1. New Developments in Reprocessing Semicritical Items
William A. Rutala, Ph.D., M.P.H.
Director, Hospital Epidemiology, Occupational Health and Safety, UNC Health Care; Research Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology, University of North Carolina at Chapel Hill, NC, US

2. DISCLOSURES Consultation
ASP (Advanced Sterilization Products)-2014, Clorox-2014, 2015
Honoraria (2014, 2015)
3M, ASP, Clorox
Grants
CDC, CMS, Nanosonics

3. Reprocessing Semicritical Items
New Developments in Reprocessing
Endoscopes (other channeled scopes)
Laryngoscopes
Endocavitary probe
Prostate biopsy probes

4. DISINFECTION AND STERILIZATION Rutala, Weber, HICPAC. November 2008
DISINFECTION AND STERILIZATION Rutala, Weber, HICPAC. November
EH Spaulding believed that how an object will be disinfected depended on the object’s intended use
CRITICAL - objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile
SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-level disinfection[HLD]) that kills all microorganisms except for high numbers of bacterial spores
NONCRITICAL - objects that touch only intact skin require low-level disinfection

5. Processing “Semicritical” Patient Care Objects
Classification: Semicritical objects come in contact with mucous membranes or skin that is not intact. Object: Free of all microorganisms except high numbers of bacterial spores. Level germicidal action: Kills all microorganisms except high numbers of bacterial spores Examples: Respiratory therapy and anesthesia equipment, GI endoscopes, endocavitary probes, etc. Method: High-level disinfection

6. High-Level Disinfection of “Semicritical Objects”
Exposure Time > 8m-45m (US), 20oC
Germicide Concentration_____
Glutaraldehyde > 2.0%
Ortho-phthalaldehyde %
Hydrogen peroxide* %
Hydrogen peroxide and peracetic acid* %/0.08%
Hydrogen peroxide and peracetic acid* %/0.23%
Hypochlorite (free chlorine)* ppm
Accelerated hydrogen peroxide %
Peracetic acid %
Glut and isopropanol %/26%
Glut and phenol/phenate** %/1.93%___
*May cause cosmetic and functional damage; **efficacy not verified

7. Semicritical Equipment
Reprocessing semicritical items has been shown to have a narrow margin of safety
Generally, the narrow margin of safety attributed to high microbial load and complex instruments with lumens
Any deviation from the recommended reprocessing protocol can lead to the survival of microorganisms and an increased risk of infection
Problems encountered with reprocessing semicritical equipment often related to improper cleaning

8. Reprocessing duodenoscopes
The Joint Commission surveyors will likely check on several high visibility items during your next survey
Reprocessing duodenoscopes

9. Reprocessing Semicritical Items
New Developments in Reprocessing
Endoscopes (other channeled scopes)
Laryngoscopes
Endocavitary probe
Prostate biopsy probes

10. Reprocessing Channeled Endoscopes Cystoscopes, Ureteroscopes, Hysteroscopes

11. Reprocessing Channeled Endoscopes Cystoscope- “completely immerse” in HLD (J Urology 2008.180:588)

12. Reprocessing Channeled Endoscopes Cystoscope-air pressure in channel stronger than fluid pressure at fluid-air interface

13. Reprocessing Channeled Endoscopes Cystoscope-HLD perfused through lumen with syringe (luer locks onto port and syringe filled and emptied until no air exits the scope nor air in barrel of syringe-syringe and lumen filled with HLD)

14. Reprocessing Channeled Endoscopes Rutala, Gergen, Bringhurst, Weber
Pathogens must have exposure to HLD for inactivation
Immerse channeled flexible scope into HLD will not inactivate channel pathogens
Completely immerse the endoscope in HLD and ensure all channels are perfused
Air pressure in channel stronger than fluid pressure at fluid-air interface
Exposure Method
VRE Contamination Before HLD (glutaraldehyde)
VRE Contamination After HLD
Passive HLD
(immersed, not perfused)
3.6x108
2.0x108
1.1x108
7.5x108
1.0x108
6.8x107
Active HLD (perfused HLD into channel with syringe)
8.4x107
1.5x108
2.8x108
1 CFU

15. Reprocessing Channeled Endoscopes Cystoscope-HLD perfused through lumen with syringe (luer locks onto port and syringe filled and emptied until no air exits the scope nor air in barrel of syringe-syringe and lumen filled with HLD)

16. Reprocessing Semicritical Items
New Developments in Reprocessing
Endoscopes (other channeled scopes)
Laryngoscopes
Endocavitary probe
Prostate biopsy probes

19. Reprocessing of Rigid Laryngoscopes JHI 2008, 68:101; ICHE 2007, 28:504; AJIC 2007, 35: 536; AJIC 2013,41:S60
Limited guidelines for reprocessing laryngoscope’s blades and handles
For years, many hospitals consider blade as semicritical (HLD) and handle as noncritical (LLD)
Blades linked to HAIs; handles not directly linked to HAIs but contamination with blood/OPIM suggest its potential and blade and handle function together
Ideally, clean then HLD/sterilize blades and handles (UNCHC-blades wrapped in a tray-HP gas plasma; handle wrapped in tray [without batteries]-steam); the blades and handles placed together in a Ziploc bag. Blades and handles checked for function prior to packaging.

20. Contamination of Laryngoscope Handles Rutala, Weber. AJIC 2013
Contamination of Laryngoscope Handles Rutala, Weber. AJIC :S60-S66
J Hosp Infect 2010;74:123
55/64 (86%) of the handles deemed “ready for patient use” positive for S. aureus, enterococci, Klebsiella, Acinetobacter
Anesth Analg 2009;109:479
30/40 (75%) samples from handles positive (CONS, Bacillus, Streptococcus, S. aureus, Enterococcus) after cleaning
AANA J 1997;65:241
26/65 (40%) of the handles and 13/65 (20%) of the blades were positive for occult blood. These blades and handles were identified as ready for patient use.

23. Laryngoscopes Blades The Joint Commission, FAQ, October 24, 2011
How should we process and store laryngoscope blades?
Processed via sterilization or HLD
Packaged in some way
Stored in a way that prevents recontamination. Examples of compliant storage include, but are not limited to, a peel pack post steam sterilization (long-term) or wrapping in a sterile towel (short term)
Should not place unwrapped blades in an anesthesia drawer

24. Laryngoscopes Blades The Joint Commission, FAQ, October 24, 2011
How should we process and store laryngoscope blades?
Processed via sterilization or HLD
Packaged in some way
Stored in a way that prevents recontamination. Examples of compliant storage include, but are not limited to, a peel pack post steam sterilization (long-term) or wrapping in a sterile towel (short term)-specula, endocavitary probes, etc
Should not place unwrapped blades in an anesthesia drawer

25. Storage of semicritical items
The Joint Commission surveyors will likely check on several high visibility items during your next survey
Storage of semicritical items

26. McGrath Video Laryngoscopes

27. McGrath Video Laryngoscopes
Used to aid the intubation of the trachea
Image is displayed on a LCD screen contained within a monitor mounted to the handle of the device
Device is sterilized with HP gas plasma (with battery). Manufacturer states “wherever practical a HLD or sterilization is preferred to a wipe-based process”
Disposable laryngoscope blade covers (sterile and single use) the camera and LED assembly

28. GlideScope AVL Video Laryngoscope

29. GlideScope AVL Video Laryngoscope
GlideScope AVL single use is a combination of a nonsterile, reusable video baton and a sterile, single-use stat (external shell for baton).
Low-level disinfection is recommended for the AVL video baton after every patient use (external shell cover blade and handle)
High-level disinfection is recommended for the video baton when it is visibly soiled

30. Reprocessing Semicritical Items
New Developments in Reprocessing
Endoscopes (other channeled scopes)
Laryngoscopes
Nasopharyngoscopes
Endocavitary probe
Prostate biopsy probes

32. Endocavitary Probes Rutala, Weber, HIPAC. www.cdc.gov 2008
Probes-Transesophageal echocardiography probes, vaginal/rectal probes used in sonographic scanning
Probes with contact with mucous membranes are semicritical
Guideline recommends that a new condom/probe cover should be used to cover the probe for each patient and since covers may fail (1-80%), HLD (semicritical probes) should be performed

33. Endocavitary Probe Covers
Sterile transvaginal probe covers had a very high rate pf perforations before use (0%, 25%, 65% perforations from three suppliers)
A very high rate of perforations in used endovaginal probe covers was found after oocyte retrieval use (75% and 81% from two suppliers) but other investigators found a lower rate of perforations after use of condoms ( %)
Condoms superior to probe covers for ultrasound probe (1.7% condom, 8.3% leakage for probe covers)

34. Trophon EPR (uses HP mist to achieve HLD in 7m-no independent efficacy data)

35. Effectiveness of Trophon EPR in Inactivating Healthcare Pathogens Rutala, Gergen, Sickbert-Bennett, Weber 2015
Designed to provide HLD of ultrasound probes
Automated, closed system that uses hydrogen peroxide mist
>106 pathogens inoculated onto probe at 2-3 sites
Inactivated bacteria and good but not complete kill of mycobacteria, spores
5% FCS
VRE
CRE-Kp
M. terrae
C. difficile spores
Present
0/4
0/6
3/6
Absent
0/3 ND
1/3
1/9

36. ENDOSCOPE REPROCESSING: CHALLENGES Susceptibility of Human Papillomavirus J Meyers et al. J Antimicrob Chemother, Epub Feb 2014
Most common STD
In one study, FDA-cleared HLD, no effect on HPV
Finding inconsistent with other small, non-enveloped viruses such as polio and parvovirus
Further investigation needed: test methods unclear; glycine; organic matter; comparison virus
Conversation with CDC: validate and use HLD consistent with FDA-cleared instructions (no alterations)

37. Efficacy of Trophon (HP) Against HPV Meyers C et al. SHEA Poster, 2015
HLD widely used to reprocess semicritical items including endocavitary probes
Tested OPA, hypochlorite and Trophon
Trophon and hypochlorite >4 log10 reduction, OPA achieved <1 log10 reduction

38. Reprocessing Semicritical Items
New Developments in Reprocessing
Endoscopes (other channeled scopes)
Laryngoscopes
Endocavitary probe
Prostate biopsy probes

40. Disinfection of Prostate Probe Rutala, Gergen, Weber. ICHE. 2007;28:916
Needle guide must be removed from the probe for disinfection

41. Do Not Reuse Single-Use Devices
Federal judge convicted a urologist who reused needle guides meant for single use during prostate procedures (Sept 2014)
Third party reprocessor OK
Criminal prosecution (based on conspiracy to commit adulteration)

42. Reprocessing Semicritical Items
New Developments in Reprocessing
Endoscopes (other channeled scopes)
Laryngoscopes
Endocavitary probe
Prostate biopsy probes

43. Summary
High-level disinfection guidelines must be followed to prevent exposure to pathogens that may lead to infection (laryngoscopes, endocavitary probes)
Ensure channeled scopes are perfused with HLD
Do not reuse single-use devices

44. THANK YOU! www.disinfectionandsterilization.org