Outfitting for the Outpatient Ortho Boom
Between aging Baby Boomers’ growing needs and a strong same-day preference among patients and insurers, the demand for outpatient orthopedic procedures like total knees and...
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By: Robert Manasse
Published: 10/2/2008
Materials that will be used during surgery must be sterile and free of all living microorganisms, be they bacteria or viruses. The same does not hold true of surfaces, which are continually exposed to the environment, making it impossible for us to sterilize them. The most we can do with surfaces is to reduce the microbial burden to a level that will significantly reduce the chance that there will be an infection caused by microorganisms on hands or surfaces. This is where disinfectants enter the scene. Disinfectants come in various forms for various purposes. They also have varying abilities to decrease the number of viable organisms present. Here are some helpful tips and points to keep in mind as you consider the right tool for your surface disinfection needs.
1. Disinfectants won't be sufficiently effective if the surface is dirty. This is especially true with proteinaceous substances such as blood. Disinfectants have to get to the area that has to be treated and organic matter of all kinds will prevent their penetration to the surface you want to disinfect. Treating the area with a detergent will usually take care of the problem by breaking up the material covering the surface to be disinfected.
2. One product for all surfaces. Ideally, you'll select a single product to disinfect OR surfaces. Choosing the best product for your conditions will depend on the types of surgeries performed and the environment in which your OR is situated, as well as the product's effectiveness against organisms of concern, cost, ease of use, storage, impact on surfaces and potential irritation to users' skin, eyes and mucous membranes.
Detergent, Disinfectant or Sterilant? |
Here's how to distinguish among detergents, disinfectants and sterilants as they apply to the OR and its personnel.
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3. What do regulators say? Four regulatory bodies influence the disinfectant you choose:
4. Low, intermediate or high? There are three levels of disinfectants as categorized by the EPA:
5 Disinfectant Myths | ||
Despite numerous reasons and supporting documentation about the importance of disinfectant use, some still argue against routinely disinfecting surfaces in a healthcare setting. I've listed their arguments as myths on the left and countered them with what science tells us on the right. | ||
Myth |
Reality |
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1. Their use doesn't decrease infection rates in the healthcare setting. |
Many studies from high-quality laboratories have been published in peer-reviewed journals demonstrating the efficacy of disinfectant use. Countries with the lowest rate of disinfectant use have been shown to have the highest increase in MRSA infections. |
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2. Both patients and employees can become allergic to them. |
Yes, there's the potential of irritation with some agents, such as glutaraldehyde, but consider the need to decrease the bacterial load on specific surfaces. Careful use of agents that can affect the upper respiratory tract, skin and mucous membranes is very important. Read the Material Safety Data Sheet (MSDS) before using any chemical agent. |
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3. These chemicals have negative ecological effects. |
There should be a well-thought-out use of disinfectants and their disposal. |
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4. Organisms will become resistant. |
The chemical composition of many disinfectants makes it highly unlikely that pathogens will develop resistance. |
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5. It increases the cost of health care. |
The estimated added cost of one surgical site infection far exceeds the cost of disinfectants. |
5. Beware bacteria that form spores. Bacterial spores are like seeds, which explains why some bacteria survive harsh environments. Most disinfectants don't affect bacteria. Among the disease-causing bacteria that form spores are Clostridium difficile (C. diff) and Clostridium tetani (tetanus). An instrument used on a patient with C. difficile or an area that had a patient with the organism can become contaminated with spores very quickly. Unless you use adequate disinfection procedures and products, other patients and personnel handling the patient or entering the area may become colonized. The "right" conditions can change colonization to infection very quickly.
6. The big three bacteria. A disinfectant that is EPA-approved for use in an outpatient surgical facility must be active against three bacteria:
7. Stronger the agent, the better it kills? Not true for many disinfectants. A 1:10 dilution of household bleach (prepared fresh daily) is very effective in killing HIV as well as C. difficile vegetative cells and spores. One would expect 100 percent to be the best concentration of alcohol to kill bacteria and viruses, but mixing alcohol into a water-based solution makes it easier for alcohol to penetrate and kill cells. Alcohol gels and foams used as hand disinfectants are usually about 65 percent to 70 percent alcohol. This concentration is most effective in denaturing protein, thereby killing the germs. Quaternary ammonium compounds are usually used at dilutions of about 1:1,000. These chemicals, as well as most others, should be left on the surface for at least 10 minutes in order to be most effective.
Disinfectants: One Size Does Not Fit All | |||||
Based on this table, you might think that chlorine in the form of diluted bleach would be the best chemical to use for all types of disinfection. But bleach is very corrosive on some materials, including many metals used in surgical instruments as well as on flexible fiberoptic endoscopes. It can destroy expensive equipment quickly and even instantaneously in some cases. It's also very harmful to skin, eyes and mucous membranes. That's why you can't use bleach for all disinfection. It's always important to consider the specific uses, contaminants and types of equipment that are being disinfected. Remember, however, that any reusable instrument that comes in contact with normally sterile tissue, including the bloodstream, should always be reprocessed using an autoclave, ethylene oxide or dry heat when possible. The specific uses and properties of any disinfectant can be obtained from the product's manufacturer. Data should include length of exposure required. |
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Most Frequently Used Classes of Disinfectants | |||||
Activity vs. |
Chlorine |
Iodine |
Chlorhexidine |
Alcohol |
Phenol |
Bacteria |
Good |
Good |
Good |
Good |
Good |
Bacterial spores |
Good |
Poor |
Poor |
Poor |
Poor |
Viruses |
Good |
Good |
Poor |
Fair |
Poor |
• Enveloped viruses[1] |
Yes |
Yes |
Limited |
Yes |
Limited |
• Non-enveloped viruses[2] |
Yes |
Limited |
No |
No |
No |
Fungi |
Good |
Fair |
Fair/Good |
Good |
Fair |
SOURCE: CDC Web site
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