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The Risks of ‘Casual Culture’ in Decontam

By: Lisa Wakeman

March 24, 2020

How do you clean a dirty instrument in a dirty room and make it safe enough to pass to the clean side for someone you know to touch with bare hands? No one wants to deliberately hurt another person; however, being casual in this space can have a serious impact on people that we work with and the patients who trust us with their lives.

Imagine the daily routine of brushing your teeth in the morning and the gritty feeling of plaque that has built up over the course of the night. Your tongue is coated with a white paste and the taste in your mouth is unpleasant. The plaque is biofilm from an intricate community of diverse microorganisms collected from the various food sources you enjoyed the day before. Even though you brushed your teeth before you went to sleep, some microbes still survived hiding within the grooves and crevices around and between your teeth and others nestled in just below your gum line. This small colony banded together within just a few hours and grew into an army. Meanwhile, endotoxins and exotoxins induced inflammation of the gums and started to breakdown the protective barrier of enamel on your teeth.

Most of us don’t set a timer for the recommended two minutes it takes to manually clean our teeth, then we rinse, swish, and spit before getting on with our day. Let me ask some other questions though. Would you casually let your toothbrush graze against the sidewalls of your bathroom sink? Would you set it down in the sink before putting it in its holder? How often is your sink scoured out and disinfected? When do you know it’s time to change your brush? At home we are comfortable and may only clean our bathroom sink once a week, knowing that countless times we are leaving residue to form long after flushing contaminants down the drain.

The risks are real

Pyrogens are fever-producing substances, and usually a by-product of a microbe. Endotoxins are produced as gram-negative bacteria die and pieces of their cell wall are expelled from the organism during lysis. Exotoxins are toxic substances that are secreted from bacteria from within the cell. In either instance, human exposure to these toxins send signals to our immune system to induce an inflammatory response. As you can see, even after the bacteria are killed, their waste products can still contaminate and cause damage. Depending on the amount and types of toxins present, coupled with the body’s ability to manage that dose determines if the response will accelerate and become septic. According to a peer-reviewed study published in Virulence, a microbiology medical journal,

Bacterial sepsis is a major cause of fatality worldwide. Sepsis is a multi-step process that involves an uncontrolled inflammatory response by the host cells that may result in multi organ failure and death. Both gram-negative and gram-positive bacteria play a major role in causing sepsis. These bacteria produce a range of virulence factors that enable them to escape the immune defenses and disseminate to remote organs, and toxins that interact with host cells via specific receptors on the cell surface and trigger a dysregulated immune response… These toxins include endotoxin or lipopolysaccharide (LPS) that is present in the outer membrane of the gram-negative bacterium and several other secreted exotoxins and enterotoxins in other bacteria (Ramachandran G, 2014).

Sterile Processing is a public service, and the instruments we handle represent a community of patents and their loved ones. If a device is not clean enough to touch with bare hands, then it is not safe enough to sterilize. We must be mindful of the state of our gloves and all touchpoints as we work in the Decontamination space being certain not to inadvertently re-contaminate something. According to the Centers for Disease Control and Prevention’s (CDC’s) Infection Control: Disinfection and Sterilization statement entitled, A Rational Approach to Disinfection and Sterilization- Guideline for Disinfection and Sterilization in Healthcare Facilities (2008), “Critical items confer a high risk for infection if they are contaminated with any microorganism. Thus, objects that enter sterile tissue or the vascular system must be sterile because any microbial contamination could transmit disease” In Sterile Processing bio-matter on thousands of instruments pass through our hands every day with seriously contagious pathogens. Considering the fact that surgical instruments require such a significant amount of detailed care to ensure that contamination does not transfer to patients, we must demonstrate commitment each moment to own the processes that we know are ethically right.

Universal precautions set minimal expectations for cleaning so that all medical devices are handled as contaminated and receive the same quality of decontamination treatment. According to The Joint Commission Environment of Care (EOC) Standards, the concept of an environment of care refers to the safety and effectiveness of a space for both patients and staff and the standards manual provides guidance on ways to promote reducing the risk of harm.

Doing our part

How we interact and behave within our environment impacts how safe and effective it is. Comparing Sterile Processing with other industries, one begins to wonder why we don’t see a greater emphasis on using more deliberate means of consistent deep cleaning in this space. How often is the Decontamination room decontaminated? Most facilities have work practices for general surface cleaning of the counters and sinks, but many other surfaces in this space are not routinely cleaned. Increasing technological advances are improving opportunities to disinfect the surgical suites with UV lights and other interventions; however, why not consider routine terminal disinfection in the Decontamination room as well? Even with negative air pressure in the Decontamination room, coupled with a conscious effort to brush under the surface of the water, there are still airborne microorganisms landing and multiplying on all surfaces of this space.

Over the years, I have had the opportunity to see many practices that have raised questions in my mind regarding risks of cross-contamination and this has opened up conversations that led to some positive changes. For example, there are still facilities that allow Environmental Services to ride their industrial floor buffers in and out of Decontamination while en route to other areas of the hospital. Not only is this equipment not designed to decontaminate the floor, it is not disinfected after going into the dirtiest area of the hospital. I have also seen facilities with shred boxes in Decontamination for patient sensitive OR schedules and surgeon preference cards. Companies that handle shreddable documents are not prepared to handle cross-contaminated paper. They make paper towels and other goods from the paper that is recycled by organizations. Many times, the workers on a route for these companies do not understand that the paper kept in decontamination spaces are contaminated. They handle the paper with their bare hands and are not instructed to wear PPE when entering these restricted spaces. I have guided other facilities in changing this practice because in every instance we learned that the company handling their recycled paper had no knowledge or capacity to transport or decontaminate it.

When people first enter this profession, they are more aware of the idea of being exposed to pathogenic organisms and tend to generally be more careful about how they interact with their environment. There is risk that technicians are desensitized to the hazards of their work environment over time, because assignments become routine. This feeling of being more at ease with tasks at work can lead to more casual day-to-day behaviors, just as we are with brushing our teeth at home. In our rush to keep up with caseload demand, worker safety is easily disregarded, and shortcuts adopted for the sake of pushing items through to the clean-side. Even though overly emphasized, so many technicians find themselves becoming comfortable with walking in and out of decontamination, leaning against or working with equipment without wearing appropriate personal protective equipment. We must remember that there is no such thing as a five-second rule and exposure to contamination is immediate. In addition, we can easily be carriers of disease without becoming sick ourselves, therefore, exposing others both at work and at home to pathogens.

As an educator and a leader, I spend a lot of time emphasizing the importance of establishing solid work practices with a designated flow from dirty to clean. We must continuously remind ourselves to really think through the process of each touchpoint in our practice of decontamination. In the same way that a surgical technologist is the guardian of the sterile field in the OR, we are the guardians of cross-contamination from dirty to clean.

The most fundamental truth ingrained in every aspect of Sterile Processing is to keep dirty, clean, and sterile areas separated at all times. Remaining situationally aware of how we behave and interact in the art and science of decontamination is the mission of our work. Moreover, seasoned technicians have a duty to lead by example. New-hires who see mixed messages from more experienced technicians are either discouraged or confused when observing practices where cross-contamination occur. According to the CDC, “Hand hygiene is considered a primary measure for reducing the risk of transmitting infection among patients and health care personnel.”

The following are some examples of casual behaviors that cause risk for cross-contamination:

  • Bringing cell phones into biohazard spaces (even when they are kept in a plastic sleeve)
  • Any task completed with bare hands: 1) Touching push plates to activate doors with bare hands in the decontamination room 2) Running into the decontamination room from the clean side without PPE in order to push the start button on a wall washer without gloves
  • Washing a dirty instrument at a Decontamination sink and then going over to open the pass-through window to talk to someone on the clean side.

Conclusion

Infection prevention is everyone’s responsibility and we must all grasp hold of the importance of being cognitively aware and mindful of this moral obligation in every task we perform. In a professional setting, we cannot allow ourselves to be so comfortable that we unknowingly are casual about the lives that each instrument represents. Likewise, being mindful of maintaining the cleanliness of our decontamination space is one of the most fundamental elements in determining how well we can designate a one-directional flow and eliminate cross-contamination.

Resources

Centers for Disease Control and Prevention. Infection control- disinfection and sterilization: a rational approach to disinfection and sterilization guideline for disinfection and sterilization in healthcare facilities (2008). https://www.cdc.gov/infectioncontrol/guidelines/disinfection/rational-approach.html

Centers for Disease Control and Prevention. Hand hygiene. https://www.cdc.gov/oralhealth/infectioncontrol/faqs/hand-hygiene.html

The Joint Commission. The 2020 comprehensive accreditation manual for hospitals. The Joint Commission Publications, 2020.

Ramachandran G. 2014. Gram-positive and gram-negative bacterial toxins in sepsis: a brief review. Virulence, 5(1), 213–218. doi:10.4161/viru.27024.

Lisa Wakeman, MBA, CRCST, CIS, CHL, MBTI is a Sterile Processing Education and Quality Coordinator for the Indianapolis suburban region of IU Health Network.