Does it really matter if surgical instruments are submerged in cleaning solution when technologists or nurses scrub them after a case? Is there a reason for the 3-foot separation between dirty and clean areas? Do germs stop at the red line?
During the COVID-19 pandemic, much attention has been focused on the potential for personal exposure of OR staff to viral particles emitted during aerosol-generating procedures, says epidemiologist Cori L. Ofstead, MSPH, president and chief executive officer, Ofstead & Associates, St Paul, Minnesota. However, there are personnel in endoscopy and sterile processing who also get splashed often, and it’s time to take a look at them, she says.
Ofstead and Krystina M. Hopkins, MPH, research manager with Ofstead & Associates, decided to investigate the science behind the guidelines for reducing risks associated with splashes in sterile processing and endoscopy departments. In a webinar, Ofstead and Hopkins describe evidence of splashes generated during procedures and reprocessing activities, and they explain current guidelines and strategies for reducing exposures. The webinar can be accessed for free at https://ofstead.elevate.commpartners.com/p/splash.
Part 1 of this two-part series provides examples of how splashes occur and the dangers they pose. Part 2 will look at where the idea for a 3-foot separation between dirty and clean areas came from.
In the following case studies, Ofstead describes evidence of splashes generated during procedures and reprocessing activities.
Case Study 1. In a gastrointestinal (GI) endoscopy case that was documented in 1974, patient fluid shot out of the biopsy port and hit the endoscopist in the eye. A week later, the physician developed conjunctivitis and an itchy papule under the eye. He also developed a sore throat, a stiff neck, enlarged lymph nodes, and an enlarged spleen.
He was diagnosed with a herpes blood infection that was caused by the splash into his eye from the biopsy port.
Case Study 2. In this study, a group of GI endoscopists wanted to know whether it was really necessary to wear face shields during every procedure. For the study, they wore face shields, and they fastened other face shields to the wall, 6 feet away.
Microbial culturing after each GI procedure found microbes on the clinicians’ face shields 45.8% of the time, and they found microbes on the face shields fastened to the wall 21% of the time. High colony counts were found on 5% of the clinicians’ face shields and 3% of the face shields on the wall.
The clinicians also kept notes on when they thought they got splashed, and documented only 1.6% of the time. This means, they could not tell they were getting splashed, even when they were specifically paying attention and documenting it.
Case Study 3. Ofstead found a pair of dirty goggles in a urology suite (photo at right). This was concerning because urologists have been found to be exposed to patient secretions or irrigation fluids during 37.5% to 100% of procedures. In fact, urologists’ eyes are exposed to blood in almost half (42.8%) of the procedures they perform.
Case Study 4. Splashes also are a significant problem during reprocessing of contaminated surgical instruments. ANSI/AAMI ST91 (American National Standards Institute/Association for the Advancement of Medical Instrumentation Standard 91) guidelines say that: “Contaminated endoscopes and other medical devices are sources of microorganisms to which personnel could be exposed through nicks, cuts, or abrasions on the skin or through contact with the mucous membranes of the eyes, nose, or mouth.”
While doing an audit, Ofstead took some photographs of an outpatient surgical center that had a utility room used for decontaminating and sterilizing instruments. There was a sign posted that said: “Please scrub all instruments of blood and tissue before soaking them.” Personnel were scrubbing the instruments in the hand hygiene sink and dropping them into a basin of detergent to soak.
Some red droplets on the side of the soaking basin caught Ofstead’s eye. The personnel apparently did not get all of the blood or body tissue off the instruments before soaking, and it splashed halfway up the basin (photo at right). Ofstead found more splatters that looked like blood in the sink where the instruments were scrubbed, as well as brownish-red splotches on the wall next to the sink.
Case Study 5. A sterile processing manager at one of Ofstead’s study sites (Hospital A) told her the technologists were afraid of reprocessing chemicals, specifically peracetic acid, after one employee had sustained life-threatening injuries when a peracetic acid cup burst during use. Because the employee wasn’t wearing proper personal protective equipment (PPE), the acid splash caused second- and third-degree burns, requiring extended hospitalization.
At another hospital (Hospital B), there was a similar situation, except the healthcare worker took a splash to the face that ruined her eyes, says Ofstead.
Critical Insight: It’s time to look at the risk of cross-contamination and personnel exposure in reprocessing areas.
Hopkins says she and Ofstead have been hearing from managers and technologists in reprocessing areas that COVID-19 has made PPE harder to get, and they are concerned about exposure to droplets and aerosols during reprocessing.
A search of the literature and guidelines on splash-related risks revealed that many organizations recognize that splashing of contaminated fluids and disinfecting chemicals during reprocessing is a potential hazard for personnel.
• ANSI/AAMI ST58 says “… personnel should avoid splashing water and thereby contaminating attire, the area near the sink, and other surfaces in the environment.”
• ESGE (European Society of Gastrointestinal Endoscopy) 2018 says: “Splashing should be avoided throughout the entire reprocessing procedure in order to avoid contact with infectious material, detergents, and disinfectants.”
Guidelines and recommendations for managing the risk of contamination from splashes cover a number of important considerations.
Physical reprocessing area. Hopkins cites four major guidelines that provide recommendations for setting up a reprocessing area, including CDC/HICPAC (Centers for Disease Control and Prevention/Healthcare Infection Control Practices Advisory Committee) Endoscope Reprocessing Toolkit, AORN, AAMI ST91, and AAMI ST58. She notes that there is a lot of alignment between the guideline-issuing bodies on the need for designing the reprocessing area specifically to keep clean and dirty activities separate (sidebar, “Recommendations for the reprocessing room environment”).
All of the guidelines provide recommendations on:
• keeping dirty and clean reprocessing areas separate from each other and from procedure areas
• having a one-way workflow
• keeping dirty items in the dirty areas, using ventilation, separation, dividers, and easily cleaned surfaces.
AORN recommends two separate rooms for reprocessing—one for dirty items and decontamination activities, and one for clean activities. However, says Hopkins, many institutions, especially outpatient and endoscopy centers, may only have a one-room reprocessing setup.
When dirty and clean activities can’t be separated into two rooms, AORN recommends having at least 3 feet of separation between decontamination and clean work areas, and a physical barrier like a wall or divider that extends at least 4 feet above the dirty sinks to separate soiled from clean work areas.
Best practices, training, IFUs. AORN and AAMI recommend best practices to reduce splash, such as the AAMI ST58 recommendation that says: “Immersible devices should be cleaned under the water level to minimize aerosolization; devices that cannot be immersed should be cleaned in a way that will not produce aerosols, rinsed, and dried according to the device manufacturer’s written IFU [instructions for use]…”
Training reprocessing personnel to perform a task in a way that limits splash reduces risk, and conducting audits to make sure the task is being performed the recommended way, ensures that personnel know the best practice, and they are using it every time.
Manufacturers note the importance of reducing splashing during reprocessing in their IFUs. For example, Olympus mirrors some of the guidelines and recommended practices in its IFU, including:
• keeping endoscopes submerged while doing manual cleaning to avoid splashes when removing the cleaning brush from the endoscope channel
• covering openings like the distal end and ports with a lint-free cloth when removing endoscopes from the sink and placing them in a basin for transport, rinsing them, and flushing them with alcohol.
PPE. PPE is the last line of defense for protecting reprocessing personnel, and it should not be relied on as a primary prevention strategy, says Hopkins. Instead, PPE should be combined with effective engineering (ie, setting up the physical space) and administrative (ie, setting up policies and workflows) controls and used when risks cannot be completely eliminated, she says.
According to the Occupational Safety and Health Administration (OSHA), whenever there is the possibility of risk to a worker, the employer has to provide, at no cost, appropriate PPE, including gloves, gowns, and face shields or
masks and eye protection, particularly when “splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.” OSHA also requires liquid-resistant shoe covers in these settings.
Another type of exposure is to reprocessing chemicals, such as high-level disinfectants, sterilants, alcohol, and detergents. Workers also should make sure they protect their skin, nose, and eyes whenever using them, says Hopkins (sidebar, “Toxicity warnings for reprocessing chemistries”).
When examining what specific PPE is recommended for reprocessing by guideline-issuing bodies, Hopkins found a lot of alignment among the different professional organizations. All of the guidelines recommended at least face masks, eye protection like face shields or goggles, fluid-resistant gowns, and gloves. Others also recommended head and shoe covers (sidebar, “Professional associations’ guidelines for PPE use in reprocessing”).
In other words, says Hopkins, when working in the decontamination area, personnel should be fully suited up with a hair cover, a face shield and mask, gloves, scrubs, a fluid-impermeable gown, and shoe covers. ✥
The webinar was supported by an educational grant from Healthmark. All Ofstead & Associates’ webinars will be free for 2021, using the code NEWYEAR. (https://ofstead.elevate.commpartners.com).
ANSI/AAMI ST58. Chemical sterilization and high-level disinfection in health care facilities. 2013:1-154.
ANSI/AAMI ST91. Flexible and semi-rigid endoscope processing in health care facilities. 2015:1-70.
AORN. Guideline for environmental cleaning. Guidelines for Perioperative Practice. 2021. 1145-1176.
AORN. Guideline for processing flexible endoscopes. Guidelines for Perioperative Practice. 2021. 177-266.
Beilenhoff U, Biering H, Blum R, et al. Reprocessing of flexible endoscopes and endoscopic accessories used in gastrointestinal endoscopy: Position statement of ESGE and ESGENA—Update 2018. Endoscopy. 2018;50:1205-1234.
Doizi S, Audouin M, Villa L, et al. The eye of the endourologist: What are the risks? World J Urol. 2019;37(12):2639-2647.
HICPAC. Essential elements of a reprocessing program for flexible endoscopes—recommendations of the Healthcare Infection Control Practices Advisory Committee. 2016. https://www.cdc.gov/hicpac/pdf/flexible-endoscope-reprocessing.pdf.
Johnston E, Habib-Bein N, Dueker J M, et al. Risk of bacterial exposure to the endoscopist’s face during endoscopy. Gastrointest Endosc. 2019;89(4):818-824.
Kaye M D. Herpetic conjunctivitis as an unusual occupational hazard (endoscopists’ eye). Gastrointest Endosc. 1974;21(2):69-70.
Ofstead C, Hopkins K. Making a splash: Contaminated droplet dispersal in decontamination areas. Webinar. 2021. https://ofstead.elevate.commpartners.com/p/splash
OSHA. Bloodborne pathogens. Standard 1910.1030. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030.