Infection prevention in OR.pptx

July, 2021 © Haramaya University, CHMS,
Department of Emergency and Critical Care Nursing
Infection Prevention in OR
By:- Ame Mehadi (BSc, MSc-EMCCN)
INFECTION PREVENTION
IN
THE OPERATING THEATRE

August , 2021 © Haramaya University, CHMS,
Contents
Infection Prevention in Operating Theatre
►Teaching of the staff
►General; preparation
►personal hygiene
►clothing and shoes
►Hair cover and mask
►Preparation of theatre for an infectious cases.
►Procedure of hand-washing/scrubbing:
 short scrub
 long scrub
Theatre cleaning
►Daily/routine/cleaning, at the beginning, and at the end of the day.
2

Contents
►Cleaning between cases
►Weekly cleaning
Instrument processing
Decontamination
Cleaning
Disinfection
Sterilization
Proper use of PPE
►Procedure for wearing sterilized gown.
►Gloving
 closed method
 open method
3

Definitions
 Infection is the most important and preventable cause of impaired wound healing.
 MOs can reach tissues during surgery or manipulation of surgical wound carried
and transmitted by:
►People, including patients
►Inanimate objects, including
 instruments, sutures, linen, swabs, solutions, mattresses, blankets
►Air around wounds, which can be contaminated by
 dust & droplets of moisture from anyone assisting at surgery or caring for
wound.
 Aseptic treatment of a wound: an attempt to prevent MOs contamination from
these sources, during surgery.
4

Sources of contamination in the OR
External sources of contamination in the OR
►Poor scrubbing up, gowning and gloving technique
►Excessive inappropriate mov’t into and out of the OR.
►Too many people in the operating room – excessive mov’t.
►Unnoticed perforation of a glove.
►Contamination of instruments by an unscrubbed person
5

Sources of Contamination and Infection
1. Members of the operating team,
2. The patients,
3. All articles used in the wound and in the sterile setup,
4. Dust in the air,
5. Other personnel or visitors in the OR.
incidence & type of infections that occur in surgical pts may be the
result of:
►preexisting localized infectious process,
►systemic communicable disease, or
►acquired pre op complication.
6

Principles of Infection Prevention in the OR
 Every person is potentially infectious and susceptible to infection.
 Minimize number of people allowed to enter.
 Keep all doors closed except
►as needed for passage of equipment, personnel, patients.
 Using PPE to provide barriers
 Donning (wearing) gloves
►before touching anything potentially infectious and wet or
►before performing invasive procedures.
 Washing hands before and after any procedure
 Doing hand rubs or surgical hand scrub.
 Using antiseptic agents
►for cleansing the skin or mucous membrane prior to surgery.
7

Principles ………
Cleaning and disinfect table, instruments and surfaces between cases.
Using safe work practices, such as
►do not recapping or bending needles,
►safely passing sharp instruments, and
►disposing sharps in puncture resistant containers.
Processing instruments and other items that come in contact with
► blood, body fluids, secretions and excretions.
 Routinely cleaning and disinfecting equipment and furniture.
 Disposing contaminated materials and contaminated waste properly.
 Breaking the disease transmission cycle by
8

By:- Ame Mehadi (BSc, MSc)
breaking the chain of infection is
achieved by:
►Reducing the number of infection causing
MOs present
 e.g., simple hand washing, cleaning of
instruments
►Killing or in activating infection causing MOs
 e.g., hand washing with a waterless alcohol
preparation, decontamination
►Creating barriers to prevent infectious agents
from spreading
 e.g., wearing gloves or PPE;
►Reducing or eliminating risky practices
 e.g., using disposable gloves and syringes
IPP in the OR……cont’d
the chain of infection

IPP in the OR……cont’d
The most efficient measures are:
Decontamination
Cleaning
Disinfection
Sterilization
Proper use of PPE

Decontamination
is the process of making inanimate objects safer to be handled by staff
before cleaning.
►Inactivates HBV and HIV
►Must be done before cleaning
►done by soaking the equipment in 0.5% chlorine solution
►Prior to decontamination, it is recommended that
 the instruments be pretreated with a preliminary cold water rinse or soak
in cold water with or without a soil dissolving enzymatic cleaner.
11

Introduction to OR Technique
 To Prepare Dilute Chlorine Solutions
 Total parts (TP) (H2O) =
% Concentrate
% Dilute
− 1
=
5% Concentrate
0.5% Dilute
− 𝟏
= 9 Total parts (TP) (H2O)
To make a 0.5% chlorine solution
from 5% bleach, mix 1 part bleach
to 9 parts water.
 To Prepare a Chlorine Solution from
a Powder
 Gram/Liter =
% Dilute
% Concentrate
𝑋1000
=
0.5% Dilute
35% 𝐂𝐨𝐧𝐜𝐞𝐧𝐭𝐫𝐚𝐭𝐞
𝑋1000
= 14.2 Gram/Liter
To make a 0.5% chlorine solution
from a 35% chlorine powder, mix 14.2
grams of powder to 1 liter of water.

Decontamination practices
Place instruments and reusable gloves in 0.5% chlorine solution after
use.
Soak for 10 minutes and rinse immediately.
Do not soak instruments in decontaminating solution for more than 10
minutes, because it results corrosion.
Use plastic container with cover for decontamination .
Wipe surfaces (exam tables) with chlorine solution.
Flush syringe and needles with 0.5% chlorine solution.
The decontamination room should be a room that is physically separate
from areas where clean instruments, supplies and equipment are
undergoing preparation for sterilization to prevent the risk of cross-
contamination.
13

Decontamination practices
Use three buckets,
►one filled with 0.5% chlorine solution,
►one with soap and water and
►one with clean water

Completely submerge instruments
Labeling of the containers is one of the
important aspects of decontamination

CLEANING
is the method of removing or reducing the number of MOs/infectious
agents and other organic matters present on inanimate objects or
surfaces.
is an essential pre-requisite to any method of sterilization process.
is the obligated prior step to ensure effective disinfection or sterilization
process.
is separating residues from inanimate surfaces through d/t methods.
►Physically, mechanically or Chemically.

CLEANING………
The cleaning of surgical instruments should
►begin during the surgical procedure
 to prevent drying of blood, soil and debris on the surface and within lumens.
 the first scrub role should keep the instruments free of debris and blood during the
surgical procedure.
►continue at the point of use post-procedure, including
 sorting and disassembly of instruments,
 containment and transportation to the decontamination room.
All instruments that were on the sterile field, whether used or not used,
are considered contaminated, and a possible source of MOs that could
cause an infection.

CLEANING………
Instruments should be disassembled and in the open position.
Instruments with lumen should be thoroughly rinsed or soaked
vertically.
All instruments should be thoroughly rinsed to remove detergent
residue.
water-soluble lubricant is recommended following decontamination.

CLEANING………
 Scrub sinks & hand washing stations should not be used for cleaning instruments.
►Cleaning dirty instruments in the scrub or hand washing sink will
contaminate the faucet, sides and bottom of the sink thus contributing
to cross contamination during hand washing or performing the surgical
hand and arm scrub.
 Instruments should never be soaked in saline or sodium hypochlorite (bleach)
solution.
 The chloride ions in both solutions are highly corrosive, causing the breakdown of
the finish on instruments, as well as the metal.
 Antimicrobial solutions, such as iodophors that are used for skin antisepsis,
should never be used for cleaning instruments.

 Selected cleaning agents should
not damage the cleaning equipment
not damage instruments
effectively clean instruments.
not corrosive to instruments and the
cleaning equipment
not cause electrolytic action b/n the
instruments and cleaning equipment.
easily removed from the instruments by
rinsing with water
e.g., use of liquid soap is effective for cleaning.
 Ideal characteristics of a cleaning
agent.
►Low sudsing/foaming
►Easily rinsed off
►Disperse organic soil
►Biodegradable
►Nontoxic
►Nonabrasive
►Effective on all types of organic soil
►Cost-effective
►Long shelf life
CLEANING………

 may be performed manually, mechanically or a
combination of both.
 selection of the cleaning method should be
based upon
►the type of device and manufacturer’s
recommendations.
Two main types:
►Manual cleaning
►Mechanical cleaning:
 Automatic washing.
 Ultrasonic treatment.
CLEANING………Types

Manual CLEANING
 has 4 phases:
►Soaking
►Brushing
►Rinsing
►Drying
 is recommended for delicate instruments and devices,
such as
►microsurgical instruments,
►lensed instruments,
►power equipment, and
►other instruments that cannot tolerate an automated
cleaning process.
 Universal safety precaution must be followed.

Mechanical cleaning:
 for instruments and devices that can
withstand the process.
►for heat-resistant materials.
►The washer designed to clean,
disinfect and dry.
►provides the advantage of exposing
the instruments and devices to a
microbicidal process.

Mechanical cleaning………
►Double gloves
►Open or disassemble instruments
►Place instruments in wire baskets
►Do not overload trays
►Check that the material is clean

Cleaning practices
►Use PPE during cleaning to protect from
♪soil and debris, blood and body fluids, and
♪splashes from liquid chemical cleaning agents.
►Disassemble instruments
►Wash with detergent, water, and a soft brush.
►Scrub instruments under the water surface until
visibly clean.
►Thoroughly rinse with clean water.

Cleaning practices
DRYING
Important process through which small drops
of liquid are removed after cleaning the
material.
It is done to avoid stain and corrosion on
metal items.

DISINFECTION
is a process that results in the destruction of most pathogens, but not
necessarily their spots.
Common methods of disinfection include the use of
►alcohol wipes,
►hexachlorophene or
►chlorohexidine gluconate soap scrub, or
►povidone-iodine scrub to kill MOs on the skin.
Stronger disinfectants include
►phenol and mercury dichloride,
 too strong to be used on living tissue.
Boiling
►can be used to disinfect an animate objects.
►does not destroy all MOs or spores.

SPAULDING CLASSIFICATION SCHEME
Devices are classified based on the degree of risk of infection
►Critical
 Items that contact sterile tissue or the vascular system.
 They always need to be sterilized.
►Semi-critical
 Items that contact mucous membranes or non-intact skin.
 Require HLD.
►Non-critical
 Items that contact intact skin.
 Require an ILD.

DISINFECTION………
Types
►High Level Disinfection(HLD)
►Intermediate Level Disinfection(ILD)
►Low Level Disinfection(LLD)

 Eliminates all MOs except some resistant organisms or
bacterium spores, which are inhibited.
 Obtained through immersion.
 Necessary for critical and semi-critical items.
 There are high-level disinfectants that eliminate spores,
like chemical sterilants.
 For example, Peracetic Acid (Perasafe)
►Only acceptable alternative when sterilization equipment is not
available.
High Level Disinfection(HLD)

Common Methods of HLD
31
Boiling
Chemical
Steaming

August, 2021 © Haramaya University, CHMS,
HLD……… Cont’d
Practices of HLD by Boiling
►Boil instruments for 20 minutes.
►Always done in a pot with a lid.
►Start timing is when the water
begins to boil.
►Do not add anything to the pot
after timing begins.
►Air-dry before use or storage.

Practices of HLD by Steaming
►Steam for 20 minutes.
►Be sure there is enough water in the bottom pan for
the entire steam cycle.
►Bring water to a rolling boil.
►Start timing when the steam begins to come out
from under the lid,
►Do not add anything to the pan after timing starts.
►Air-dry and store instruments in covered steamer
pans. Steamer Used for HLD

Practices of HLD by Chemical
►For HLD, a 0.1% chlorine solution shall be prepared from
boiled water.
►Decontaminate, clean, rinse and dry instruments,
►Cover all items completely with disinfectant,
►Soak for 20 minutes,
►Rinse thoroughly with boiled water three times,
►Air-dry before use and storage,
►Remove items using HLD or sterile forceps/gloves
Note:
 Chemical disinfectants
should be stored in a cool, dark area,
 Never store chemicals:
in direct sunlight or
in excessive heat
Steamer Used for HLD

1. Chlorine solution 0.1%
►Safe for stainless and plated
instruments
►Concentrated solutions >0.5% can
corrode metals
2. Glutaraldehyde 2-4%
►Less irritating but still needs to be in
well ventilated area
3. Hydrogen peroxide 6%
►Highly corrosive
►should not be used to disinfect:
 copper, aluminum and zinc
►Loses potency rapidly when exposed
to heat and light.
4. Formaldehyde 8%
►Vapors are irritating (staff should wear
appropriate PPE)
►A potential carcinogen
►Do not mix with chlorine
 can produce dangerous gas
Chemicals used for HLD

Intermediate Level Disinfection(ILD)
Inactivates many MOs.
Efficient against fungi and viruses but not against spores.
Obtained through immersion.
Intermediate Level Disinfectants are:
►Ethyl alcohol 70%
►Isopropyl alcohol 70-90%
►Phenol
►Aldehydes (glutaraldehyde + formaldehyde + glyoxal)
A minimum of 10 min contact time is needed for an ILD.

Low Level Disinfection(LLD)
Used in non-critical medical devices.
eliminates most viruses and fungi but neither the tubercle bacillus nor
spores.
Obtained through cleaning of surfaces with special chemical products.
Low-level disinfectants are:
►Sodium hypochlorite 100 ppm.
►Quaternary ammonium compound.
A minimum of 10 min contact time is needed for a LLD

Characteristics of a Good Disinfectants
Wide germicidal activity
►Broad spectrum
Homogeneous (does not precipitate)
Good penetration
►Solubility (water, fat)
Compatible with other products
►Non-toxic, non-corrosive
►Odorless
►Surface compatibility
►Economical

Recommendations for Disinfectant Use
Items must be clean, rinsed and dry.
Use of safety measures:
►gloves, masks, goggles/visors, aprons.
In case of fumes, use closed containers and air the room.
Prepare the disinfectant solution following the manufacturer’s instructions.
Immerse the items completely.
Immerse the items according to manufacturer’s immersion time
Do not mix disinfectants.
Items will be rinsed with sterile water or not, depending on use.
It is essential to dry the instruments.
Instruments will be stored away for protection.

STERILIZATION and STORAGE

STERILIZATION
is the destruction or total elimination of MOs from the surfaces of
inanimate objects, including spores.
is complete elimination or destruction of all living MOs, including spores
on inanimate surfaces or in fluids.
Destroys all MOs, including endospores.
Used for instruments and other items that come in direct contact with
the blood stream or tissue under the skin.
can ensure the safe use of invasive medical devices.
Seen as an absolute concept:
“An item is sterile or it is not”.

Characteristics of a Sterilizing Agent
Broad-spectrum microbicidal activity:
►bactericidal,
►sporicidal,
►tuberculocidal,
►fungicidal and
►viricidal
Strong penetrability
Compatibility
Non-toxic
Monitoring capability
Cost-effective
The ideal
sterilizing
agent
Germicide
and
sporicide
Fast-acting
Strong
penetrability
Compatibility
Non-irritant
Atoxic
Ecological

STERILIZATION METHODS
Method Agent System
Physical
Dry heat Poupinel device
Steam under pressure Autoclave in Chemical Industry
Ionizing radiations (Gamma radiation) Industry
Non-ionizing radiations (electrons) Gas autoclave
Chemical
Ethylene oxide Gas autoclave
Hydrogen peroxide gas (Plasma gas) Plasma-gas Chamber sterilizer
Peracetic acid Sterilizing peracetic acid
Physical-
Chemical
Formaldehyde Formaldehyde sterilizing gas

Common Methods of Sterilization
44
High-Pressure Steam (Autoclave)
Chemical
Dry-heat (Oven)

METHODS OF STERILIZATION
Various methods of sterilization are available:
►Steam sterilization,
►Dry heat sterilization,
►Chemical Sterilization,
►Gas sterilization using
 ethylene oxide,
 formaldehyde or
 vapor-phase hydrogen peroxide.
►Ionizing radiation
 is another method
 is mainly used for industrial sterilization of single-use items.
The procedure for sterilization of prions is still controversial.

STEAM STERILIZATION
 Also called an Autoclave.
 Steam, especially under pressure, carries thermal energy.
 The protective outer layer of the MOs can be softened by the
steam, allowing coagulation.
 Certain contaminants, such as grease or oil materials, can
protect MOs against the effects of steam.
 Sterilizing agent:
► Steam. Program at 134 oC (instruments and textile) and 121oC (latex)
 Conditions:
►time, temperature and pressure
 Systems:
► steam autoclaves
Requirements:
► Adequate contact
► Sufficiently high temperature
► Correct time
► Sufficient moisture

Steam Sterilization……..cont’d
The temperature, pressure & time combination
for steam sterilization is:
►121°C (250°F); 106 kPa pressure:
♪20 minutes for unwrapped items
♪30 minutes for wrapped items
►132°C (270°F), pressure of 206 kPa
♪15 minutes for wrapped items.
Allow all items to dry before removing.

STEAM STERILIZATION……..cont’d
Sterilization depends on correctly following certain
practices and processes including:
Routine maintenance
Preparing items to be sterilized
Packing and wrapping
Operating
Unloading the sterilizer

Advantages
►Most common
►Safe for env’t & healthcare workers
►Non-toxic/Does not leave toxic waste
►Inexpensive/Low cost
►No aeration necessary
►Short sterilization time
►Suitable for most materials
►Suitable for Heat-resistant materials
►Quick and efficient due to the high
penetration
►Easy to monitor
Disadvantages
►can be impaired by trapped air,
grossly wet materials, & decreased
steam quality.
►can be damage heat & moisture
sensitive components.
►Heat causes corrosion.
►Affected by oil or powder (does not
penetrate)
►Affected by organic debris present
in the materials, so sterility cannot
be guaranteed if materials have
residues after the process.
Steam Sterilization………

Packing instruments for Sterilization
to avoid recontamination after the sterilization process.
►All items to be sterilized should be wrapped or packed
Wrapping materials should
►be inexpensive,
►be free of pinholes,
►be impervious to bacteria,
►allow printing and labeling,
►not delaminate when opened,
►be sealable before sterilization,
►not generate nonviable particles,
►provide a seal of proven integrity,
►be compatible with the sterilization process,
►be durable enough to resist tears and punctures,
►be flexible enough to allow swift wrapping and unwrapping.

Techniques for packing instruments for the autoclave
Envelope wrap
Square wrap

 PACKAGING CHARACTERISTICS
►Maintain the sterility of the item.
►Allow the sterilizing agent to penetrate.
►Protection of content.
►Resist tears and punctures, during sterilization & normal
handling
►Non-toxic
►Allow package to be opened in an aseptic manner.
►Ensure antimicrobial barrier and adequate protection,
 a double wrapping is carried out (internal and external).
►is sealed externally with adhesive tape which has an
external chemical indicator printed.
Packing Instruments for the Autoclave

Paper: single-use heat-resistant.
Several types:
Non-woven fabric: made of cellulose and polyester.
Crepe paper: 100% medical quality cellulose.
Propylene: without cellulose.
 The non-woven fabric and the crepe paper
are suitable for steam, ethylene oxide and
formaldehyde sterilization.
can be used for textile and instrumentation packaging.
 Propylene wrap is suitable for
steam, ethylene oxide and plasma sterilization.
Ideal for large trays/baskets and textile.
Types of Packaging
TYPES OF PACKAGING

Disposable peel pouches
►Paper/plastic bag
►Paper bag
►Tyvek bag
Rigid sterilization containers:
►Should allow:
 Penetration of sterilizing agent
 Adequate drying
 Ensure antimicrobial barrier during extraction,
transport and storage.
Types of Packaging………
TYPES OF PACKAGING

Types of Packaging………
Rigid sterilization containers:
►Containers with filter
♪Paper filter
♪Fabric filter
►Containers with valve
►There is a tamper protection device which indicates whether the
container has been opened.

Loading an Autoclave

Instructions for Operating Autoclave
 Decontaminate, clean, and dry all instruments and other items to be sterilized.
 All jointed instruments should be in an open or unlocked position; when possible, instruments should
be disassembled.
 Instruments should not be held tightly together by rubber bands.
 Allow free circulation and penetration of steam to all surfaces.
 Wrap instruments in double thickness of muslin or newspaper.
 Allow instrument packs to dry completely before removal.
 Wet packs act like a wick, drawing in bacteria, viruses, and fungi from the env’t.
 Wrapped instrument packs are considered unacceptable if there are water droplets or visible
moisture on the package exterior when removed from the autoclave.
 Place sterile trays and packs on a surface padded with paper or fabric, away from windows or fans.
 Wrapped items remain sterile as long as the pack remains clean, dry (including no water stain), and
intact.
57

DRY HEAT STERILIZATION
 Also called Oven.
 accomplished by thermal (heat) conduction.
 Initially, heat is absorbed by the exterior surface of an item and then
passed to the next layer.
 MOs die as their proteins are slowly destroyed.
 takes longer time than steam sterilization because the steam speeds
up the penetration of the heat.
 Sterilizing agent: dry air at a very high temperature
 Conditions: long exposure time, high temperature
 System: Poupinel device
 Requirements:
► Adequate temperature
► Correct time
Poupinel device

Oven……cont’d
Recommended temperature/time ratios
180°C (356°F) 30 minutes
170°C (340°F) 60 minutes
160°C (320°F) 120 minutes
150°C (300°F) 150 minutes
140°C (285°F) 180 minutes
121°C (250°F) overnight
Remember:
►Depending on the temperature selected, the total cycle time
(preheating, sterilization time, and cool down) will range from
about 2.5 hrs at 170°C to more than 8 hrs at 121°C.

 Decontaminate, clean, and dry all instruments and
other items to be sterilized.
 Items can be wrapped in aluminum foil or placed in a
metal container with a tight-fitting lid.
 Wrapping helps prevent recontamination prior to
use.
 Place loose (unwrapped) instruments in metal
containers or on trays in the oven and heat to desired
temperature.
 Begin timing after the desired temperature is
reached.
 Items should be removed and stored after cooling.
Instructions for dry heat Oven

Advantages
►Non/low-corrosiveness
►Deep penetration in the material
►Safe for the env’t
►Activates pyrogens > 250ºC
►Easy installation
►Low cost
Disadvantages
►long sterilization time
►Requirements of temperature and
cycle time are conflicting
►can damage Heat-labile
components
►Suitable for only metal surgical
instruments, glassware, jellies,
powders, oil, waxes, paraffin
►Cannot be used with textile, latex or
ophthalmic products
Dry Heat Sterilization…………cont’d

 is an alternative for items that would be
damaged if subjected to steam or dry heat
sterilization.
 Sterilization takes place by soaking.
 Rinse with sterile water.
 is powerful enough to destroy germs.
 When handling these products:
►Wear gloves to avoid skin contact.
►Wear protective eyewear to protect from
splashes.
►Limit exposure time.
►Be in a well-ventilated area.
Chemical Sterilization

Instructions for Chemical Sterilization
Decontaminate, clean, and dry all instruments and other items to be
sterilized.
Completely submerge the items in a clean container filled with the chemical
solution and place the lid on the container.
Allow items to soak
►For 10 hours in 2–4% glutaraldehyde solution or
►For 24 hours in 8% formaldehyde.
Remove objects from the solution with sterile forceps, rinse all surfaces three
times with sterile water, and air-dry.
Store objects in a sterile container with a tight-fitting lid.

Ethylene oxide
Sterilizing agent: ethylene oxide
Conditions: time of exposure, temperature, pressure
(37ºC – 55ºC), relative humidity and gas concentration
Systems: special chambers

Advantages
►Penetrates packaging materials and
many plastics
►Suitable for most material
►Compatible with most medical
materials
►Simple to operate and monitor
►Used for Heat-sensitive materials
►Does not require containers
►Suitable for endoscopes material
with lumens
►Efficacy
►Does not cause rusting
Disadvantages
►Requires aeration time
►Small sterilization chamber
►Very long cycles
►Highly toxic for humans
►Carcinogen and mutagenic
►Specific facilities
►Flammable, explosive
►Residue monitorization
Ethylene Oxide…………

Peroxide Gas Plasma Sterilization
 Advantage
►Low process temperature
►No toxic residuals
►Safe for env’tal and healthcare worker
►Simple to operate, install, and monitor
 Disadvantage
►Cellulose, linens, and liquids cannot be
processed
►Small sterilization chamber
►Medical devices with long or narrow
lumen cannot be processed
►Requires synthetic packaging
Formaldehyde
Advantage
►is not flammable and explosive
►Compatible with most medical
materials
Disadvantage
►Potential for residual on the
surface
►is toxic and allergenic
►Requires long sterilization time
►Long processing time due to
removal of residual after
sterilization.

Sterilizing agents: peracetic acid.
Conditions: temperature 50-55ºC,
time and concentration of sterilizing
agent is constant.
Systems: specific chambers.
 Advantages
►Does not activate with the presence of
organic matter.
►Low temperature cycle
►Fast cycle: 30min.
►Suitable for immediate use in situ:
 Endoscopes,
 dental instruments,
 Non-toxic for the env’t.
►Does not leave residues
►Only sterilizes material
 Disadvantages
►Unable to maintain its sterile condition
through time
►Material for immersion cannot be packaged
►Corrosive
►Costly
Peracetic Acid

is essential quality assessment
procedure for infection control.
The success of a sterilization procedure
must be monitored.
Types of controls:
►Physical
►Biological
►Chemical
STERILIZATION CONTROL/MONITORING

 Equipment monitoring
►Bowie-Dick test (prevacuum steam autoclaves)
►Physical indicator
 Process indicator
►External chemical indicator
 Packaging indicator
►Internal chemical indicator
 Load indicator
►Internal chemical and/or biological indicator
Specific Quality Controls
Equipment indicator: Bowie – Dick test

CONTROL/MONITORING …………
Physical monitoring
►is the observation of sterilizer functioning.
 e.g., temperature, pressure, time.
►Any deviation from the expected readings should
alert the operator to potential problems.
An item should not be used if its sterility is
questionable,
►e. g. if its package is punctured, torn, or wet.

Chemical indicators
 describes color or physical change indicators that monitor exposure to sterilizing agents or
conditions.
 Strips with patterns that react and change color when they reach a certain temperature.
 Internal indicator
► Placed inside the package before sterilization.
External indicators
►Indicators printed on:
 Individual packages or Adhesive tape

Biological indicators
is the most important check on sterilizer and
should be performed at least weekly.
Sufficient amount of high-resistance spores used.
Every load containing implantable objects should be
monitored with a spore test.
 It is recommended that Sterilizer loads containing implantable
or intravascular devices should be quarantined until the spore
test has been reported as negative.
Two types of spores are used:
►Bacillus Subtilis
►Bacillus Stearothermophilus

Biological indicators
24 hr READING
►If there is spore growth, color changes
QUICK READING INCUBATOR
►3h
►1–awaiting result
►2–negative result (no growth)
►3–positive result (spore growth)

STERILE MATERIAL STORAGE

STERILE MATERIAL STORAGE……………
The sterile material storage should follow optimal conditions:
►Relative humidity: 40% – 60%.
►Temperature: 15 ºC – 25 ºC.
►Ventilation: 6 air exchanges/h.
Sterile material packages need to be stored
►at a minimum height of
 25 cm above the ground and
 40 cm from the ceiling,
►on wire shelving, to avoid dust accumulation and humidity
condensation.
►where packaging is not crushed, bent, compressed, or punctured.
If a package is torn, perforated or with signs of humidity, it will be discarded.

Storage of a Sterile Package
 An optimal sterile storage area
►is best located next to or connected to the place of sterilization.
►is easy-cleaning closed spaces.
►is smooth walls for easy cleaning and disinfection.
►should be in a separated enclosed area with limited access that is used only to store
sterile supplies.
►should be restricted access area
►protects the packs or containers from dirt, moisture & animals/insects.
►protects the sterile products against
 dust, moisture, insects, vermin, and
 temperature and humidity extremes.
76

77

Identification label
►Expiry date control
Expiry of sterile material depends on:
►Packaging characteristics
►Storage conditions

STERILE MATERIAL HANDLING & TRANSPORT
 sterile material handled with gloves to avoid burns.
 Clean hands before handling packages of sterile material.
 must ensure package integrity when handling sterile
materials.
 Open shelves, far from pipes and heat/humidity sources.
 avoid unnecessary handling of sterile material and contact
with wet or soiled surfaces.

STERILE MATERIAL HANDLING & TRANSPORT
 Transportation of sterile material should be done:
►by clean trolleys, preferably closed hermetically, for larger
items.
►by closed plastic bags for smaller items.
►with an additional outer dust-protection cover that can be
removed before the items are taken into the clean zone.

The Shelf-Life System
The shelf-life of sterile items remains unclear but some recommendations are:
the shelf life of the item after sterilization
►may stay till one month, as long as, the sterile pack remains dry &
intact.
►is until something causes the package to become contaminated.
81
Loss of sterility
►is event-related e.g., by
 the frequency of handling,
 method of handling, and
 storage area conditions
►is not time-related.
 An event can be:
►A tear or worn area in the wrapping
►The package’s becoming wet
►Anything that will enable MOs to
enter the package or container
 These events can occur at any time

The Shelf-Life of a sterilized Object
Depends on the following factors:
►Quality of the wrapper or container
►Number of times a package is handled before use
►Number of people who handled the package
►Status of package storage (in an open or closed shelves)
►Condition of the storage area (humidity, cleanliness)
►Use of plastic dust covers and method of sealing
82

Summary
Decontamination: is the process of making inanimate objects safer to be
handled by staff before cleaning (i.e. inactivates HBV, HCV and HIV, it reduces
the number of other MOs but does not eliminate them).
Cleaning: is process of physically removing all visible dust, soil, blood or other
body fluids and sufficient numbers of Mos from inanimate objects to reduce
risks for those who touch the skin or handle the object. It consists of
thoroughly washing with soap or detergent and water, rinsing with clean
water and drying.
HLD: is the process of eliminating all MOs except some bacterial
endospores from inanimate objects by boiling, steaming or chemical
disinfectants.

Summary……
Sterilization: is the process of eliminating all MOs (bacteria, viruses,
fungi & parasites) including bacterial endospores from inanimate
objects by high-pressure steam (autoclave), dry heat (oven), chemical
sterilant or radiation.
Steam sterilization should be used for all items that will not be
damaged by heat, pressure, or moisture.
Biological monitoring of sterilization procedures should be performed
regularly, e. g. once a week, monthly or every 6 months etc based on
the institutional policy.
Shelf-life and expiration dating-policies of sterilized surgical
instrument mainly depends on packaging materials used & storage
facilities.

References
 Berry & Kohn: Introduction to Operating Room Techniques, 3rd Edition (The Blakiston Division,
McGraw-Hill Book Company, 1966)
 Abebaw Eredie: Operating Room Technique LECTURE NOTES For Nursing Students, Ethiopia
Public Health Training Initiative, USAID, 2008.
 A Guide to Operating Room Technique by Irene Gregory, June 1969.
 Introduction to the Operating Room U.S. Army Medical Department Center and School Fort Sam
Houston, Texas 78234-6100, 100th Edition.
 Emergency and Essential Surgical Care (EESC) programme www.who.int/surgery
 Internet sources

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