most microorganisms are killed except spores

Kills most microorganisms, including bacteria, most viruses and fungi. M. tuberculosis and HBV; ineffective against spores.

105

Disinfection Principles and Disinfecting Agents

Low-level disinfection

Kills some fungi and viruses, and most bacteria, but is not effective against spores and M tuberculosis.

106

Disinfection Principles and Disinfecting Agents

Sterilization

Destruction of all microorganisms in or about an object with steam (flowing or pressurized), chemical agents (alcohol, phenol, heavy metals, or ethyl-ene oxide gas), high-velocity electron bombardment, or ultraviolet radiation.

107

Glutaraldehyde

is a high-level disinfectant. Its common commercial name is Cidex.

is used for devices that can withstand complete immersionimmersion Placing an item in a container so it is completely covered by a liquid, such as immersing a surgical instrument in glutaraldehyde in liquid. The liquid must contact all surface areas of the item, including lumens.

108

Sodium Hypochlorite

household bleach) is an effective disinfectant for surfaces, floors, and equipment. is such an effective and fast-acting solution, and the CDC recommends its use in cleaning blood and body fluid spills.

109

Phenol (Carbolic Acid)

is usually used as a concentrate with detergent additives and is diluted with tap water. is used to disinfect large areas such as floors and countertops and is used on a general basis as a health care facility cleaning agent.

110

Quaternary Ammonium Compounds

commonly called quats, are bactericidal, fungicidal, and pseudomonacidal. They are not sporicidal, vi-rucidal, or tuberculocidal. Common compounds include ben-zalkonium chloride and dimethyl benzyl ammonium chloride; however, newer and more effective compounds are available, such as dialkyl quats. Some facilities consider quats low-level disinfectants because of their inability to kill TB, spores, or viruses and their vulnerability to inactivation.

111

Alcohol

Isopropyl and ethyl alcohol

dilution of 60-70% alcohol concentration are tuberculocidal, bactericidal, virucidal, and fungi-cidal; they are not sporicidal. most useful in cleaning and disinfecting small noncritical surfaces. Recent studies show that these solutions may be as effective or more effective than other compounds for use in skin disinfection for surgical scrub and patient skin prep. Further studies are warranted.

112

Guidelines for house keeping laundry and regulated waste procedures

  • A routine schedule should be established for the cleaning and decontamination of OR surfaces, scrub sinks, cabinets, floors, walls, and ceilings.
  • Contaminated work surfaces such as the OR floor should be decontaminated by the circulator with a disinfectant. When it is not possible to immediately decontaminate the floor while a surgery is in process (concurrent cleaning), this should be completed as soon as possible or at the end of the procedure.
  • Reusable contaminated linens must be handled as little as possible to prevent airborne contamination. The contaminated linen should be placed and contained in a leak-proof, red-colored biohazard bag that is clearly marked with the biohazard symbol.
  • Contaminated linens must not be rinsed or sorted in the area of use.
  • When handling contaminated linens, the surgical technologist must wear gloves and other PPE as deemed necessary.
  • Regulated waste must be placed in leakproof bags that are either clearly marked with the biohazard symbol or are red in color. Only contaminated waste should be put in these designated bags because they are more costly to dispose of than common hospital waste.
113

Cleaning Actions

  • Clean all surfaces in the OR, paying particular attention to horizontal surfaces.
  • Damp dusting should begin with the highest surface, such as the OR lights, to the lowest. This avoids the settling of dust on objects that have already been damp dusted.
  • When cleaning the OR table, the pads should be removed in order to clean both sides of the pads and the surfaces and hinges of the OR table underneath the pads.
  • The OR table should be unlocked and moved to one side to facilitate mopping the floor under the table. This also allows for the cleaning of the posts and casters on the OR table.
  • If blood or body fluids are present on the OR walls, clean the area.
  • Clean cabinet doors, paying attention to the track in which the door is opened and closed.
  • Do not clean the surgical lights if they have not yet cooled off; the disinfectant solution, even though it is room temperature, may be too cold and the expensive light bulb could break upon contact with the solution.
114

Decontamination Practices in the or

The surgical technologist, along with environmental services personnel, may be involved in the “turnover” of the room, which marks the preparation for the next procedure.

115

More Decontamination practices

  • Suction containers must be disconnected from the suction unit, and the outside of the containers wiped down and disposed of according to hospital policy.
  • The surgical technologist is responsible for disposing of the sharps by placing them into the puncture-proof sharps container. The container should not be allowed to overflow and should be immediately replaced when full.
  • The linen and trash bags must be sealed and placed in the designated area for transfer by environmental services personnel for proper disposal.
  • The surgical technologist is responsible for placing all instruments in a case cart or open cart or table that is covered with plastic for transfer to the decontamination room. Some ORs contain contaminated instruments in the same rigid containers used for sterilization. Care must be taken not to transfer bioburden to the exterior of the containers.
116

Terminal Cleaning

Each health care facility designs its own end-of-day or “terminal cleaning” routine

  • Ceilings and floors including surgical lights are wiped down. Ceilings and floors can be wiped down using a sponge mop.
  • All furniture is wiped down, including the legs, casters, or wheels.
  • The OR table is thoroughly wiped down, including the wheels. The pads should be removed and completely wiped down. Attachments used during procedures should be cleaned.
  • All other equipment, including tables, stools, kick buckets, anesthesia machine, ESU, and suction unit should be completely cleaned.
  • All other horizontal surfaces, such as cabinet shelves, cabinet doors, and handles, are cleaned.
  • Once the above has been accomplished, the furniture and equipment (with the exception of the anesthesia machine) is moved to one side of the room and the OR floor is thoroughly wetted/flooded with a disinfectant solution and wet vacuumed.
117

Weekly Cleaning

  • Ceilings, walls, and floor should be thoroughly cleaned inside and outside the ORs; this includes outside corridors.
  • Mounted lighting tracks and fixtures should be cleaned.
  • Air vents and heating duct grills must be vacuumed to remove dust laden with bacteria.
  • Inside and outside of supply cabinets, including shelves, should be cleaned.
  • Sterile and nonsterile supply rooms should be cleaned, including linen room.
  • Housekeeping supply room should be cleaned.
118

Dirty Cases

the floor should be cleaned with a phenolic detergent and all equipment and furniture should be wiped down with 70% alcohol solution. Rubber and plastic tubing in the room should be replaced and if gross contamination of walls and ceilings has occurred, these should be wiped down with a disinfectant solution as well

Usually last in the room

119

Surgical Instrument Decontamination Process

any critical patient item or instrument that will be used on open tissue or be placed in the sterile field must be sterilized to remove all microbes, including spores.

120

Design of the decontamination area

  • Filtered air is exhausted to the outside of the health care facility.
  • The minimum air exchange rate is 10 times per hour.
  • Temperature should be maintained between 64° and 70°F with a humidity of 35% to 72%.
  • Negative air pressure is maintained.
121

Cleaning

The first step in the decontamination process begins at the point of use.

122

The solutions that may be used to soak insturments

  1. Sterile water; do not use saline. The salt will pit the metal on the instrument, permanently damaging the instrument and leading to the formation of rust.

2.Enzymatic solution

  1. Proteolytic enzymatic cleaner: Facilitates the removal of protein materials such as blood.
  2. Lipolytic enzymatic cleaner: Facilitates the removal of fatty material such as adipose tissue and bone marrow.

3.Detergent solutions

123

Advantages and Limitations of Presoaking Solutions

Sterile water

Advantages: Keeps organic debris moist

Limitations: Ineffective in softening or removing dried debris

124

Advantages and Limitations of Presoaking Solutions

ENZYME

Advantages: Removes moistened and dried debris without the need for mechanical action

Limitations:Efficiency depends on concentration of solution, temperature, and contact time

125

Advantages and Limitations of Presoaking Solutions

Detergent

Advantages:Keeps organic debris moist while loosening dried-on debris

Limitations: Mechanical action is necessary to completely remove soil

126

Common Chemical Cleaners

Enzymatic

Organic substance that aids in the chemical reaction of breaking down organic debris. As previously stated, enzymes are specific to the type of debris to be removed. Enzymes are usually used as a soaking solution. They require dilution and are more effective in warm water than cold because the temperature of the warm water increases the speed of the chemical reaction.

127

Common Chemical Cleaners

Ultrasonic

Cleaning solutions are manufactured specifically for use in ultrasonic cleaners. The solution may contain a surfactant (to enhance wetting ability) and chelating agents.

128

Common Chemical Cleaners

Manual Detergent

Products usually used for hand cleaning of items and/or for presoaking. Some of the manual cleaners are high foaming and therefore should not be used in mechanical cleaning equipment. They must be diluted for use but are safe to use on most materials, including stainless steel. Mechanical action is required to assist in removing the soil. Surgical instruments must be thoroughly rinsed after being placed in the detergent.

129

Common Chemical Cleaners

Washer Decontaminator

Liquid solution that is available in three different pH levels. Neutral-pH product: Least corrosive to surgical instruments but less effective at removing substantial amount of organic soil.

130

Washer Decontaminator

Moderate-pH product

Low-level alkaline; may be combined with surfactants and chelating agents. Safe for use on stainless steel instruments but could be harmful to the chromium oxide layer that protects the instruments from corrosion.

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Washer Decontaminator

HIGH-PH Product

Most effective for removing heavy amounts of soil. Can be corrosive to stainless steel. If used, it must be neutralized by a neutralizing rinse to prevent damage to the instruments.

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Different Cleaning Solutions

  • Chelation: The process of binding minerals, such as iron and magnesium, in the solution. This prevents their deposit on the surface of surgical instruments, which causes spotting.
  • Enzymatic: Enzymes are catalysts that aid in breaking down organic soil such as blood and tissue into solution.
  • Emulsification: The action of dispersing two liquids not capable of being mixed.
  • Solubilization: The action by which the solubility of a substance is increased within a solution.
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Step one of the cleaning process (manual)

Instruments are immersed in a solution of lukewarm water, detergent, and/or enzymatic cleaner with a neutral pH. Hot water should not be used to initially rinse instruments to avoid blood and tissue from being set with heat on the metal surface. The manufacturer’s instructions must be followed for correct dilution, temperature, and use of detergent solutions. The enzymatic cleaner aids in the removal of bioburden. Each instrument must be individually cleaned with a soft-bristled brush using friction to loosen the organic debris. The foundation of manual cleaning is friction. Friction will loosen the organic material to allow its removal during the rinsing process. When cleaning stainless steel instruments, a back-and-forth motion should be used to follow the grain of the instrument. Do not use a circular motion, which can scratch the surface of the item. The instrument and brush must be kept submerged in the solution during cleaning to prevent contaminated water droplets from aerosolizing. Particular attention must be directed toward serrations on jaws, ratchets, box locks, and teeth of instruments. Instruments with lumens may be cleaned with a tube brush, pipe cleaner, or handheld water pressure gun. The cleaning solution should be changed frequently to avoid buildup of microbes and soil.

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Step 2 of the cleaing process (manual)

The last step is to rinse the instruments in distilled water. Do not use tap water because it may contain minerals that can stain and form a film on the instruments when the tap water evaporates.

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Step 3 of the cleaning process (manual)

To avoid spotting the instruments, the items should be immediately dried after rinsing.

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recommendation should be followed when decontamination

  • Instruments must be placed into a perforated or wire mesh tray to prevent interference with the cleaning action of the machine.
  • Heavier instruments should be placed on the bottom of the tray to avoid damage to the lighter, more delicate instruments.
  • Hinged instruments must be left in an open position to allow water, cleaning agent, and steam to contact the total surface area.
  • Instruments with attachments must be disassembled.
  • Instruments with concave surfaces should be placed upside down to allow proper cleaning, rinsing, steam contact, and drainage.
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Washer Decontamination Cycles

1.Prerinse cycle: Some models allow the use of an enzymatic solution in this phase.

2.Cleaning cycle: Detergent solution is used in this cycle.

3. Final rinse: Hot water is used during this rinse. The water temperature is maintained at 180°–195°F

4.Drying phase: High temperature is used to dry the instruments.

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Washer Sterilizer cycles

1.Prerinse: A continuous cool or tepid water spray rinse aids in removing organic and soil matter such as blood and tissue.

2.Automatic detergent injection: The machine injects a measured amount of detergent into the chamber.

3.Fill phase: The chamber is filled with water for total instrument immersion and cleaning.

4.Wash phase: Water is agitated inside the chamber for soil removal; the machine controls water temperature.

5.Postrinse: Loose soil and detergent film are rinsed off items.

6.Sterilization phase: Steam sterilization cycle-this is usually a gravity cycle.

7.Lubrication (milking)

8.Drying phase

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Ultrasonic Cleaners

A machine used to remove minute organic particles and soil from the areas of instrumentation hardest to reach by manual or other mechanical methods of cleaning; the washer utilizes the process of cavitation for cleaning instruments

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How the Ultrasonic Cleaners Work

  • As the ultrasonic waves travel through the cleaning agent, the energy causes the molecules to be set in rapid motion, forming microscopic bubbles on the surface of the instruments.
  • The bubbles enlarge, become unstable, and implode (collapse inward). The implosion creates a vacuum, dislodging minute particles of soil and organic material from the instruments.
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Powered Insturments

must never be submerged in cleaning solution or placed in any type of mechanical decontaminating equipment.

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What happens in the clean room

Instruments must be checked for function and integrity and prepared for sterilization

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What does Impervious to moisture mean

Waterproof

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Two Types of Peel Pack

  • Paper-plastic combinations that are used for steam and EtO sterilization
  • Tyvek-plastic combination used for EtO and Sterrad
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Rigid Instrument Containers

  • They provide containment of items during sterilization.
  • The provide assurance of sterile package integrity because metal or plastic containers cannot be torn or compromised.
  • They are easily opened and provide for excellent sterile presentation of contents.
  • They can be used for returning contaminated items to the decontamination area.
  • A disposable chemical indicatorchemical indicatorInternal or external monitor that changes color when exposed to the sterilization process; only indicates that the sterilization process has occurred; it does not guarantee the sterility of the item chemical indicator Internal or external monitor that changes color when exposed to the sterilization process; only indicates that the sterilization process has occurred; it does not guarantee the sterility of the item to verify exposure to sterilizing conditions may be incorporated within the lid or construction of the rigid instrument container.
  • The containers are available in a variety of sizes and designs but always feature a removable lid that is sealable with some type of locking device. The containers are generally manufactured of a sturdy anodized aluminum, stainless steel, plastic, or a plastic-metal combination that allows the stacking of the containers in storage without damaging the containers or contents.
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How Heavy should instrument sets be

no more than 25lbs

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What should be followed for proper inspection of powered instruments

The manufacturer’s instructions An instrument may need to be lubricated and operated for a designated amount of time to ensure lubricant distribution. The power hose should be checked for cracks and cuts. The power hose should be coiled loosely to prevent kinking and damage.

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What will proper preparation ensure?

  • The sterilant comes into contact with all surface areas.
  • The instruments are positioned in a protective manner until they are used.
  • The instruments are evenly distributed.
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What should instruments be placed in?

in a mesh-bottom or wire mesh basket with an absorbent towel lining the bottom.

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Instruments with lumens should be prepared like?

require special preparation. Air trapped in the lumen may prevent steam from contacting the inner surface. To prevent this entrapment of air, a residual amount of distilled water should be left inside the lumen. The water will boil during sterilization, turning to steam and displacing the air within the lumen.

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Basin Sets

are conducive to the formation and retention of condensate due to their density. Basins that will be nested within each other or that may contain other metal items must have adequate air space between each item. An absorbent towel should be used to separate the basins and items

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Julian Date

that indicates the date of sterilization. The Julian date is the number of the calendar day (1-365/366); for example, the Julian date for February 27, 2013 is 58 and March 5, 2013 is 64.

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Steam Sterilizer

The destruction of all microorganisms in or about an object can be accomplished with the use of stream under pressure, chemical agents (alcohol, phenol, heavy metals, and ethylene oxide gas), high-velocity electron bombardment, or ultraviolet radiation

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Advantages of Steam Sterilizers

Saturated steam is many times more effective in trans-ferring thermal energy than hot air.

It is the most economical and inexpensive sterilizing agent.

It is the safest method of sterilization in comparison to other methods.

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Factors that are critical to steam sterilizers

Contact: The sterilant must have contact with all surfaces of the items being sterilized.

Pressure: Pressure increases the temperature of steam to the level where it can destroy all microbes. Pressure that is greater than that of the atmosphere is necessary to increase the temperature of the steam in order to cause the destruction of microbes.

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Cycle Time

Contents 270°F Drying Times

Instrument set, 4 minutes 20–30 minutes Wrapped

Instrument set, 3 minutes NA unwrapped, no lumen instrument

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Reason For failure in Sterilizers

2.Containers are positioned incorrectly on the sterilization cart. Instrument trays, basins, and peel packs must be positioned to allow air to escape.

3.Items to be sterilized are inadequately cleaned. Soil and debris prevent the saturated steam from making direct contact with surface areas to kill microbes.

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Autoclaves

generate their own steam When steam is suppliedfrom an outside source, the walls of the chamber are preheated before the steam is allowed into the chamber. This is accomplished with a metal jacket that is built around the chamber. The space between the jacket and chamber is filled with steam to preheat the chamber walls when the machine is turned on.

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Gravity dIsplacement Sterilizer

are slower than prevacuum/dynamic-air-removal sterilizers because gravity is relied on to remove the air.