As I conduct walk-through inspections of off-site physician offices, I often see troubling variations in disinfection practices. These include poor ventilation, inadequate space, improper cleaning protocols and improper separation of clean and dirty instruments. I sometimes also find equipment not properly disinfected—a reality not often discussed.

This column will address disinfection of “semi-critical” items—instruments that make contact with, but do not penetrate mucous membranes or normally sterile areas of the body. Examples include endoscopes, endotracheal tubes, bronchoscopes, respiratory therapy equipment, cystoscopes, vaginal specula, vaginal and prostate probes, laryngoscopes and blades.

Many semi-critical items cannot withstand the heat of steam sterilizers and must be disinfected chemically. The most commonly used chemical is glutaraldehyde. But this is irritating to skin and mucous membranes, and requires ventilation or a fume hood. A less toxic alternative, Ortho-Phthalaldehyde, was approved by the FDA in 1999.

Top Ten Tips for Safe, Effective Disinfection

1. Plan Ahead—Identifying semi-critical items helps determine space needs, staffing and proper cleaning protocol. Contact equipment manufacturers for recommendations on high level disinfection. Certain chemicals may damage equipment. Write out the protocol, review with chemical provider and make sure staff is educated on proper practice.
2. Separate Clean from Dirty—A medical practice should be set up so that dirty and clean instruments are separated, preferably by a wall or other physical separation. This reduces risk of cross contamination, but it can be a challenge in a small practice where space is tight.
3. Preclean Instruments—Soaking in a chemical disinfectant without pre-cleaning is a waste of time. Enzymatic cleaners are excellent, but the equipment must first be washed to remove gross contamination. Blood, mucus or other organic material on the instrument will prevent that spot from being disinfected. Dedicate a sink or basin for pre-cleaning and ensure that items with lumens are scrubbed with a brush on the inside surfaces. Submersion is best. After washing by hand, soak the equipment in the enzymatic solution for three to five minutes. Some clinics skip this altogether; others use sprays or wipes. Neither one is acceptable.
4. Rinse, Rinse, Rinse—After the enzymatic solution, rinse each part of the instrument thrice, one minute per rinse, so all organic material is removed. Dry the instrument well. Only now are you ready for disinfection. If using an automatic washer, make sure the timer is set for adequate rinsing. More is not better when it comes to soap. Too much leads to a build-up of suds and may be difficult to rinse. Follow manufacturer guidelines.
5. Read the Label—Whether using Glutaraldehyde, Ortho-pthalaldehyde or any other chemical—READ THE LABEL! Manufacturers may require different temperatures, activation versus no activation, or have other specific instructions. Glutaraldehyde, while effective, is irritating to mucous membranes and skin unless good ventilation and proper protective equipment are used. OSHA sets an upper limit of 0.2 PPM for vapor Air testing must be done at least annually, and results must be shared with staff. OSHA has no upper limit for Ortho-Phthalaldehyde.
6. Rinse, Rinse, and Rinse Again—Ortho-Phthalaldehyde will stain clothes and anything with protein. If equipment is not properly rinsed prior to disinfection, a gray stain will appear. This can be a control indicator: if a gray spot appears on any portion of the equipment, it must be reprocessed. After the equipment is soaked for the appropriate time (12 minutes for Ortho-Phthalaldehyde, 20 minutes for Glutaraldehyde) rinse again three times.
7. Personal Protective Equipment—Whether using Glutaraldehyde or Ortho-Phthalaldehyde, personal protective equipment is a must. This includes an apron, eye protection and mask.
8. Documentation—Whatever method is used, documentation is required. A logbook must be maintained to document daily testing of disinfectants. With a test strip provided by the manufacturer, the effectiveness of the chemical or minimum effective concentration (MEC) is determined. Even if the guidelines say a chemical is effective for 14 days, it must be tested daily. Conversely, even if it still meets the MEC after the 14th day, regulations say you should still dispose of it.
9. Monitor/Educate—Good work practices will be maintained when staff is well informed and observed regularly. Educational videos and tools are usually available from chemical vendors. Reward staff for good practices.
10. Prepare for Spills—When working with any hazardous material, be prepared for spills. Refer to Material Safety Data Sheets or speak directly with manufacturers to inquire about spill response. Both Glutaraldehyde and Ortho-Phthalaldehyde can be neutralized with Sodium Bisulfite and Glycine, respectively. Spill cleanup protocols should be posted in the work area and spill supplies readily available.

For more information, refer to the Centers for Disease Control and Prevention’s draft guidelines, “Disinfection and Sterilization in Health Care Facilities” at www.cdc.gov/ncdod/hip/dsguide.htm. Or email your specific questions to me at jhbrown@bethisraelny.org. Thanks to David Crimmins, RN, Infection Control, Beth Israel Medical Center, for review of this article.

Janet Brown is the medical Waste Manager for Beth Israel Medical Center, New York City. Beth Israel is firmly committed to reducing the volume and toxicity of its waste stream. Many of the strategies that work for Beth Israel can also work for you.