Chapter 4: Systems in Hospital

Learning Outcome

The main objective of this topic is to analyze:

•Different types, methods and principles of
sterilization and disinfection.
•A pragmatic approach to the judicious selection and
proper use of disinfection and sterilization processes
 DISINFECTION AND STERILIZATION
INTRODUCTION
•Disinfection and sterilization are essential for ensuring
that medical and surgical instruments do not transmit
infectious pathogens to patients..
•Each procedure involves contact by a medical devices
and surgical instruments with a patient’s sterile tissue
or mucous membranes.
•A major risk of all such procedures is the introduction
of pathogens that can lead to infection.
• Failure to properly disinfect or sterilize equipment
carries not only risk associated with breach of host
barriers but also risk for person-to-person
transmission (e.g., hepatitis B virus) and
transmission of environmental pathogens (e.g.,
Pseudomonas aeruginosa).
• Multiple studies in many countries have documented
lack of compliance for disinfection and sterilization.
 Definition Of Terms
DECONTAMINATION
•Any procedure that reduces pathogenic microbes to a
level where items are safe for handling & disposal.
•It can be achieved by cleaning, disinfection and
sterilization..
CLEANING
•A process that removes foreign material (dirt, organic
matter).
•Must precede disinfection and sterilization.
•Usually done with soap and water or detergent.
DISINFECTION
•Destruction of most but not necessarily all
pathogenic microbes or their spores.
STERILIZATION
•Killing of all living forms of microbes including
spores.
ANTISEPTICS
•Chemical compounds that could be applied typically
on animate surfaces.
DISINFECTANTS
•Chemical compounds applied for inanimate surfaces.
Importance of sterilization and disinfection:
•Safety in the laboratory.
•The patient safety depends on using proper methods
of sterilization to prepare instruments, needles, IV
fluids.
•The accuracy and validity of microbiological tests.
 What to Sterilize?
• It is mandatory to sterilize :
• All instruments that penetrate soft tissues and
bone.
• Instruments that are not intended to penetrate
the tissues, but that may come into contact with
oral tissues.
• If the sterilization procedure may damage the
instruments, then, sterilization can be replaced by
Disinfection procedure.
 DISINFECTION
• Destruction of most but not necessarily all
pathogenic microbes or their spores.
TYPES OF DISINFECTION
• Heat
• Radiation: (Ultraviolet rays)
• Chemical: (Disinfectants)
 Cont.
DISINFECTION BY HEAT
1.Moist heat at temperature below 100 degree.
Pasteurization
•Used for milk disinfection.
•Milk is heated either at 63 degree for 30 minutes or
72 degree for 20 seconds and immediately cooled to
below 10 degree.
 Cont.
2. Moist heat at temperature 100 degree:
Boiling
•Heating at 100 degree for 20 minutes.
•Used for disinfection of surgical and medical
equipments in emergency.
 Cont.
Steaming
•Heating at 100 degree for 30 - 60 minutes.
•Done in Koch’s steamer.
•This sterilizer is vertical metal cylinder with removable
conical lid having a small opening for escaping steam.
•The articles to be sterilized are placed on a perforated
tray situated above water which is placed in the bottom
of the cylinder
 Cont.
Tyndallization
•Intermittent sterilization by exposure to steam at 100
degree for 20-45 min. for three successive days.
•Used for sterilization of nutrient media & media
containing sugar & gelatin which decompose at high
temperatures.
•The principle is that one exposure will kill only
vegetative bacteria. In the coming two days the spores
will vegetate to be killed during subsequent exposure.
 Cont.
Disinfection by radiation
Ultraviolet rays
• Present in sun rays or artificially produced by
mercury lamp have weak penetrating power.
•Used to reduce the number of bacteria in air inside
operation rooms, laboratory safety cabinet.
Disinfection by chemical disinfectants(Ass.1)
Disinfectants may be:
•High level disinfectants.
•Intermediate level disinfectants.
•Low level disinfectants
 Level Disinfection
• High level disinfection
– large number of spores after prolonged exposure
– Vegetative bacteria
– Tubercle bacilli
– Fungi
– Viruses
• Intermediate level disinfection
– Few number of spores
– Vegetative bacteria
– Tubercle bacilli
– Fungi
– Enveloped viruses (HBV, HIV)
 Cont.
• Low level disinfection
• Mainly vegetative bacteria
• Some fungi
• Narrow range of viruses
 STERILIZATION
3 different sterilization principles:
1. Heat sterilization
2. Chemical sterilization
3. Radiation sterilization
Heat
•It is the simplest, most effective and inexpensive
method
1. Dry heat (Red heat, hot air oven, incineration)
2. Moist heat at temperature above 100 degree
(Autoclave)
 Cont.
Moist heat sterilization (Autoclaving)
1. Principle:
– When water is heated in a closed vessel under
pressure, the boiling point of water rises above
100 degree.
– Water is heated at 2 atmospheric pressure and
the boiling temperature will be 121 degree or at 3
atmospheric pressure and the boiling temperature
will be 134 degree.
 Cont.
Its process is divided in three periods.
•Pre-vacuum period: air is withdrawn from device.
•Sterilizing period: steam is introduced under
pressure to specific temperatures & times.
•Post-vacuum: steam is withdrawn to dry autoclave.
 Cont.
2. Autoclaving is highly efficient because:
– High temperature.
– High penetrating power of the steam under
pressure.
– When steam condenses on the articles, it release
latent heat to the articles to be sterilized.
– Non toxic.
– Not time consuming.
– Maintains integrity of liquids (e.g. Lubricants) due
to the 100% humidity within the chamber.
 Cont.
Disadvantages:
•Non stainless steel metal items corrode.
•May damage plastic and rubber items
•Sharp instruments get dulled.
Temperature (oC) Time (Minutes)

132 - 134 3 -4

121 8 – 30

115 35 – 45

111 80 - 180
 Cont.
CHEMICAL STERILIZATION
•Generally, chemical sterilization procedures have the
disadvantages of presenting health hazards to users
(e.g. poisonous, flammable, )
•The chemical compounds used can be:
a)Gas Sterilization
b) Liquid Sterilization
1.Gas Sterilization
 Ethylene Oxide (EtO)
• Ethylene oxide (EtO) is a chemical agent that kills
microorganisms, including spores.
• EtO gas must have direct contact with
microorganisms on the items to be sterilized.
• Due to EtO being highly flammable and explosive in
air, it must be used in an explosion-proof sterilizing
chamber in a controlled environment.
• it is an effective, low temperature chemical
sterilization method.
• It also takes longer than steam sterilization,
typically, 16-18 hours for a complete cycle.
 Cont.
• Temperatures reached during sterilization are usually in
the 50-60°C range.
• Items sterilized by this process must be packaged with
wraps and be aerated. The aeration time may be long
and is needed to make sterilized items safe for handling
and patient use.
• EtO gas is a reliable and safe agent for sterilization when
handled properly.
• Note: There are also gas sterilizers available that use a
mixture of EtO with carbon dioxide or chlorofluorocarbon
(CFC) to represent it as nonflammable for use in
healthcare facilities. In addition to safety concerns, this
type of sterilization process requires an even longer
aeration process compared to pure EtO sterilization.
 Cont.
Procedure:
•Keep objects in constant atmospheric humidity.
•Heat to temperatures between 30º and 60º C.
• maintain for a period of 10 - 18 hrs.
•Residual ethylene oxide must be ventilated
 Cont.
Disadvantages:
•Ethylene oxide autoclaves have the following
disadvantages:
– it can leave toxic residues on sterilized items
and it possesses several physical and health
hazards to personnel and patients that merit
special attention.
– Unsuitable for hospitals but used in industry (e.g.
for sterilizing disposable materials that can not
tolerate high temperatures).
 Cont.
Formalin gas autoclaves have been developed for
sterilizing endoscopes and anesthetic apparatus.
Plasma gas sterilizer
•Plasma means any gas which is formed of ions,
electrons, neutral particles.
•Used for surgical instruments mainly those with
narrow lumen such as arthroscopies & laparoscopes.
•Non toxic
 Cont.
b) Liquid Sterilization
•Can be performed with buffered glutaric aldehyde.
•frequently used on surgical cameras (endoscopes).
Procedure:
•The item must be thoroughly cleaned and dried before
immersion.
•Immerse the object in liquid for several hours.
•Rinse with sterile water after end of procedure.
 Cont.
3. Radiation Sterilization
•Provides effective way of sterilization when used in
high doses.
Ionizing radiation:
•Such as gamma rays emitted from radioactive cobalt
60 or beta rays emitted from electron accelerators.
•High penetrating power.
•Used for plastic syringes, catheters, gloves, surgical
sutures.
 Cont.
• Irradiation is an effective sterilization method, but it
is limited to commercial use only.
• The product to be sterilized is exposed to radiation
for 10 to 20 hours, depending on the strength of the
source.
• Ionizing radiation: produces ions by knocking
electrons out of atoms.
• These electrons are knocked out violently, and strike
an adjacent atom and either attach themselves to it,
or dislodge an electron from the second atom.
 Cont.
• The result is ionic energy that becomes converted to
thermal and chemical energy. This energy kills
microorganisms by disruption of the DNA molecule,
therefore preventing cellular division and
propagation of biologic life.
• The principal sources of ionizing radiation are beta
particles and gamma rays.
• Beta particles, free electrons, are transmitted
through a high-voltage electron beam from a linear
accelerator.
 Cont.
• These high-energy free electrons will penetrate into
matter before being stopped by collisions with other
atoms.
• This means their usefulness in sterilizing an object is
limited by the density, thickness of the object and by
the energy of the electrons.
• These free electrons produce their effect by ionizing
the atoms they hit, producing secondary electrons
that kill microorganisms
 Cont.
• Gamma rays: are electromagnetic waves that have
the ability to penetrate a much greater distance than
beta rays before losing their energy from collision.
• Because they travel with the speed of light, they
must pass through a thickness measuring several
feet before making sufficient collisions to lose all of
their energy.
• Cobalt 60 is a radioactive isotope capable of breaking
down to produce gamma rays.
• Cobalt 60 is the most commonly used source for
irradiation sterilization.
 Cont.
Advantages and Disadvantages
Advantages:
•Clean process
•Dry process
•Ensures full exposure of object from all directions
Disadvantages:
•Posses threat to humans (radiation)
•Lengthy process
•Requires very qualified personnel
 Category Items in each category Procedure

Items that: (1) enter the

Critical tissue; (2) Enter vascular Sterilization
system; (3) through which
blood flows.

Items that: (1) touch

Semi-critical mucous membranes; (2)
touch non-intact skin (e.g. High level
endoscopes, respiratory disinfection
therapy equipment, and
diaphragms)

Items such as bedpans,

Non-critical blood pressure cuffs, and Low level
bedside tables disinfection

Which procedure to use?

 Cont.
Instrument Packing
•Often instruments are packed for sterilization to be
stored and handled without being contaminated.
•Packing depend on the intended shelf life after
sterilization.
•The available packing options are:
• Textile has shelf life of 1 month
• Paper has shelf life of 1 – 6 months
• Nylon, glass, and metal have shelf life of 1 year
if tightly closed.
 Conclusion
• Sterilization and disinfection are costly and time
consuming process.
• However, it is an essential in all health care facilities
to avoid spread of diseases.
• It depends on the ethics of the instrument users.
• Users should keep in mind that contaminated
instrument present risk to patient as well as the user
himself.