By Brandon Huffman, BS, CRCST, CIS
With all the different cleaning, disinfecting and sterilizing processes that go on inside of hospitals, I find disinfection to be the most complex and complicated among them. Disinfection is often looked upon as a simple concept needing no advanced experience or education. You can generally find disinfection processes outside of sterile processing departments in radiology, respiratory therapy, physical therapy, endoscopy, dental offices, you name it. But the question remains, should disinfection be performed outside of sterile processing?
Before we explore this question, I believe we need to break down the complexity of disinfection and how we apply it first. If you look up the definition of disinfection, you may find it to be misleading and somewhat lost in translation. This is due to disinfection having different forms and different activity levels of strength depending on the purpose of its uses. Having a single definition isn’t practical since disinfection can represent different expected outcomes. The Spaulding Classification is a great place to start when determining the appropriate method and activity level of a disinfectant to be used. Under the Spaulding classification, disinfection is applicable to the semi-critical and non-critical categories with the critical category belonging to sterilization. The Spaulding categories are of course not to be confused with disinfectant activity levels which are low-level, intermediate-level and high-level.
Let’s jump into the methods of disinfection. Disinfection is most often known in the chemical form as you may have observed during this current COVID-19 pandemic. Hospitals and people in general were desperately trying to purchase disinfecting wipes and chemicals with active ingredients such as isopropyl alcohol in order to keep surfaces disinfected and safe. The chemical forms of disinfection are also well known if you disinfect items such as flexible endoscopes, for instance; Ortho-Phthalaldehyde (OPA) and Peracetic Acid are two well known high-level disinfectants used for that purpose.
One other popular type of disinfection is thermal. Thermal remains one of the top disinfection processes for surgical instrumentation in sterile processing departments. Thermal disinfection is generally fully automated and built into instrument washers that are already performing the function of automated cleaning. Ask any sterile processing technician who has picked up a tray from the automated washer too soon and they will let you know just how hot thermal disinfection can get.
Now that we have covered a couple of popular methods of disinfection, we should discuss the activity levels. Different methods of disinfection can be utilized across different levels of disinfection activity depending on the type, temperature and time frame of application. I know it sounds confusing but stick with me. Thermal disinfection, for instance, can achieve all three activity levels of disinfection depending on the temperature and time of application. Thermal disinfection is used to achieve intermediate-level disinfection for safe handling of surgical instrumentation during the assembly process. It is also used to achieve high-level disinfection for items such as respiratory equipment in between patient uses. The only difference may be the amount of time the items are exposed to a certain water temperature.
Chemical disinfection can have the same capabilities of reaching across multiple disinfection activity levels as well, however, you need to make sure you read the instructions for each chemical used to verify its capabilities and surfaces or items it is validated to disinfect. Generally, chemical disinfectants are designed to achieve specific disinfection activity levels for specific purposes.
That was a lot to cover, and I’m glad you stuck it out. We should now circle back to the question of whether disinfection should be performed outside the sterile processing department. I believe when it comes to the activity levels of low- and intermediate-level disinfectants, those most certainly can and should occur outside of sterile processing. These, of course, cover the general cleaning and disinfection of the environment and equipment that only encounters intact skin. I do, however, believe that high-level disinfection should remain a sterile processing function to be performed by competency validated technicians. This is not only due to the level of training and knowledge required to perform the function of high-level disinfection, but also because sterile processing is usually designed to handle the potentially dangerous chemical disinfection process with areas supported by negative air pressure and proper personal protective equipment (PPE). Chemical disinfection can be hazardous if proper ventilation and proper PPE use are not in place.
All in all, disinfection remains a highly complex and challenging process that is further complicated by the workflows and products each facility utilizes and/or has access to. With some process observations and a full risk assessment you can determine whether your high-level disinfection processes are adequate, or a patient/employee safety issue waiting to happen.
Brandon Huffman, BS, CRCST, CIS, is an infection preventionist and quality and improvement professional for the PeaceHealth Oregon Network.