Standards for cleaning and processing anesthesia equipment The following standards were developed by the Technical Standards Committee of the Association of Operating Room Nurses, Inc (AORN). They have been reviewed by a panel of anesthesiologists and approved by the AORN Board of Directors. Purpose. It is believed that most respiratory illnesses stem from the viral spectrum, which we are seldom able to isolate and identify with common laboratory studies. All patients, therefore, must be considered potentially infective whether or not they are symptomatic. When a patient is being anesthetized or ventilated, the risk of cross infection should be minimized by preventive measures and the use of suitable anesthetic breathing circuits. It has been proven that anesthesia apparatus can act as a vehicle of infection; therefore, this equipment should be properly and regularly cleaned and sterilized. Such apparatus should not be used without taking steps to remove known or potential pathogens. There is a need for written procedures for the processing of anesthetic apparatus to insure uniformity. These procedures should be formulated jointly by the anesthesia and operating room nursing staffs.
Standard 1. The entire anesthesia equlpment system must be terminally decontamlnated, cleaned, and sterlllzed after each use If reusable components are employed or discarded If slnglause components are used. Criteria 1. Endotracheal tubes, stylettes, masks, breathing tubes, bags, connectors, airways, forceps, laryngoscope blades, and head straps should be terminally sterilized between each patient use, or sterile single-use items should be used and discarded. 2. Suction catheters should always be sterile single-use items because of difficulty in cleaning. 3. A sterile, single-use absorber and valve system is recommended. If reusables are employed, terminal ethylene oxide sterilization is necessary, thus requiring an adequate supply of absorbers. 4. When bacterial filters are used, they should be placed as near the patient as possible in the respiratory circuit to reduce contamination of equipment. Such filters form another defensive barrier against the invasion of some
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pathogenic microorganisms. Bacterial filters, at best, can only reduce the number of larger organisms. 5. Anesthesia ventilators are only an extension of the bag in the anesthetic circuit and can become contaminated very rapidly. It is recommended that equipment be used that permits removal of all contaminated parts for terminal steam sterilization. 6. Self-inflating breathing bags, such as the Ambum, should be disassembled, cleaned, and ethylene oxide sterilized between each patient use. 7. As a minimum, each item sterilized or decontaminated should be properly labeled as to contents and date of treatment. The method of labeling each package should be standardized, and it should be done in a manner that does not violate the sterility of the package.
Standard 11. The exterlor surfaces of equipment that does not come into direct contact with the respiratory circuit must also be routinely decontaminated. Criteria 1. The exterior surfaces of anesthesia machines, instruments
attached to and kept on them, storage drawers, and equipment carts should be thoroughly cleaned with a d e tergent germicide at least once every 24 hours. 2. Blood pressure cuffs and tubing should be cleaned with a germicidal solution after each use. They may be left on the patient going to the postanesthesia recovery room and cleaned after the patient leaves that unit. 3. Suction bottles should be decontaminated, cleaned, and steam sterilized between patient uses if reusable. Clean singleuse containers may be used. 4. Suction tubing should be a singleuse item because of the difficulty in cleaning.
Standard ill. The processing of anesthesia and/or respiratory therapy equipment in the postanesthesia recovery room should be accompllshed in the same manner as in the operating room. Standard IV. Hand washing between contacts with patients should be done by all persons who are involved in patient care using an effective antimicrobial agent to reduce the bacterial count on the hands and thus lessen the risk of cross infection. Standard V. it is lmperatlve that the cleaning and sterilizing of anesthesia equipment be delegated to conscientious, weiltrained Individuals who understand the principles of containment of contamination and the sterillzatlon process. Guidelines These guidelines represent additional general information to be used when implementing the above standards. 1. Nonheat-stable items should be terminally sterilized by ethylene oxide (EO).
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a. EO sterilization and areation of items should only be done following appropriate cleaning, rinsing, and drying. Use an automated and programmed EO sterilization process and follow the sterilizer manufacturer’s recommendations for EO sterilizer loading. 1) Personnel handling contaminated items should wear gloves. 2) Disassemble all items. 3) Rinse all items well with tap water to remove debris. The use of cold water will prevent coagulation of protein material (ie, blood, sputum, vomitus). 4) Wash items in low-sudsing detergent, using a brush to remove contaminating materials. Keep the brush below the surface of the water to prevent the formation of aerosols. 5) Rinse items several times in clean, warm tap water. 6) Use a filtered, compressed air drying cabinet for drying the interior of bags and tubing in preference to hanging items up to air dry. Absolute dryness is not necessary, but no visible water droplets should remain. 7) Place items in packaging material known to be easily penetrated by EO (ie, not nylon or polyvinylchloride, which delays elution). 8) The pressure inside and outside the cushion or closed space on face masks should be equalized by removing the pin closure. 9) Rubber items should be packaged separately from metal and sterilized according to sterilizer manufacturer’s instructions. 10) The circle absorber, dome valves, and gauge should be sterilized according to sterilizer manufacturer’s instructions after cleaning, rinsing and drying, and appropriate packaging. The dome valves and gauge should be removed from the canister to avoid gas entrapment. Soda lime cannot be EO sterilized since it combines chemically with the ethylene oxide and its capacity for carbon dioxide absorption is changed. Soda lime should always be discarded. 11) a) After EO sterilization, items should be aerated in a heated aerator whenever possible in accord with the manufacturer’s instructions. If aeration is at room temperature, items should be placed in a room away from personnel and other supplies and kept for seven days if plastic, five days if rubber. b) Steam sterilization may be used on some of these items, but life of items may be shortened. 2. Heat-stable parts should be terminally sterilized by steam under pressure.
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a. laryngoscope blades, metal connectors, stylettes, and forceps can be steam sterilized following cleaning and rinsing. (See guidelines 1 a. 1) through 5).) b. Packaging material that allows adequate penetration of steam should be used. 3. The construction and design of most present-day anesthesia ventilating equipment make it difficult to clean between patient use. There is a need for redesign of such equipment to allow easier cleaning and sterilization. a. If using the “difficult to clean” models, the ventilator should be cleaned thoroughly at least daily according to the manufacturer’s instructions. b. A method of filtering gas entering the circuit and using presterilized detachable or disposable circuits would be ideal and should be used as suitable apparatus becomes available. 4. Cloth and Velcro%’ blood pressure cuffs can be washed in a washing machine and EO sterilized. If EO sterilization is used, aerate item as recommended by the sterilizer manufacturer. 5. If pasteurization is to be used, remember that pasteurization only kills certain types of microbial life and reduces the viable population of others. The heat applied does not produce sterility. Even if sanitizing were recommended,the wet equipment from pasteurization would be messy to store and susceptible to finger and towel contamination if dried by hand. Pasteurization, therefore, should never be used without a mechanism for drying. 6. A solution of 2% activated glutaraldehyde may be used to immerse some nonheat-stable items after appropriate cleaning, rinsing, and drying. It must be remembered that ten hours of exposure is necessary to produce sterility using the alkaline 2% solution. a. Careful rinsing must be carried out to avoid toxic residuals. b. A mechanism for drying should be employed to avoid finger and towel contamination of the wet items. Rationale 1. It has been clearly demonstrated in both the operating room and in the laboratory that all parts of the anesthesia breathing circuit may become contaminated during use.’ 2. While institutional practices may differ as to what department is responsible for cleaning anesthesia-related equipment, there is clearly a shared accountability on the part of the hospital and the anesthesia staff for ascertaining that As the safe methods and equipment are being direct agents of the employing hospital, nurses working in the OR should participate in determining appropriate infection control procedures for this equipment. 3. In one study, a retrospective evaluation of 220 patient charts revealed that the incidence of postoperative pulmonary infection dropped from 23% before adequate cleanup 1’
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to 6% after effective cleaning of the total circuit and use of a disposable absorber.' 4. Considering the protective physiology of the upper airway and the changes created by the anesthetic agents and procedures, it is mandatory that bacteria or viruses not be introduced into the inhalation system of the patient.' 5. The alkalinity of the soda lime is not a dependable bacteriocidal agent or an effective mechanical filter. Bacteria from healthy patients have been found to contaminate the valves of the anesthesia circle absorber at an average rate of 35 microorganisms per minute.' 6. A study by Jet Propulsion Laboratories supported by the federal government concluded that none of the current commercial air filters performed satisfactorily in all aspects studied.' Other studies have shown inconsistent filtration capacities of bacteriophages and Serratia in any given make of filter. 7. Any apparatus that harbors microorganisms, some of which are pathogenic, is a hazard in the operating room. Apart from the danger of respiratory cross infection, which is the only one considered by most authors, there is the danger of airborne wound contamination and contact transmission from personnel handling the apparatus.' 8. Experiments supposedly showing that patients do not infect breathing circuits are not entirely convincing in the light of laboratory evidence that aerosols of microorganisms are able to traverse 3-fOOt lengths of corrugated tubing and soda lime canisters and that the interiors of breathing circuits become contaminated when volunteers cough or sneeze into them.s16 9. There is much recent evidence of cross infection from machines used for resuscitation and inhalation therapy. These are similar to anesthesia ventilators.' 10. The work of Snow and colleagues shows that it is possible to provide all apparatus sterile for each case.' 11. There is much evidence that microorganisms such as Pseudomonas aeruginosa and fungi are playing an increasing part in hospital infections. Such microorganisms are frequently found in anesthetic apparatus.' If Pseudomonas and fungi are found on cultures of anesthesia apparatus, it is a signal to review the entire system and apply corrective measures. 12. Many authors have reported a plethora of microorganisms cultured from many parts of the anesthesia equipment. Dryden states that MacCallum has shown that many microorganisms can survive for long periods in the dark, moist recesses of the equipment.8 13. Any microorganism can cause hospital-acquired infection; there is no such thing as a nonpathogenic o r g a n i ~ m . ~ ~ ~ 14. Droplets of water remaining in the corrugations of widebore tubing can harbor and allow proliferation of microorganisms, which thus may be transmitted to another patient . O
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15. Concern centers now on the common Gram-negative microorganisms for which man acts as host. These can act as secondary invaders in an already weakened individual.* 16. Humid environments existing in anesthesia equipment provide potential habitats for Gram-negative microorganisms.” 17. In cases where the diagnosis is not known until after an operative procedure when pathologic sections are available, subsequent patients will be protected against cross contamination if the anesthesia circuit has been properly cleaned and sterilized. 18. Singleuse or disposable items should not be reused because: a. They may lose their elasticity and malfunction if processed for reuse. b. The practice of reusing disposable medical devices introduces potentially serious risks to the patient or to the medical procedures because the design does not normally include consideration for reuse. Economic considerations cannot justify acceptance of these risks. c. Product design and material components are selected to meet test requirements after sterilization by the manufacturer, not on the basis of recycling at the user Ie~e1.’*1’~ d. Liability reverts to the user of the item if he reprocesses and reuses a single-use item.” e. Hospital personnel usually are not sufficiently aware of the specific details required to manufacture, package, and sterilize the disposable medical devices.13 f. EO-sterilizeddisposable medical devices should not be resterilized unless desorption data is available to allow such practice or such data can be documented from the medical device manufacturers.e 19. Limited-use devices can be cleaned, packaged, and resterilized if careful analysis indicates sizable cost savings with no reduction in safety or efficacy. The manufacturer must make available the type of plastic from which the item is fabricated and must help develop a sterilization cycle with a probability of or less of a survivor and sufficient time for elution of EO r e s i d u e ~ . ’ ~ * ’ ~ Notea 1. Willard H Albrecht, Gale E Dryden, “Fiveyear experience with the development of an indi-
vidually clean anesthesia system,” Anesthesia and Analgesia 53 (January-February 1974) 24-28. 2. Glenn M Shiotani, “Prevention of contamination of the circle system and ventilators with a new disposable filter,” Anesthesia and Analgesia 50 (September-October 1971) 844-855. 3. “Guidelines to the ethical practice of anesthesiology,’’ American Society of Anesthesiology (Oct 11, 1973).
4. Gale E Dryden, “Uncleaned anesthesia equipment,” Journal of the American Medical Association 233 (Sept 22, 1975) 1297-1298. 5. Edward T Thomas, “The sterilization dilemma: Where will it end?” Anesthesia and Analgesia 47 (November-December 1968) 659662. 6. “Revised guidelines for EO sterilization,” AORN Journal 24 (December 1976) 1086-1088. 7. “The sterilization of anesthesia equipment by ethylene oxide,” Sterilization Systems, Medical Products Division, St Paul, 3-M Co 3-M Center.
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8. Gale E Dryden, “Risk of contamination from the anesthesia circle absorber: An evaluation,” Anesthesia and Analgesia 48 (November-December 1969) 939-943. 9. R B Roberts, ed. “Infections and sterilization problems” in lnternational Anesthesiology Clinics, vol 10 (Boston: Little, Brown & Co, 1972). c 10. C Snow, el al, “Sterilization of anesthesia equipment with ethylene oxide,” The New England Journal of Medicine 266 (March 1, 1962) 443-445. 11. V Knight, “Instruments and infection,” Hospital Practice 2 (September 1967) 89-99. 12. Association for the Advancement of Medical Instrumentation Sterilization Standards Subcommittee Policy Statement on Reprocessing of Disposable Medical Devices by Users, unpublished. 13. “Ban the bug,” Great Plains Society for Hospital Central Service Personnel 3 (March 1977) 3. 14. Carl K Bruch, “Safety aspects of resterilization of single-use disposable devices by hospitals,” Respiratory Care 18 (May 1974) 354-360.
Suggested reedings Altemeier, William A, et al, eds. Manual on Control of lnfection in Surgical Patients. Philadelphia: J B Lippincott, 1976. Engley, Frank 6, Jr. “Disinfection is not sterilization.” Hospital lnfection Control, lnc 2 (April 1975). Errera, Dorothy W. “Selected OR bibliography.” Hospital Topics 52 (July-August 1974) 69-70. Gross, F L. “Decontamination of anesthesia apparatus.” Anesthesiology 16 (1955) 902. Jenkins, J R E, Edgar, W M. ”Sterilization of anesthesia equipment.” Anesthesia 19 (April 1964) 177-190. Joseph, J M, Shay, D E. “Disease transmission by inefficiently sanitized anesthesia apparatus.” Journal of the American Medical Association 149 (July 26, 1952) 1196-1198. Lowbury, E J L, el al. “Aseptic methods in the operating suite.” Lancet 1 (April 13, 1968) 763768. McWilliams, Rose Marie, et al, eds. Every OR Supervisor Should Know. Denver: Association of Operating Room Nurses, 1974, 432-436. Meeks, Charles H, et al. “Sterilization of anesthesia apparatus.” Journal of the American Medical Association 199 (Jan 23, 1967) 276-278. Roberts, R 6. “The eradication of cross infection from anesthetic equipment.” Anesthesia and Analgesia 49 (January-February1970) 63. Roberts, R 6. ”Cleaning the laryngoscope blade.” Canadian Anaesthetists’ Society Journal 20 (March 1973) 241-244. Roberts, R 6. “Gamma-rays + PVC + EO = OK.” Respiratory Care 21 (March 1976) 223-224. Sabo, Betsy. “Sterilization of anesthesia ap-
1274
paratus.” Journal of the American Association of Nurse Anesthetists 41 (October 1973) 421-426. Sandusky, W R. “Pseudomonas infections: Sources and cultured data in a general hospital with reference to surgical infection.” Annals of Surgery 153 (June 1961) 996-1002. Snow, J C, Anderson, M D. “How the anesthesiologist can lessen infection.” Modern Hospital 105 (October 1965) 128+. Stratford, B C, et al. “The disinfection of anesthetic apparatus.” British Journal of Anaesthesia 36 (August 1964) 471-476. Walter, Carl W. “Multiple factors to consider in hospital infection control.” Hospital Topics 48 (October 1970) 65-69. Wisler, M G. “Guidelines for use of ethylene oxide.” AORN Journal 19 (June 1974) 12861295.
Hospitals must give community service Hospitals and other health care facilities constructed or remodeled with federal funds under the Hill-Burtonprogram must now give assurances that “community service” will be rendered indefinitely, the US Department of Health, Education, and Welfare (HEW) has announced. Previously these institutions were required to give such assurances for 20 years after construction was completed or during the period in which a direct loan or loan guarantee and interest subsidy remained unpaid. The community service assurance obligates Hill-Burton facilities to make their services available to the general public, allowing them to limit the availability of services only because of age, medical indigency, or the type of condition affecting the patient. Facilities must also provide required services to patients eligible for benefits under Medicare and Medicaid programs or other state and local programs without discrimination because of source of payment. The Hill-Burton program is being phased out and replaced by the Health Facilities Construction Program, authorized by the 1974 National Health Planning and Resources Development Act (PL 93-641).
AORN Journal, June 1977, V o l 2 5 , No 7
Standard 1. The entire anesthesia equlpment system must be terminally decontamlnated, cleaned, and sterlllzed after each use If reusable components are employed or discarded If slnglause components are used. Criteria 1. Endotracheal tubes, stylettes, masks, breathing tubes, bags, connectors, airways, forceps, laryngoscope blades, and head straps should be terminally sterilized between each patient use, or sterile single-use items should be used and discarded. 2. Suction catheters should always be sterile single-use items because of difficulty in cleaning. 3. A sterile, single-use absorber and valve system is recommended. If reusables are employed, terminal ethylene oxide sterilization is necessary, thus requiring an adequate supply of absorbers. 4. When bacterial filters are used, they should be placed as near the patient as possible in the respiratory circuit to reduce contamination of equipment. Such filters form another defensive barrier against the invasion of some
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pathogenic microorganisms. Bacterial filters, at best, can only reduce the number of larger organisms. 5. Anesthesia ventilators are only an extension of the bag in the anesthetic circuit and can become contaminated very rapidly. It is recommended that equipment be used that permits removal of all contaminated parts for terminal steam sterilization. 6. Self-inflating breathing bags, such as the Ambum, should be disassembled, cleaned, and ethylene oxide sterilized between each patient use. 7. As a minimum, each item sterilized or decontaminated should be properly labeled as to contents and date of treatment. The method of labeling each package should be standardized, and it should be done in a manner that does not violate the sterility of the package.
Standard 11. The exterlor surfaces of equipment that does not come into direct contact with the respiratory circuit must also be routinely decontaminated. Criteria 1. The exterior surfaces of anesthesia machines, instruments
attached to and kept on them, storage drawers, and equipment carts should be thoroughly cleaned with a d e tergent germicide at least once every 24 hours. 2. Blood pressure cuffs and tubing should be cleaned with a germicidal solution after each use. They may be left on the patient going to the postanesthesia recovery room and cleaned after the patient leaves that unit. 3. Suction bottles should be decontaminated, cleaned, and steam sterilized between patient uses if reusable. Clean singleuse containers may be used. 4. Suction tubing should be a singleuse item because of the difficulty in cleaning.
Standard ill. The processing of anesthesia and/or respiratory therapy equipment in the postanesthesia recovery room should be accompllshed in the same manner as in the operating room. Standard IV. Hand washing between contacts with patients should be done by all persons who are involved in patient care using an effective antimicrobial agent to reduce the bacterial count on the hands and thus lessen the risk of cross infection. Standard V. it is lmperatlve that the cleaning and sterilizing of anesthesia equipment be delegated to conscientious, weiltrained Individuals who understand the principles of containment of contamination and the sterillzatlon process. Guidelines These guidelines represent additional general information to be used when implementing the above standards. 1. Nonheat-stable items should be terminally sterilized by ethylene oxide (EO).
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I
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a. EO sterilization and areation of items should only be done following appropriate cleaning, rinsing, and drying. Use an automated and programmed EO sterilization process and follow the sterilizer manufacturer’s recommendations for EO sterilizer loading. 1) Personnel handling contaminated items should wear gloves. 2) Disassemble all items. 3) Rinse all items well with tap water to remove debris. The use of cold water will prevent coagulation of protein material (ie, blood, sputum, vomitus). 4) Wash items in low-sudsing detergent, using a brush to remove contaminating materials. Keep the brush below the surface of the water to prevent the formation of aerosols. 5) Rinse items several times in clean, warm tap water. 6) Use a filtered, compressed air drying cabinet for drying the interior of bags and tubing in preference to hanging items up to air dry. Absolute dryness is not necessary, but no visible water droplets should remain. 7) Place items in packaging material known to be easily penetrated by EO (ie, not nylon or polyvinylchloride, which delays elution). 8) The pressure inside and outside the cushion or closed space on face masks should be equalized by removing the pin closure. 9) Rubber items should be packaged separately from metal and sterilized according to sterilizer manufacturer’s instructions. 10) The circle absorber, dome valves, and gauge should be sterilized according to sterilizer manufacturer’s instructions after cleaning, rinsing and drying, and appropriate packaging. The dome valves and gauge should be removed from the canister to avoid gas entrapment. Soda lime cannot be EO sterilized since it combines chemically with the ethylene oxide and its capacity for carbon dioxide absorption is changed. Soda lime should always be discarded. 11) a) After EO sterilization, items should be aerated in a heated aerator whenever possible in accord with the manufacturer’s instructions. If aeration is at room temperature, items should be placed in a room away from personnel and other supplies and kept for seven days if plastic, five days if rubber. b) Steam sterilization may be used on some of these items, but life of items may be shortened. 2. Heat-stable parts should be terminally sterilized by steam under pressure.
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a. laryngoscope blades, metal connectors, stylettes, and forceps can be steam sterilized following cleaning and rinsing. (See guidelines 1 a. 1) through 5).) b. Packaging material that allows adequate penetration of steam should be used. 3. The construction and design of most present-day anesthesia ventilating equipment make it difficult to clean between patient use. There is a need for redesign of such equipment to allow easier cleaning and sterilization. a. If using the “difficult to clean” models, the ventilator should be cleaned thoroughly at least daily according to the manufacturer’s instructions. b. A method of filtering gas entering the circuit and using presterilized detachable or disposable circuits would be ideal and should be used as suitable apparatus becomes available. 4. Cloth and Velcro%’ blood pressure cuffs can be washed in a washing machine and EO sterilized. If EO sterilization is used, aerate item as recommended by the sterilizer manufacturer. 5. If pasteurization is to be used, remember that pasteurization only kills certain types of microbial life and reduces the viable population of others. The heat applied does not produce sterility. Even if sanitizing were recommended,the wet equipment from pasteurization would be messy to store and susceptible to finger and towel contamination if dried by hand. Pasteurization, therefore, should never be used without a mechanism for drying. 6. A solution of 2% activated glutaraldehyde may be used to immerse some nonheat-stable items after appropriate cleaning, rinsing, and drying. It must be remembered that ten hours of exposure is necessary to produce sterility using the alkaline 2% solution. a. Careful rinsing must be carried out to avoid toxic residuals. b. A mechanism for drying should be employed to avoid finger and towel contamination of the wet items. Rationale 1. It has been clearly demonstrated in both the operating room and in the laboratory that all parts of the anesthesia breathing circuit may become contaminated during use.’ 2. While institutional practices may differ as to what department is responsible for cleaning anesthesia-related equipment, there is clearly a shared accountability on the part of the hospital and the anesthesia staff for ascertaining that As the safe methods and equipment are being direct agents of the employing hospital, nurses working in the OR should participate in determining appropriate infection control procedures for this equipment. 3. In one study, a retrospective evaluation of 220 patient charts revealed that the incidence of postoperative pulmonary infection dropped from 23% before adequate cleanup 1’
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to 6% after effective cleaning of the total circuit and use of a disposable absorber.' 4. Considering the protective physiology of the upper airway and the changes created by the anesthetic agents and procedures, it is mandatory that bacteria or viruses not be introduced into the inhalation system of the patient.' 5. The alkalinity of the soda lime is not a dependable bacteriocidal agent or an effective mechanical filter. Bacteria from healthy patients have been found to contaminate the valves of the anesthesia circle absorber at an average rate of 35 microorganisms per minute.' 6. A study by Jet Propulsion Laboratories supported by the federal government concluded that none of the current commercial air filters performed satisfactorily in all aspects studied.' Other studies have shown inconsistent filtration capacities of bacteriophages and Serratia in any given make of filter. 7. Any apparatus that harbors microorganisms, some of which are pathogenic, is a hazard in the operating room. Apart from the danger of respiratory cross infection, which is the only one considered by most authors, there is the danger of airborne wound contamination and contact transmission from personnel handling the apparatus.' 8. Experiments supposedly showing that patients do not infect breathing circuits are not entirely convincing in the light of laboratory evidence that aerosols of microorganisms are able to traverse 3-fOOt lengths of corrugated tubing and soda lime canisters and that the interiors of breathing circuits become contaminated when volunteers cough or sneeze into them.s16 9. There is much recent evidence of cross infection from machines used for resuscitation and inhalation therapy. These are similar to anesthesia ventilators.' 10. The work of Snow and colleagues shows that it is possible to provide all apparatus sterile for each case.' 11. There is much evidence that microorganisms such as Pseudomonas aeruginosa and fungi are playing an increasing part in hospital infections. Such microorganisms are frequently found in anesthetic apparatus.' If Pseudomonas and fungi are found on cultures of anesthesia apparatus, it is a signal to review the entire system and apply corrective measures. 12. Many authors have reported a plethora of microorganisms cultured from many parts of the anesthesia equipment. Dryden states that MacCallum has shown that many microorganisms can survive for long periods in the dark, moist recesses of the equipment.8 13. Any microorganism can cause hospital-acquired infection; there is no such thing as a nonpathogenic o r g a n i ~ m . ~ ~ ~ 14. Droplets of water remaining in the corrugations of widebore tubing can harbor and allow proliferation of microorganisms, which thus may be transmitted to another patient . O
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15. Concern centers now on the common Gram-negative microorganisms for which man acts as host. These can act as secondary invaders in an already weakened individual.* 16. Humid environments existing in anesthesia equipment provide potential habitats for Gram-negative microorganisms.” 17. In cases where the diagnosis is not known until after an operative procedure when pathologic sections are available, subsequent patients will be protected against cross contamination if the anesthesia circuit has been properly cleaned and sterilized. 18. Singleuse or disposable items should not be reused because: a. They may lose their elasticity and malfunction if processed for reuse. b. The practice of reusing disposable medical devices introduces potentially serious risks to the patient or to the medical procedures because the design does not normally include consideration for reuse. Economic considerations cannot justify acceptance of these risks. c. Product design and material components are selected to meet test requirements after sterilization by the manufacturer, not on the basis of recycling at the user Ie~e1.’*1’~ d. Liability reverts to the user of the item if he reprocesses and reuses a single-use item.” e. Hospital personnel usually are not sufficiently aware of the specific details required to manufacture, package, and sterilize the disposable medical devices.13 f. EO-sterilizeddisposable medical devices should not be resterilized unless desorption data is available to allow such practice or such data can be documented from the medical device manufacturers.e 19. Limited-use devices can be cleaned, packaged, and resterilized if careful analysis indicates sizable cost savings with no reduction in safety or efficacy. The manufacturer must make available the type of plastic from which the item is fabricated and must help develop a sterilization cycle with a probability of or less of a survivor and sufficient time for elution of EO r e s i d u e ~ . ’ ~ * ’ ~ Notea 1. Willard H Albrecht, Gale E Dryden, “Fiveyear experience with the development of an indi-
vidually clean anesthesia system,” Anesthesia and Analgesia 53 (January-February 1974) 24-28. 2. Glenn M Shiotani, “Prevention of contamination of the circle system and ventilators with a new disposable filter,” Anesthesia and Analgesia 50 (September-October 1971) 844-855. 3. “Guidelines to the ethical practice of anesthesiology,’’ American Society of Anesthesiology (Oct 11, 1973).
4. Gale E Dryden, “Uncleaned anesthesia equipment,” Journal of the American Medical Association 233 (Sept 22, 1975) 1297-1298. 5. Edward T Thomas, “The sterilization dilemma: Where will it end?” Anesthesia and Analgesia 47 (November-December 1968) 659662. 6. “Revised guidelines for EO sterilization,” AORN Journal 24 (December 1976) 1086-1088. 7. “The sterilization of anesthesia equipment by ethylene oxide,” Sterilization Systems, Medical Products Division, St Paul, 3-M Co 3-M Center.
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8. Gale E Dryden, “Risk of contamination from the anesthesia circle absorber: An evaluation,” Anesthesia and Analgesia 48 (November-December 1969) 939-943. 9. R B Roberts, ed. “Infections and sterilization problems” in lnternational Anesthesiology Clinics, vol 10 (Boston: Little, Brown & Co, 1972). c 10. C Snow, el al, “Sterilization of anesthesia equipment with ethylene oxide,” The New England Journal of Medicine 266 (March 1, 1962) 443-445. 11. V Knight, “Instruments and infection,” Hospital Practice 2 (September 1967) 89-99. 12. Association for the Advancement of Medical Instrumentation Sterilization Standards Subcommittee Policy Statement on Reprocessing of Disposable Medical Devices by Users, unpublished. 13. “Ban the bug,” Great Plains Society for Hospital Central Service Personnel 3 (March 1977) 3. 14. Carl K Bruch, “Safety aspects of resterilization of single-use disposable devices by hospitals,” Respiratory Care 18 (May 1974) 354-360.
Suggested reedings Altemeier, William A, et al, eds. Manual on Control of lnfection in Surgical Patients. Philadelphia: J B Lippincott, 1976. Engley, Frank 6, Jr. “Disinfection is not sterilization.” Hospital lnfection Control, lnc 2 (April 1975). Errera, Dorothy W. “Selected OR bibliography.” Hospital Topics 52 (July-August 1974) 69-70. Gross, F L. “Decontamination of anesthesia apparatus.” Anesthesiology 16 (1955) 902. Jenkins, J R E, Edgar, W M. ”Sterilization of anesthesia equipment.” Anesthesia 19 (April 1964) 177-190. Joseph, J M, Shay, D E. “Disease transmission by inefficiently sanitized anesthesia apparatus.” Journal of the American Medical Association 149 (July 26, 1952) 1196-1198. Lowbury, E J L, el al. “Aseptic methods in the operating suite.” Lancet 1 (April 13, 1968) 763768. McWilliams, Rose Marie, et al, eds. Every OR Supervisor Should Know. Denver: Association of Operating Room Nurses, 1974, 432-436. Meeks, Charles H, et al. “Sterilization of anesthesia apparatus.” Journal of the American Medical Association 199 (Jan 23, 1967) 276-278. Roberts, R 6. “The eradication of cross infection from anesthetic equipment.” Anesthesia and Analgesia 49 (January-February1970) 63. Roberts, R 6. ”Cleaning the laryngoscope blade.” Canadian Anaesthetists’ Society Journal 20 (March 1973) 241-244. Roberts, R 6. “Gamma-rays + PVC + EO = OK.” Respiratory Care 21 (March 1976) 223-224. Sabo, Betsy. “Sterilization of anesthesia ap-
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paratus.” Journal of the American Association of Nurse Anesthetists 41 (October 1973) 421-426. Sandusky, W R. “Pseudomonas infections: Sources and cultured data in a general hospital with reference to surgical infection.” Annals of Surgery 153 (June 1961) 996-1002. Snow, J C, Anderson, M D. “How the anesthesiologist can lessen infection.” Modern Hospital 105 (October 1965) 128+. Stratford, B C, et al. “The disinfection of anesthetic apparatus.” British Journal of Anaesthesia 36 (August 1964) 471-476. Walter, Carl W. “Multiple factors to consider in hospital infection control.” Hospital Topics 48 (October 1970) 65-69. Wisler, M G. “Guidelines for use of ethylene oxide.” AORN Journal 19 (June 1974) 12861295.
Hospitals must give community service Hospitals and other health care facilities constructed or remodeled with federal funds under the Hill-Burtonprogram must now give assurances that “community service” will be rendered indefinitely, the US Department of Health, Education, and Welfare (HEW) has announced. Previously these institutions were required to give such assurances for 20 years after construction was completed or during the period in which a direct loan or loan guarantee and interest subsidy remained unpaid. The community service assurance obligates Hill-Burton facilities to make their services available to the general public, allowing them to limit the availability of services only because of age, medical indigency, or the type of condition affecting the patient. Facilities must also provide required services to patients eligible for benefits under Medicare and Medicaid programs or other state and local programs without discrimination because of source of payment. The Hill-Burton program is being phased out and replaced by the Health Facilities Construction Program, authorized by the 1974 National Health Planning and Resources Development Act (PL 93-641).
AORN Journal, June 1977, V o l 2 5 , No 7
