Cut Citation Risks: Follow the Updated Manual High-Level Disinfection Guideline


AORN offers two HLD resources to help teams better protect patients and pass surveys

Joint Commission surveyors often cite inpatient hospitals and ASCs for the same deficiency. Regardless of setting, teams have shortcomings in their manual high-level disinfection (HLD) processes.

“If manual HLD doesn’t kill all pathogens, devices can transmit deadly microorganisms,” notes Amber Wood, MSN, RN, CNOR, CIC, FAPIC. Wood is a senior perioperative practice specialist at AORN. She says these infections are avoidable. 

Wood recommends periop RNs review two AORN resources to help teams better protect patients and pass surveys. One is the recently updated Guideline for Manual High-Level Disinfection. The other is a new handover tool.

Where to Start: At the Point of Use & During Disinfectant Solution Testing

  1. Improve Communication about Point-of-Use Treatment

After use of a semi-critical device, the team scrub should promptly apply a pretreatment product. An example of this: use of a transesophageal echocardiography (TEE) probe. This will initiate the cleaning process and keep the probe moist during transport. The longer the dirty device sits, the harder it will be to remove the bioburden during the cleaning process.

“The key to successful HLD is to have a clean device before performing disinfection. This starts at the point of use,” Wood advises. She stresses these essential steps:

  • Use pretreatment products that are compatible with the device
  • Keep the device moist after use
  • Perform decontamination as soon as possible

Where Do Teams Go Wrong?

The person in the OR responsible for point-of-use treatment can get delayed in removing soil and moistening the device for transport. Also, nuances with the case that could impact disinfection may not get communicated.

Adopt This Tool to Get It Right

AORN's new Hand-Over Tool (eGuidelines+ subscription required) standardizes each point-of-use treatment. You can adjust your disinfection approach as needed. For example, the tool offers space to note if the device was exposed to a large amount of blood or difficult-to-clean products.

  1. Test the Disinfectant Concentration

What is one of the biggest compliance issues staff face with manual HLD? Testing the disinfectant concentration before each use (as recommended by the manufacturer).

How to test the disinfectant for correct concentration? AORN recommends staff use a test strip or other FDA-cleared testing device compatible with the high-level disinfectant. Do this before each use according to the manufacturer’s recommendations.

How to get it right? Teams should audit their HLD practices. Place an extra focus on concentration testing and look for ways to address barriers to compliance.

More Updates to Plan For

Teams should discuss how to improve point-of-use treatment and disinfectant concentration testing. Wood reminds periop staff that it's important to talk about other key practice changes in the guideline update:

  • Before HLD, inspect the device for cleanliness and damage, and make sure to provide space, sufficient lighting, and lighted magnification to facilitate inspection.
  • After HLD, use a cleaning verification test to determine the effectiveness of the cleaning process (visual inspection is not sufficient to evaluate cleanliness).
    • If the device fails testing, then cleaning should be repeated according to the manufacturer's instructions for use until it passes cleaning verification.
    • If the device repeatedly fails testing or is damaged, the device should be removed from service according to facility policy.
  • During post-HLD drying, complete all drying steps, including drying any lumens with pressure-regulated instrument air or HEPA-filtered air.

Remember: Studies have shown that moisture on the device after processing can facilitate biofilm formation and microbial growth during storage. 

Related Resources

We recommend you read the October issue of AORN Journal – see the “Guideline First Look: Manual High-Level Disinfection”.

Make sure you have facility subscription access to eGuidelines+ ( Access will provide you with the revised guideline and the complementary updated implementation tools.

Introducing: Leader Exchange

In this new, panel-driven webinar series from AORN Center for Perioperative Leadership, you’ll learn effective practices for leaders, from leaders. Topics address hard and soft skills and range from staff management to leveraging new technologies for patient safety and efficiency. Each webinar will provide the tools you need to excel in the many facets of perioperative leadership. See the lineup of monthly topics and save your seat at the first live session on Nov. 14. Register for the webinar.

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