Part 1 of this two-part series discussed the splashes and the potential for exposure to pathogens that personnel face daily in sterile processing and endoscopy departments, as well as the current guidelines and strategies for reducing
exposures (OR Manager, July 2021, pp 1, 9-11, 15). These risks were derived from research by Cori L. Ofstead, MSPH, president and chief executive officer, Ofstead & Associates, St Paul, Minnesota, and Krystina M. Hopkins, MPH, research manager with Ofstead & Associates.
Part 2 looks at the science behind guidelines for reducing risks associated with splashes and answers the question: Do droplets really stop on that 3-foot line?
As scientists, Hopkins says she and Ofstead were curious about the recommendation for a 3-foot separation for clean and dirty areas and how researchers determined that droplets don’t go any farther than 3 feet.
They found that a study by Hota and colleagues in 2009 was a basis for this recommendation. Those researchers used a fluorescent marker to track where splashes from sinks in an ICU were landing. They hypothesized that splashing from these sinks was causing an outbreak of multidrug-resistant Pseudomonas aeruginosa.
What they discovered was that droplets of the fluorescent marker were visible at least 1 meter (about 3.3 feet) from the sink, and they assumed that smaller, less visible particles went farther.
Hopkins and Ofstead decided to use the idea of visualizing splashes with a marker to assess splashes in the reprocessing area in a pilot study.
They first tried Glo Germ as the marker, which is a simulated germs product that comes in lotions and powders that are barely visible under normal lighting but glow under ultraviolet (UV) light. However, they found that once they put Glo Germ in the sink, they could not remove it, no matter how much they cleaned and scrubbed the sink.
Instead, Ofstead decided to use ScopeDry—the blue paper that is used to detect droplets of fluid that are retained inside endoscopes and other instruments with lumens. The paper turns white when exposed to water.
Healthmark provided them with the paper for the pilot study.
Critical Insight: Getting sinks clean is extremely difficult, even under the best circumstances.
The goal of the pilot study was to find ways to detect splashes and answer some questions from the field.
• What reprocessing activities generate splashes?
• Where do the droplets go?
• Do droplets travel farther than 3 feet?
• Does scrubbing under the surface of the water make a difference?
• How well does personal protective equipment (PPE) prevent exposure to splashes during reprocessing?
• Which PPE components get splashed?
• Do technologists get wet even when they are wearing PPE?
Splashes to reprocessing area. Ofstead and Hopkins asked Marie Brewer, CHL, CST, CRCST, CIS, GTS, sterile processing manager at Unity Point Health, Cedar Rapids, Iowa, and her sterile processing department (SPD) team what activities they thought generated the most splashes. They answered: filling the sink, rinsing instruments with high-pressure water, using air guns, and accidentally dropping an instrument into the sink.
They also wondered whether brushing and scrubbing instruments below the water surface, rather than holding them above the water, kept splashing to a minimum, and they were curious about whether the sonication sink generated droplets.
Ofstead, Hopkins, and Brewer targeted those activities during their pilot study. They wanted to position the moisture detection paper so they could detect splashes on the technologist’s PPE at various distances from the decontamination sink.
Using a combination of duct tape and zip ties, they positioned the blue paper on the technologists, the walls behind the sink, the sink areas to the left and right of the faucet, the floor, and the area behind the technologist standing at the sink.
They found that visible droplets were generated by every one of the routine reprocessing activities they targeted except running the sonication sink.
There were a lot of droplets from 3 to 3-1/2 feet away, but there were also droplets near the 4-foot mark and beyond to 5 feet from the sink (photo, “Droplet detection on the floor behind the technician”).
Critical Insight: Reprocessing generated droplets that traveled 5 feet, so a 3-foot separation between dirty and clean areas is probably not sufficient to prevent cross-contamination.
Splashes to PPE. Just a brief rinsing of a stainless steel basin in the decontamination sink soaked the technologist’s cover gown, with the chest, abdomen, and both arms getting heavily splashed. It also splashed down to the shoe covers (photos, “PPE exposure when spraying a basin”).
AORN guidelines recommend wearing extended cuff gloves, and they state that: “Wearing utility gloves with cuffs that extend beyond the cuff of the gown helps provide protection from fluid during cleaning of flexible endoscopes and other items in the decontamination sink.”
Ofstead says when she talked to people in the field, she found that COVID-19-related PPE shortages meant that personnel didn’t always have access to the correct size of gowns and gloves.
When gloves are too large, they are not snug enough to keep water from getting in over the top of the cuff, and they can fall down during manual cleaning, which risks exposure for the technologist.
In addition, personnel with small hands have a hard time handling complex instruments when they are wearing big gloves because they can’t feel through finger material that’s too loose, says Ofstead. This increases the risk to personnel and the instruments.
For the pilot study, Ofstead, Hopkins, and Brewer tested the impact of different glove arrangements:
• a gown with exam gloves that were covered by long extended cuff gloves pulled over the cuff of the gown
• a glove and then a gown and then a long glove pulled up over the gown
• a glove covered by a long glove with a gown over the top of the gloves (note, this is the wrong way to don PPE).
To measure the effectiveness of these configurations, the technologists affixed blue paper strips to their gloves, on the skin of their hands, and on their arms from the wrist to the elbow.
When cleaning an endoscope with a brush while wearing double gloves—an exam glove, then a gown, then a medium-size extended cuff outer glove that fit well and was pulled up all the way over the gown—the blue paper strips for the most part remained blue.
However, a small amount of water got over the top of the gloves and through the gown, which was detected because there was a little bit of white on the blue paper on the forearm. The wrist and hand were dry, which showed that double gloving is helpful.
When the outer glove was too big, a lot more water got over the tops of the gloves and under the absorbent cuffs of the gown, and saturated the wrist area (photos, “Small amount of white on blue paper taped to forearm when outer glove was correct size [left]. Wrist area saturated with water and turned paper white when outer glove was too large [right]”).
When the technologist wore two pair of gloves with a gown pulled over them, water started getting into the gloves almost immediately, and her arm and the insides of both gloves were soaked.
All of the blue indicator paper had turned white, confirming that everything got wet. In addition, when the technologist lifted her hands up out of the water, there was so much water inside one of her gloves that it traveled out of the glove, along her arm inside the gown, and then followed gravity all the way down her torso and leg.
She was totally soaked and had to change her scrubs (photo, “Water that had gotten in the gloves had traveled all the way down her leg”).
This really reinforces the need to pull gloves up over the gown, and it raises the questions of how well the gown repelled water, and whether it’s appropriate to wear gowns with absorbent cuffs when working in the decontamination area, says Ofstead.
The technologist’s face shield also became heavily splattered when she was spraying the basin. Her hair cover also got splashed, as did the area underneath her chin and along the bottom of the mask under the face shield, and her neck area.
A study that Ofstead did previously showed that face masks are not totally fluid resistant, which Ofstead says adds to her concerns about the vulnerability of the face and neck. This research was reported in OR Manager, April 2021, pages 1, 6-10, and the photos above, “Exposure to the face shield, hair cover, and neck when spraying a basin,” illustrate this vulnerability.
Critical Insight: Because personnel literally get splashed head to toe during routine reprocessing, they need to wear PPE that reliably protects them from head to toe.
The pilot study findings are provocative, but there is a lot of work left to do to figure out how to most effectively protect frontline reprocessing personnel and minimize contamination of instruments and devices, says Hopkins.
Although evidence-based solutions don’t yet exist, here are some strategies to consider when trying to minimize splash in reprocessing areas:
• Maintain a one-way workflow, and avoid going back and forth between dirty and clean sides. If it can’t be avoided, PPE must be changed and hand hygiene performed every time personnel move from dirty to clean areas.
• During manual cleaning, follow recommended practices and manufacturers’ instructions for use (IFU), such as placing instruments gently in the sink and brushing instruments under water.
• After manual cleaning, wipe down the counters and back splashes around the sink, as well as the faucets because those are in the splash zone, too. One of the biggest takeaways from the pilot, says Hopkins, was learning that most reprocessing activities generate at least a small amount of splash, and those splashes are landing in and around the sink. When cleaning work-stations, she says, consider what is stored around the sink, and work with managers to streamline the cleaning process.
• Ensure that personnel are wearing the correct size of PPE and using it correctly. If shortages cause healthcare workers to use lower quality PPE or an incorrect size, Hopkins says, to the extent they are able, healthcare workers should make sure they are using each component correctly.
It is critical that, after personnel remove their PPE, they perform thorough hand hygiene, and consider thoroughly washing the neck, chest, and face area under the face shield and mask, she says.
Managers and infection preventionists also play a role in protecting workers and improving practices, says Hopkins.
Ideally, they will periodically:
• Conduct a risk assessment that includes the reprocessing areas: Are there wet floors and surfaces? Is there a sufficient barrier to separate clean and dirty activities? Are there extra supplies and equipment crowded around the sinks and splash zones?
• Review administrative details: Do personnel have access to and know the guidelines and IFUs? Are they trained and competency tested on recommended practices? Are there policies for cleaning work areas?
• Evaluate PPE supplies available to reprocessing personnel: Do they have access to complete and high-quality PPE? Is there enough PPE? Is PPE available in the right sizes? Do personnel know how to use PPE?
Managers and infection preventionists should use their assessments to develop policies and improve practices, says Hopkins. Actions they can take include advocating for high-quality, fluid-resistant PPE for reprocessing personnel and ensuring PPE is available in sufficient quantities and sizes.
Engineering and construction considerations also are important. If the reprocessing space is insufficient, engineering and construction approaches are valuable, but they can be expensive, says Hopkins. Updates could be small, like installing plexiglass barriers around decontamination areas, or larger, like increasing the separation between clean and dirty areas.
Those considering a buildout in the near future should try to either maximize space between decontamination and clean areas or separate them into entirely different rooms, she says.
When considering separate clean and dirty spaces, space isn’t the only factor. Managers also should look at:
• Who is doing what, and in what order?
• What’s the workflow?
• Are there enough staff members for one person to stay in decontamination and one to stay on the clean side, or are personnel going to have to switch sides?
• If personnel switch sides, is there enough PPE to change whenever they switch?
• Do personnel have access to hand hygiene sinks that aren’t contaminated?
Practices and physical space are equally important, says Hopkins. Considering both can help inform and guide decisions during a buildout.
Critical Insight: The pandemic illuminated the importance of workflow, distancing, and PPE—and a combination of solutions will be needed to keep staff safe in high-splash areas.
Ofstead and her team hope that infection preventionists as well as OR and SPD managers will take a critical look at the evidence behind the guidelines, or the lack thereof, with regard to the applicability of the 3-foot splash zone in reprocessing and the PPE that personnel are wearing.
Ofstead says it would be helpful if stakeholders could open a dialogue with those who are most exposed to splashes. They should try to find out what it’s like for them and what they think might help.✥
Editor’s Note: Ofstead and Hopkins give special thanks to Marie Brewer, CHL, CST, CRCST, CIS, GTS, sterile processing manager at Unity Point Health, Cedar Rapids, Iowa, and her team who helped set up the pilot study to evaluate splashing in decontamination areas of SPDs.
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).
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