Infection Control

Online Course #9008 or #5008 - 10 Contact Hours
Author: Patti V. Hoffman, RN, BS, MPH
©2010 National Center of Continuing Education, Inc.

For your convenience, this course has been divided into 3 sections:
Below is Part 1 of 3.
Table of Contents …Part 2 …Part 3 …Independent Analysis …Evaluation

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Purpose and Goals

The goal of this infection control course is to assure that nurses and other healthcare professionals understand how pathogens may be transmitted and recognize their responsibility to apply scientifically-based principles to minimize the opportunity for transmission of disease to patients, visitors, employees of healthcare facilities, and the community at large.

Instructional Objectives

1. Relate reasons for proper infection control standards as outlined by the Centers for Disease Control and Prevention (CDC).
2. Identify personal protective equipment and recognize its effectiveness against bloodborne pathogens.
3. List procedures required to minimize risk of contracting the Human Immunodeficiency Virus (HIV).
4. Select a precaution necessary for a caregiver to avoid transmitting resistant microorganisms within the hospital or clinical setting.
5. List some infection control equipment, supplies and precautions required by law to be provided to the healthcare worker environment.
6. Identify strategies to prevent the transmission of hepatitis.
7. Name a common mode of transmission of HIV and hepatitis B.
8. Select characteristics of an effective TB infection control program.
9. Recognize additional infection control procedures for prevention of the prion diseases.
10. Identify the clinical manifestations, signs and symptoms of infection.
11. List some reasons for the development of antibiotic resistant organisms.
12. List appropriate methods necessary to assure sterilization of instruments and equipment in the hospital and/or clinic.
13. Outline specific infection control practices to follow in home care, long-term care, dialysis centers, and dental settings.
14. Identify the nurse's role in the management of infection control practices.

Introduction

Infection control is not new to the practice of medicine or nursing. A glance into the history of medicine will clearly reveal that infections have always been a significant source of morbidity and mortality. The contagious nature of certain illnesses is well documented, and rudimentary control measures usually required infected persons to live apart from the non-infected population. Advances in medicine eventually led to the identification of specific disease producing organisms and mechanisms favorable for disease transmission. These advances led in turn to the development of effective measures to prevent or control the spread of communicable diseases and infections.
Life-threatening communicable diseases and infections are ever present. Many illnesses recognized since the earliest recorded history still persist as major health problems. Tuberculosis infections increased dramatically over the last decade despite the efforts of clinicians, scientists and dedicated researchers to achieve the goal of eradicating the disease by the year 2010. Hepatitis B infection persists as a significant threat to healthcare professionals despite the availability since 1982 of an effective Hepatitis B vaccine. Human Immunodeficiency Virus (HIV) infection resulting in Acquired Immunodeficiency Syndrome (AIDS) led to the universal practice of implementing blood and body fluid precautions for every client, even in the absence of overt illness. The latest threat is the emergence of antibiotic resistant organisms.
The importance of having a thorough understanding of infection control principles cannot be overemphasized. Clients entering a healthcare setting are at risk of acquiring infection because of decreased resistance, either as a result of the client's underlying illness or as a result of a specific course of therapy. Other factors increasing the risk of infection include increased exposure to numbers and types of disease-causing organisms and the need for invasive procedures to be performed. Infection control techniques are designed to prevent the spread of infection from clients, healthcare providers or visitors and are an important part of every action the nurse performs. Therefore, the nurse must become the first line of defense against disease transmission.

Infection Control Guidelines, Standards, and Enforcement Directives

Infection control in the healthcare setting is a major focus of a variety of public and private organizations. Among the most important are:

Centers For Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) are responsible for the collection of surveillance data on nationally notifiable communicable diseases. Surveillance is used to plan more effective disease control and prevention programs. Each state reports to the CDC through a state department with authority derived from the state legislature. The CDC also gathers data on hospital acquired (nosocomial) infections and publishes guidelines for infection prevention and control. Additional information is available through the Internet at www.cdc.gov

Occupational Safety and Health Administration
The Occupational Safety and Health Administration (OSHA) was established by Congress in 1970 to protect the health of American workers. OSHA establishes safety and health standards, and ensures workplace compliance through inspections. Working in cooperation with the Centers for Disease Control and Prevention (CDC), OSHA implemented the Bloodborne Pathogen Standard in December 1991 to protect healthcare workers from occupational exposure and subsequent infection from Hepatitis B, Hepatitis C and Human Immunodeficiency Virus (HIV). Additional information is available through the Internet at www.osha.gov

Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is a nationally recognized organization that accredits healthcare organizations demonstrating significant compliance with published standards. JCAHO implemented the first formal hospital infection control requirements when it published its infection control standards in 1976 as a requirement for hospital accreditation. Standards are revised periodically to reflect changes in infection control practice, and are published annually in the Comprehensive Accreditation Manual for Healthcare Organizations.
Although JCAHO accreditation is voluntary, it is viewed as critical by most hospitals because many states recognize this accreditation in licensure decisions and some accept accreditation in lieu of state inspection. Accreditation of a health facility by JCAHO is also required for Medicare and Medicaid participation. Their Web site is at www.jcaho.org

Association for Professionals in Infection Control and Epidemiology
Hospital Infection Control Committees began to appear in the 1960s, after JCAHO recommended their use as a mechanism to monitor and prevent the spread of nosocomial infections. The infection control professional followed to implement programs developed by these committees. The Association for Professionals in Infection Control and Epidemiology (APIC) was organized in 1972 and today is a multi-disciplinary, international organization. APIC strives to prevent disease and infection through education, collaboration, research, practice, and credentialing. Like the CDC and OSHA, APIC publishes guidelines for healthcare practice.

Universal, Standard and Transmission Based Precautions

In 1985, the Centers for Disease Control and Prevention (CDC) developed a strategy of "universal blood and body fluid precautions" in a effort to address concerns regarding the transmission of Hepatitis B Virus (HBV) and HIV, the causative agent in AIDS.
In 1996 the CDC published Guidelines for Isolation Precautions in Hospitals to assist healthcare organizations in maintaining up-to-date isolation practices. This guideline established a two-tiered system for precautions: standard and transmission based. Standard precautions are designed to reduce the risk of transmission of pathogens from both recognized and unrecognized sources of infection. They are used for all patients regardless of infection status. Standard precautions apply to:

1. blood,
2. all body fluids, secretions, and excretions except sweat regardless of whether on not they contain visible blood,
3. non-intact skin and
4. mucous membranes.

Transmission precautions are designed for patients documented or suspected to be infected or colonized with highly transmissible organisms that require additional precautions, above and beyond the standard precautions, to interrupt transmission of infections in hospitals. The term "universal precautions" is now used to refer to the OSHA mandated program requiring work practice and engineering controls, orientation, education and record keeping in healthcare facilities.

The OSHA Bloodborne Pathogens Standard

The Occupational Bloodborne Pathogens Standard applies to all workers with potential occupational exposure to blood or to other potentially infectious material (OPIM). Other potentially infectious material includes:

1. The following body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;
2. Any unfixed tissue or organ (other than intact skin) from a human (living or dead); HIV-containing cells or tissue cultures, organ cultures, and HIV or HBV-containing culture media or other solutions; and blood, organs or other tissues from experimental animals infected with HIV or HBV.

Exposure Control Plan: Every employer with employees who may be reasonably anticipated to encounter skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of an employee's duties, must have a written exposure control plan designed to eliminate or minimize the employee's exposure. The plan must contain:

1. a documented exposure determination,
2. a schedule and method for implementing all components of the exposure control plan and
3. a procedure for evaluating exposure incidents.

Bloodborne Pathogen Standard Components

These components, encompassed by the term Universal Precautions, are an approach to infection control used to prevent exposure to all blood or OPIM. The underlying premise is that all blood, body fluids, tissues, and OPIM must be handled as if they were infectious. OSHA defines occupational exposure as reasonably anticipated skin, eye, or other mucous membrane exposure to blood or other potentially infectious material that may result from the performance of an employee's duties. Each hospital or other healthcare facility is required to review all job classifications and identify those in which all employees have occupational exposure, as well as those in which some do.
OSHA requires that employers provide all employees who may be exposed to blood and other contaminated body fluids with a training program held during working hours. You should receive training during orientation, plus a yearly review to reinforce regulations and alert you to changes. The programs must discuss areas such as precautions, bloodborne pathogens and how they are transmitted, emergency action in case of exposure, disposal of soiled equipment, and information on the location and use of personal protective clothing and equipment (PPE). Components of the Bloodborne Pathogen Standard include:

• Engineering Controls: Engineering controls refer to methods of isolating or removing a hazard from the workplace. These include needle disposal containers and mechanical devices to reduce handling of contaminated needles.
• Work Practice Controls: Work practice controls are techniques that reduce the likelihood of exposure by changing the way a task is performed. Examples are handwashing; avoidance of needle recapping or needle breaking; designating areas for eating, drinking, smoking, and applying lip balm or contact lenses; and restrictions against locating food and beverages in places where blood or OPIM are kept.
• Personal Protective Clothing and Equipment (PPE): Personal protective clothing and equipment must be supplied at employer expense to all caregivers at risk for occupational exposure to blood and OPIM. PPE may include gloves, gowns, laboratory coats, face shields, masks, eye protection, and/or other protective items. The PPE must provide appropriate protection for the level of actual or expected exposure; i.e., gloves must be available and consistently used in situations where hand contact with blood or OPIM is expected. PPE must be available in appropriate sizes, and the employee must be instructed in the proper use and care of the PPE provided. It is also the responsibility of the employer to clean or launder all PPE as well as repair or replace it as necessary.
  The employee who is expected to have hand contact with blood or other potentially contaminated surfaces or materials must wear gloves. If more extensive contact with blood or OPIM is expected, the caregiver should use more extensive coverings to include gowns or aprons, masks and goggles or face shields, and shoe covers or boots. If gross contamination is likely, such as in situations encountered during orthopedic surgery or an autopsy, surgical caps and hoods may also be required to prevent exposure to blood and OPIM. The key to preventing exposure to bloodborne pathogens is to prevent blood or OPIM from reaching the caregiver's skin, eyes, mouth, or other mucous membranes.
  The caregiver must remove personal protective clothing and equipment before departing the work area or whenever the equipment or clothing becomes contaminated. If an item or garment is penetrated with fluids it should be removed immediately or as soon as feasible. Used PPE must be placed in designated containers for storage, decontamination or disposal.

• Orientation and Training: Initial and annual training related to the standard must be provided to each potentially exposed employee during working hours, and at no cost to the employee. Annual training must be provided within 12 months of initial training. Records must be kept of all training sessions.
• Labels and Signs: Biohazard warning labels must be placed on all substances containing blood or OPIM.
• Regulated Waste: Waste that contains blood or OPIM must be placed in special labeled containers and disposed of properly. Contaminated needles must be placed in closeable, labeled or red color-coded, puncture resistant containers.
• Contaminated Laundry: Laundry is bagged or containerized at the location where it was used and is handled as little as possible. Contaminated laundry is transported in leak proof bags or containers labeled or color-coded to indicate universal (standard) precautions must be used.
• Housekeeping: Contaminated work areas must be disinfected immediately after a spill and at least every shift using products that are effective against mycobacterium tuberculosis (MTB) and HIV. This information is readily available on the product label.
• Hepatitis B Vaccination: Hepatitis B vaccination must be offered to all potentially exposed employees within 10 days of employment. Vaccination records must be maintained and employees who decline vaccination must sign a standard declination. Employees must be informed that they may change their mind and receive the vaccine at any time.
• Post-Exposure Plans: All employees experiencing an occupational exposure must report the exposure immediately. The employer must provide all medical procedures and prophylaxis related to an occupational exposure incident. Confidential medical records must be kept related to exposure.

Prevention and Control of Infections

The nurse plays a major role in the prevention and control of infections in the healthcare environment. Nursing interventions in infection control can be divided into: (1) actions designed to prevent the onset of infection, and (2) actions designed to contain an infection once it has developed. Signs and symptoms of possible infections are listed in Table 1.

Subjective and Objective Data Suggesting Infection

• Itching
• Pain
• Swelling
• Tenderness
• Warmth

• Exudate or drainage
• Inflammation
• Warmth
• Edema
• Redness

• Chest pain
• Congestion
• Cough
• Runny nose
• Sore throat
• Sputum production
• Stuffy nose

• Sputum
• Rales
• Rhonchi
  
  
• Redness of throat
• Cough

• Anorexia
• Diarrhea
• Nausea
• Vomiting

• Vomitus
  
  
• Diarrhea

• Burning or painful urination
• Change in color/smell of urine
• Discharge
• Flank or pelvic pain
• Frequency
• Itching
• Urgency

• Color
• Odor
• Presence of WBCs/bacteria
• Purulent, foul discharge
• Amount
• Frequency
• Urinalysis
• Culture

• Anorexia
• Headaches
• Joint pain
• Malaise
• Muscle aches
• Weakness
• Shock

• Convulsions
• Hypotension
• Confusion
• Fever
• Elevated WBC counts
• Altered mental status

To prevent an infection from developing, the nurse minimizes the numbers and kinds of organisms within the environment by eliminating reservoirs of infection and avoiding actions that transmit microorganisms. These practices are known as medical asepsis and include environmental disinfection, use of appropriately processed supplies and equipment, and handwashing.
To contain an infection, the nurse controls portals of exit and entry and implements additional measures to ensure organisms are not transmitted. These practices include use of standard and transmission based precautions.
Often the same actions are taken to prevent or to contain an infection. Some of these common practices are: use of occlusive dressings, use of PPE, client placement away from other susceptible clients, work practice controls such as policies for specimen collection and transportation, and environmental controls such as appropriately ventilated work areas.
A final measure is to strengthen a potential host's defenses against infection. Nutritional support, rest, maintenance of physiological protective mechanisms, and immunizations protect the client from invasion by pathogens.

Handwashing
Handwashing is the single most effective method to prevent the transmission of infection. As nurses, our hands are in constant contact with organisms. Numerous studies continue to illustrate that in practice, handwashing is inadequate despite the constant reinforcement that hands must be washed frequently. APIC guidelines assert that hands are washed in about fifty percent of the situations that requiring handwashing, and that the duration of handwashing is generally less than recommended. In addition, healthcare workers overestimate the frequency and duration of handwashing.
Handwashing decreases the bioburden (number of organisms) on the hands and minimizes the number of organisms reaching patients, caregivers, equipment and the healthcare environment. Improper or infrequent handwashing places patients and caregivers at risk for acquiring infections or communicable diseases. The literature abounds with nosocomial infection outbreak investigations implicating inadequate handwashing in the transfer of organisms such as staphylococcus, Enterobacteriaceae, pseudomonas, and klebsiella. At the same time, inadequate handwashing places the healthcare worker at risk for such viral diseases as hepatitis A, B, C, and D; HIV; chickenpox; and multiple bacterial infections such as staphylococcus and streptococcus.

Resident and Transient Organisms. Microorganisms found on the skin are classified as either resident flora (normal flora) or transient flora. Resident flora is also known as colonizing flora. Colonization is the presence of microorganisms in or on a host with growth and multiplication but without tissue invasion or damage. Resident organisms grow and multiply on the individual's skin while transient organisms are recent contaminants that survive for only a short time. Resident organisms rarely cause infections unless they are introduced into deep tissues through invasive procedures or if the patient is severely immunocompromised. Resident organisms can be repeatedly cultured from the skin and are usually aerobic, gram-positive organisms. These organisms are not easily removed by handwashing. Staphylococcus epidermidis is a good example of resident flora.
Transient organisms are the opposite of the resident organisms. Transient organisms are usually anaerobic, gram-negative organisms that readily cause infection. They survive less than 24 hours on the skin and are easily removed with handwashing. Escherichia coli is a good example of a transient organism. Handwashing is used to remove dirt, organic material and transient organisms.

Types of Handwashing Agents. Various handwashing agents, plain or antimicrobial, are available in the healthcare setting. Plain soaps physically remove dirt and transient organisms with mechanical friction. Antimicrobial agents not only remove dirt and transient organisms but also kill or inhibit the growth of organisms to further reduce microbial levels. Antimicrobial hand rubs designed for use without water inhibit microbial flora, but have no effect on dirt. Handwashing agents are furnished in various forms such as bar, granule, liquid, leaflet and powder. You should note, however, that when bar soap is used, it should be in small bars, changed frequently, and placed on antimicrobial soap racks that promote drainage. Bar soap that is not drained appropriately and is allowed to remain moist can become contaminated. Therefore, bar soap is generally recommended for patient hygiene but not routine handwashing of healthcare workers' hands. Soap should be selected based on the type and degree of hand contamination and the need to either reduce or maintain minimal counts of resident organisms.

Handwashing Technique. Routine handwashing is indicated for removing dirt and transient microorganisms. Hands are vigorously washed under a stream of warm water for at least ten seconds using plain bar soap, granule soap, soap-filled tissues, or liquid soap. Care should be taken to wash all surfaces of the hands, especially the thumbs and under the fingernails. Rings should be removed or at least moved so the area under each ring can be washed. Hands are rinsed and then dried. A clean paper towel can be used to turn off water faucets and prevent recontamination of the hands if the sink does not have foot or knee controls or an automatic shut off. Routine handwashing agents (plain, non-antimicrobial soap) are recommended for general patient care activities. Hands should be washed with routine agents: (1) before and after patient contacts; (2) when visibly soiled; and (3) after removing gloves if hands are not visibly soiled with blood or body fluids.
Handwashing with antimicrobial agents (hand asepsis) is indicated for removing or destroying transient microorganisms. This is accomplished by handwashing with an antimicrobial agent as described above or by using alcohol-based hand rubs. Hand rubs should be used as an adjunct to handwashing in areas where running water is not readily available. Alcohol-based hand rubs are not effective in removing dirt and should be used only when hands are not visibly soiled. Hands should be washed with antimicrobial agents or alcohol-based hand rubs: (1) before performing invasive procedures such as placing intravascular catheters; (2) after contact with a source of organisms (body fluids, mucous membranes, non-intact skin, inanimate objects likely to be contaminated); (3) when caring for patients at highest risk for developing infection: patients who have burns, pressure ulcers or wounds; patients at the extremes of age (infants, the elderly); immunocompromised patients and patients in ICU; (4) when caring for patients requiring transmission-based precautions; and (5) in situations when there are known multiple drug resistant bacteria present in the environment.

Personal Protective Equipment (PPE)
Under the OSHA Standards, personal protective equipment (PPE) will be considered appropriate "only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time that the protective equipment will be used."

Gloves: Gloves are worn for three important reasons:

1. To provide a protective barrier and to prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. Wearing gloves in specified circumstances to reduce exposure to bloodborne pathogens is mandated by OSHA's bloodborne pathogen standard.
2. To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to patients during invasive or other patient-care procedures that involve touching mucous membranes and non-intact skin.
3. To reduce the likelihood that hands of personnel contaminated with organisms from a patient or fomite can transmit these organisms to another patient. In this situation, gloves must be changed between patient contacts, and hands should be washed after removal of gloves. Failure to change gloves and wash hands between patient contacts is an infection control hazard.

The type of gloves selected by the caregiver should be predetermined as appropriate to the task being performed. The following general guidelines are suggested for selecting gloves.

• Sterile gloves should be used for all invasive procedures and procedures involving contact with areas of the body that are normally sterile.
• Examination gloves should be used for procedures that do not require the use of sterile gloves or for procedures involving contact with mucous membranes, unless otherwise indicated. Single-use gloves cannot be washed or decontaminated for reuse.
• General-purpose utility gloves should be used for housekeeping chores or for cleaning and decontaminating instruments and equipment. Gloves should be designed to protect the healthcare worker's hands from the harsh cleaning chemicals as well as blood and OPIM. Utility gloves may be decontaminated if they are not compromised. They must be replaced whenever they show signs of puncture, cracking, peeling, tearing, or deterioration.

Standard precautions and OSHA's bloodborne pathogen standard require the use of gloves when touching blood or other body fluids or contaminated equipment.

Gowns. Various types of gowns and protective apparel are worn to provide protection and reduce opportunities for the transmission of organisms. Gowns are worn to prevent contamination of clothing and to protect the skin from blood and body fluid exposures. Standard precautions and OSHA's bloodborne pathogen standard require the use of fluid resistant gowns during activities that could generate aerosols, splashes or splatters.
Gowns are also worn during the care of patients infected with epidemiologically significant organisms. Gowns reduce the opportunity to transfer pathogens from patients or items in their environment to other patients or environments. When gowns are worn for this purpose, they are removed before leaving the patient's environment and hands are washed.

Face Protection. Various types of masks, goggles and face shields are worn alone or in combination to provide barrier protection. Face shields, masks and goggles are worn during procedures and patient care activities likely to generate splashes or splatters. This provides protection of the mucous membranes of the eyes, nose and mouth.
Standard precautions and OSHA's bloodborne pathogen standard require the use of masks and eye protection (face shields) during activities that could generate aerosols, splashes or splatters. Hospital personnel generally wear a surgical mask to provide protection against spread of infectious, large particle droplets transmitted by close contact. These large droplets travel only short distances (up to 3 ft.) from infected patients who are coughing or sneezing. Table 2 provides examples of the personal protective equipment recommended when performing various tasks.

Examples of Personal Protective Equipment for Caregiver Protection

Care of the Environment

Just as handwashing decreases the bioburden on the hands, cleaning decreases the bioburden in the environment. Both practices are designed to minimize the number of organisms in contact with clients, visitors or healthcare workers. A clean healthcare environment is crucial to infection control because patients colonized with pathogenic, disease-producing organisms contaminate their environment with these same organisms. Some organisms survive long enough to be transmitted to a susceptible host. Staphylococcus aureus and Enterococci have been shown to survive for days on improperly disinfected environmental surfaces. Hepatitis B is another example of an infective agent that can be readily transferred from person to person by way of the contaminated environment. Countless articles have described the transmission of infection from contact with contaminated supplies or improperly cleaned equipment. It is impossible to prevent the transmission of infections if environmental cleaning and proper handling of supplies and equipment are absent or ineffective.

Environmental Cleaning
Environmental cleaning services are generally provided by a dedicated sanitation staff; however, in some institutions or in certain situations, the nurse might be called upon to perform some types of cleaning activity. In keeping with the principles of medical asepsis, cleaning schedules should progress from the least soiled to the most soiled to prevent the inadvertent transfer of dirt and organisms from the dirty onto clean areas. Cleaning activities should also minimize turbulence to prevent the aerosolization of organisms. Each healthcare institution has unique cleaning requirements and schedules; healthcare workers should become familiar with their responsibilities to maintain a clean environment.

Detergents, Disinfectants and Cleaning Agents. Any detergent/disinfectant registered with the Environmental Protection Agency (EPA) may be used for routine environmental cleaning. However, agents designated as hospital grade detergents/disinfectants must inactivate specific organisms such as salmonella, staphylococcus and streptococcus. In the healthcare setting, detergents/disinfectants must be chosen carefully to determine which agent is appropriate for the task to be performed.
Products designed for use on patients' skin (antiseptics) are not suitable for environmental cleaning. The only exceptions are isopropyl and ethyl alcohol. Both can be effective antiseptics and environmental disinfectants. It should be noted that alcohol is inactivated by organic debris; so, if alcohol is used as an environmental disinfectant, organic contamination such as pus or blood should be wiped up before attempting to disinfect the area.
Cleaning procedures and products designed for environmental cleaning should not be applied to patient care equipment. Environmental cleaning agents may be too harsh for delicate patient equipment or so weak that the cleaning is ineffective. Dilution formulas and surface contact time must be exact according to the manufacturer's recommendations to ensure adequate destruction of organisms. It should be noted that detergents and disinfectants could also affect the well being of clients. For example, there is a strong association between the use of phenolic disinfectants and hyperbilirubinemia in newborns when improper dilutions are used or environmental surfaces are inadequately rinsed.
Specific agents are required in certain situations. OSHA requires a tuberculocidal agent or properly diluted household bleach to decontaminate blood spills and OPIM. The prion that is associated with the development of Creutzfeldt-Jakob disease (CJD) and related conditions is very resistant to routine methods of sterilization; therefore, disinfection of instruments and environmental surfaces exposed to CJD requires special procedures.
Personal protective equipment (PPE) must be used while performing cleaning activities. Gloves should be designed to withstand the chemical effects of the detergent/disinfectant and thick enough to protect against percutaneous injury to the hands. Face protection must be adequate to protect the face and eyes if splashing or splattering is anticipated, and gowns must cover and protect the skin from harsh chemicals.

Patient Care Equipment. All patient care equipment must be cleaned and disinfected or sterilized between patient uses. Numerous articles, new and old, illustrate the need for proper reprocessing and clearly illustrate the infection consequences when equipment is not properly processed. However, not all patient care equipment needs to be sterilized between uses. E.H. Spaulding devised a clear and simple classification system to assist healthcare workers in determining the level of reprocessing required for patient care items and equipment. Spaulding divided patient care items and equipment into 3 categories based on the risk of infection associated with their use. These three categories are critical, semi-critical, and non-critical. Table 3 outlines the different methods of reprocessing.

Reprocessing Methods Used in the Healthcare Setting

A. Sterilization

Destroys: All forms of microbial life including high numbers of bacterial spores.

Methods: Steam under pressure (autoclave), gas (ethylene oxide), dry heat, or immersion in EPA-approved chemical "sterilant" for prolonged period of time; e.g., 6-10 hours or according to the manufacturer's instructions. Note: liquid chemical "sterilants" should be used only on those instruments that are impossible to sterilize or disinfect with heat.

Use:For instruments or devices that penetrate skin or contact normally sterile areas of the body; e.g., scalpels, needles, etc. Disposable invasive equipment will eliminate the need to reprocess these types of items. When indicated, however, arrangements should be made with a healthcare facility for reprocessing of reusable invasive instruments.

B. High-Level Disinfection

Destroys: All forms of microbial life except high numbers of bacterial spores.

Methods: Hot water pasteurization (80-100C, 30 minutes) or exposure to an EPA-registered "sterilant" chemical as above, except for a short exposure time (10-45 minutes or as directed by the manufacturer).

Use: For reusable instruments or devices that come into contact with mucous membranes (e.g., laryngoscope blades, endotracheal tubes, etc.).

C. Intermediate-Level Disinfection

Destroys: Mycobacterium tuberculosis, vegetative bacteria, most viruses and most fungi, but does not kill bacterial spores.

Methods: EPA-registered "hospital disinfectant" chemical germicides that have a label claim for tuberculocidal activity; commercially available chlorine (a 1:100 dilution of common household bleach - approximately 1/4 cup bleach per gallon of tap water.)

Use: For those surfaces that come into contact only with skin, e.g., stethoscopes, blood pressure cuffs, splints, etc., and have been visibly contaminated with either blood or other potentially infectious body fluids. Surfaces must be pre-cleaned of visible material before the germicidal chemical is applied for disinfection.

D. Low-Level Disinfection

Destroys: Most bacteria, some viruses, some fungi, but NOT Mycobacterium tuberculosis or bacterial spores.

Methods: EPA-registered "hospital disinfectant" (no label claim for tuberculocidal activity).

Use: These agents are excellent cleaners and can be used for routine housekeeping or removal of soiling in the absence of visible blood contamination.

E. Environmental Disinfection:

Environmental surfaces which have become soiled should be cleaned and disinfected using any cleaner or disinfectant agent which is intended for environmental use. Such surfaces include floors, woodwork, ambulance seats, counter tops, etc.

Critical items have a high infection potential if any organisms including bacterial spores are present. These items must be sterile because they will enter normally sterile areas. Sterilization destroys all microbial life including highly resistant bacterial spores. Critical items include surgical instruments, cardiac and urinary catheters, and needles. Items can be purchased as sterile or sterilized by steam under pressure or dry heat. If items cannot tolerate heat, sterilization with ethylene oxide gas or chemical sterilants may be suitable. Chemical sterilants include 2% glutaraldehyde, 6% stabilized hydrogen peroxide, or demand release chlorine dioxide. Chemical sterilants are generally used for high level disinfection as described below.
Semi-critical items come in contact with mucous membranes or non-intact skin. These items must be free of all organisms except bacterial spores. Semi-critical items include respiratory therapy and anesthesia equipment, endoscopes and diaphragm fitting rings. Semi-critical items require high-level disinfection with wet pasteurization or chemical germicides. Reliable chemical germicides include glutaraldehyde, stabilized hydrogen peroxide, and chlorine and chlorine compounds. Some semi-critical items such as hydrotherapy tanks require only intermediate level disinfection. Intermediate level disinfectants inactivate most vegetative bacteria, most viruses and most fungi, but do not kill bacterial spores. Intermediate level disinfectants include phenolics, chlorine, iodophors and hospital disinfectants with a claim for tuberculocidal activity.
Non-critical items come in contact with intact skin but not mucous membranes. Since the skin acts as an effective barrier to organisms sterility is not critical. Non-critical items require only low-level disinfection. Non-critical items include bedpans, blood pressure cuffs, bed rails, linens, and patient furniture. Low-level disinfectants include phenolics, iodophors, weak household bleach (100 parts per million available chlorine) and quaternary ammonium compounds. Non-critical items are generally cleaned where they are used and do not need to be sent to a central processing area. Under certain circumstances, however, it is necessary to dedicate non-critical items to a specific patient or ensure adequate disinfection of the item before it is used on another patient. These specific circumstances include: patients infected or colonized with resistant or highly virulent organisms such as vancomycin resistant enterococci, or patients on contact precautions.
All equipment that requires reprocessing must be thoroughly cleaned before being disinfected or sterilized. Each institution will establish equipment pre-cleaning procedures and protocols for returning contaminated equipment for reprocessing. Manufacturer's instructions must be closely followed to prevent inadvertent damage to the item and provide sufficient contact time to ensure adequate disinfection or sterilization.

Storage of Supplies. Proper care and storage of supplies is just as important in the prevention of infection as maintaining a clean environment or appropriately reprocessing patient care equipment. Holes, tears, and breaks in package integrity permit the direct entry of organisms. Excessive or improper handling, improper storage techniques, heat, moisture, dust, and dirt can also compromise the integrity of supply packaging. Dropping supplies onto the floor can create enough force to push bacteria and dust into a package without creating any visible indications that the package has been compromised. The standards for proper storage of supplies have been established to minimize contamination from these environmental factors.
Supplies should be stored in a cabinet or closet free from dust, moisture and insects. Storage shelves should be eight to ten inches up from the floor to permit routine cleaning; 18-20 inches from the ceiling to ensure adequate functioning of fire sprinklers; six to eight inches in from an outside wall to eliminate moisture damage created by changes in inside and outside temperatures. Supplies must also be stored away from pipes, windows, and air vents. If open shelving is used for storage, the bottom shelf should be solid or closed to prevent the contamination of supplies on the bottom shelf from floor dust and the cleaning process.
Sterile supplies should be separated from non-sterile supplies by a functional barrier, such as a drawer, bin or shelf. This practice prevents the excessive handling of sterile supplies in order to reach non-sterile supplies and minimizes the chances that a non-sterile item will be selected for use when a sterile item is needed. Access to storage areas should be restricted to minimize traffic. If supplies are located in a large storage room, sterile supplies should be located away from doorways and high traffic lanes.
Supplies should be inspected prior to use to ensure that the package is free from tears, dampness, dried water marks, excessive dust or dirt and that the expiration date has not been reached. Any item dropped on the floor must be discarded or reprocessed before use.
Event-related sterility recognizes that a product remains sterile until some event causes the item to become contaminated. Each institution will establish storage times and specific storage conditions.

Waste Management. The policies for defining, collecting, storing, decontaminating and disposing of infective waste are determined by the healthcare institution in accordance with state and local regulations. Policies and procedures for waste management can be obtained by contacting the local and state health departments or agencies responsible for waste management.

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