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CONTINUING EDUCATION

Guideline Implementation: Manual Chemical High- Level Disinfection1.5 www.aornjournal.org/content/cme

Terri Link, MPH, BSN, CNOR, CIC, FAPIC

CONTINUING EDUCATION CONTACT HOURS indicates that continuing education (CE) contact hours are

available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and com-pleting the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.

Event: #18531Session: #0001Fee: Free for AORN members. For non- member pricing, please visit http://www.aornjournal.org/content/cme.

The contact hours for this article expire October 31, 2021. Non- member pricing is subject to change.

PURPOSE/GOALTo provide the learner with knowledge specific to implementing recommendations from the AORN “Guideline for manual chemi-cal high- level disinfection.”

OBJECTIVES 1. Identify when items may be processed by manual chemical

high-level disinfection. 2. Identify hazards associated with manual chemical high-level

disinfection. 3. Describe practices for safe use of high-level disinfectants.

ACCREDITATIONAORN is accredited with distinction as a provider of continu-ing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

APPROVALSThis program meets criteria for CNOR and CRNFA recertifica-tion, as well as other CE requirements.

AORN is provider- approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

CONFLICT-­OF-­INTEREST­DISCLOSURESTerri Link, MPH, BSN, CNOR, CIC, FAPIC, has no declared affil-iation that could be perceived as posing a potential conflict of interest in the publication of this article.

The behavioral objectives for this program were created by Liz Cowperthwaite, BA, senior managing editor, and Sharon Ann Van Wicklin, MSN, RN, CNOR, CRNFA(E), CPSN- R, PLNC, FAAN, clinical editor, with consultation from Susan Bakewell, MS, RN- BC, director, Perioperative Education. Ms Cowperthwaite, Ms Van Wicklin, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

SPONSORSHIP OR COMMERCIAL SUPPORTNo sponsorship or commercial support was received for this article.

DISCLAIMERAORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

http://doi.org/10.1002/aorn.12373 © AORN, Inc, 2018

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EDUCATION

Guideline Implementation: Manual Chemical High- Level Disinfection1.5 www.aornjournal.org/content/cme

Terri Link, MPH, BSN, CNOR, CIC, FAPIC

ABSTRACTThe Spaulding system recommends sterilization or, at minimum, high- level disinfection for semicritical medical items (ie, items that come into contact with mucous membranes or nonintact skin). High- level disinfection deac-tivates all types of microorganisms except bacterial spores and prions. If high- level disinfection is not performed correctly, however, contaminated medical or surgical devices could transmit pathogens to patients. Reusable semi-critical items may be processed using manual methods when manual chemical high- level disinfection is the only processing method recommended by the manufacturer. The AORN “Guideline for manual chemical high- level dis-infection” provides guidance to health care personnel for performing effective manual chemical high- level disinfec-tion and preventing injury associated with the use of high- level disinfectant chemicals. This article focuses on key points of the guideline that address preparation of items for high- level disinfection, use of high- level disinfectants, health care personnel safety, and documentation. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Key words: high-level disinfection, high-level disinfectant, semicritical items, Spaulding classification, ultrasound probes.

Nearly 50 years ago, Earle H. Spaulding, PhD, one of the leading authorities in the field of medical microbiology, developed a classification system

to use as a guide in disinfection and sterilization of reus-able medical items. The Spaulding classification system is logical and easy to interpret and is still used today. The categories Spaulding described are

• critical (ie, items that enter sterile tissue and must be sterilized),

• semicritical (ie, items that contact mucous membranes or nonintact skin and require sterilization or, at mini-mum, high-level disinfection), and

• noncritical (ie, items that contact intact skin and require low-level disinfection).1

Sterilization eliminates all microbial life (with the excep-tion of prions), including pathogenic microorganisms and

bacterial spores.1 High- level disinfection deactivates all types of microorganisms with the exception of bacterial spores and prions,2-5 and may not be effective against some viral pathogens.6 A correctly sterilized reusable semicriti-cal item is less likely to transmit pathogens that could lead to an infection or infectious outbreak than one processed by high- level disinfection.4 Thus, when a semicritical item is validated by the manufacturer for processing by steril-ization, it should be sterilized if possible.7

Some reusable semicritical items cannot be sterilized, how-ever. Such devices may contain heat- sensitive materials or have other properties that could be altered during the sterilization process. When a semicritical reusable device cannot be sterilized but is manufacturer- validated for high- level disinfection using automated methods, that item should be mechanically processed.8 Mechanical high- level

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disinfection is more effective and efficient than manual processing and can be more easily monitored for quality and consistency.2,9,10 In addition, mechanical processing helps protect personnel from exposure to the disinfectant chemicals that can be harmful to human tissue.2,11-17

When a reusable semicritical item cannot be mechan-ically processed and manual chemical high- level disin-fection is the only processing method recommended by the manufacturer, the item may be processed by manual chemical high- level disinfection.7,18 Personnel must per-form manual chemical high- level disinfection correctly to help prevent transmission of pathogens via contami-nated medical or surgical devices. In addition, personnel should adhere to safety precautions when performing manual chemical high- level disinfection to avoid expo-sure to hazardous chemical and biological substances.

The AORN “Guideline for manual chemical high- level disin-fection”7 was updated in January of 2018. AORN guideline documents provide guidance based on an evaluation of the strength and quality of the available evidence for a specific subject. The guidelines apply to inpatient and ambulato-ry settings and are adaptable to all areas where operative and other invasive procedures may be performed. Topics addressed in the manual chemical high- level disinfection guideline include selection of high- level disinfectants (HLDs) by an interdisciplinary team, locations of use and storage of HLDs in a health care organization, preparation of reusable semicritical items to be processed by high- level disinfection, preparation and use of HLDs, providing a safe environment for personnel who handle HLDs, education and competency verification related to high- level disin-fection, and maintenance of manual high- level disinfec-tion records to meet regulatory requirements. This article elaborates on key takeaways from the guideline document; however, perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Key takeaways from AORN’s “Guideline for manual chemi-cal high- level disinfection” include the following:

• Personnel should prepare reusable semicritical items to be processed by high-level disinfection according to the device manufacturer’s instructions for use (IFU).

• Personnel must prepare and use HLDs in accordance with the disinfectant and device manufacturers’ IFU.

• The health care organization must provide a safe envi-ronment for personnel who handle or use HLDs.

• The health care organization should maintain records of manual chemical high-level disinfection processes (Figure 1).

The following scenario highlights the key takeaways and other aspects of the AORN guideline. Each takeaway is discussed in more detail after the scenario.

SCENARIOThe nurse manager of the inpatient ORs in a large acute care hospital is approached by a member of the cardio-vascular team who has concerns that the transesophageal echocardiography (TEE) ultrasound probes are not being reprocessed appropriately after use. In this facility, it is the responsibility of the anesthesia technicians to set up the TEE probes preoperatively for the anesthesia profes-sionals who use these devices. The technicians also are responsible for cleaning and reprocessing the TEE probes between procedures. The cardiovascular team members have observed anesthesia technicians entering the OR during a procedure to retrieve and reprocess the TEE for a surgical procedure in another room. One cardiovascular nurse saw an anesthesia technician cleaning the TEE probe in a hand- washing sink in the clean anesthesia workroom.

The perioperative nurse manager contacts the infection preventionist assigned to perioperative services and asks if she will assist in evaluating the current procedures for reprocessing the TEE probes. The infection preventionist spends a day observing the process and then schedules a meeting with an interdisciplinary team of stakeholders to discuss the high- level disinfection practices for TEE probes. The stakeholders include a service line specialist; an anesthesia technician; an anesthesiologist; a cardiac surgeon; and the nurse managers of the OR, the sterile processing department (SPD), and the cardiac catheteriza-tion laboratory.

At the meeting, the infection preventionist reports that the facility has a standardized infection ratio (SIR) of 1.8 for all cardiac procedures. The SIR is a risk- adjusted summary measure calculated by comparing the observed number of infections with the predicted number of infec-tions based on National Healthcare Safety Network com-posite data.19 The benchmark for SIR is 1.0.19 She then

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shares her observations of the TEE processing, includ-ing that the anesthesia technicians are cleaning the TEE probes in a hand- washing sink in the anesthesia clean workroom and then are transporting them to the decon-tamination room in the OR in a towel for high- level disin-fection. All other instruments are now reprocessed in the SPD with the exception of the TEE probes. However, the decontamination room contains an elevator that is used to transport dirty case carts to the SPD. The door is typ-ically propped open for ease in moving case carts to the transport elevator. Personnel who access this room have complained of headaches and eye irritation, and there is a noxious odor in the room and in the corridor outside the room.

The technicians use a log to record the parameters of tem-perature, time, and HLD lot number for each item being processed by high- level disinfection, but some of these entries are incomplete. The technicians use a timer to ensure the probe is submerged for the contact time rec-ommended by the TEE probe manufacturer, but they do not consistently check the temperature of the HLD solu-tion. In addition, the infection preventionist discovered that the test strips the technicians were using to verify adequate concentration of the HLD solution were past their expiration date.

The infection preventionist asserts that she would like to move all high- level disinfection to the SPD because the SPD has standardized protocols and the SPD tech-nicians are well trained in manual and automated chem-ical high- level disinfection. She asks the anesthesia technician why the technicians do not send the TEE probes to the SPD for reprocessing and he replies, “It takes too long for the SPD to reprocess and return the probes to the OR before they are needed.” He explains that more than one cardiac procedure is generally being performed at the same time, and there are multiple cas-es throughout the day. The department has two TEE probes, and they are often needed in two ORs at nearly the same time. This requires the anesthesia technicians to retrieve the TEE probe immediately after use on a patient in the OR for cleaning and reprocessing for the next procedure.

The infection preventionist then asks about the capabil-ities of the SPD to process these probes. The SPD nurse manager says it would require 60 minutes from the time the probe arrives in the SPD until it can be set up and ready for the next procedure. After additional discussion, the interdisciplinary team determines that two more probes would be needed to meet the requirements that a probe be available for each patient throughout the procedure.

Figure 1. Key takeaways from the AORN “Guideline for high- level disinfection.”

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The SPD also would need more personnel to transport the TEE probes from the OR and catheterization laboratory to the SPD. The infection preventionist asks the nurse man-agers of the SPD, cardiac catheterization laboratory, and OR to research automated reprocessors and TEE probes available for purchase that are compatible with the exist-ing TEE probes and the feasibility of transporting the TEE probes to the SPD for reprocessing.

Next, the team focuses on how they can improve the pro-cess until a final decision about the new high- level disin-fection processes can be made and appropriate resources put in place. Working with an educator and the nurse man-agers in each department, the infection preventionist will provide education and competency verification activities for the anesthesia technicians consistent with the facility’s standardized policies and procedures. The nurse manag-ers of the OR and catheterization laboratory will replace the expired test strips and purchase containers for trans-port of the TEE probe to the decontamination room in the OR. The infection preventionist will verify with facilities management personnel that the decontamination room has 10 air exchanges per hour and recommend monitor-ing the decontamination room for hazardous levels of HLD vapors. Pending results from HLD monitoring, local exhaust ventilation installation may be needed.

High- level disinfection will be performed 3 ft away from the sink used for cleaning the TEE probes and a barri-er will be placed to separate the decontamination area from the HLD solution. The infection preventionist will instruct the technicians to keep the door closed and to place signage on the door to indicate that high- level dis-infection occurs in this room. She will reemphasize the importance of wearing personal protective equipment, including eye protection and masks when entering this room, and a protective gown and chemical- resistant gloves if handling the HLD.

Finally, the infection preventionist requests that a ster-ile probe cover be used during surgical procedures. Even though the TEE probe is passed through the esophagus and is not directly exposed to a sterile cavity, there can be trauma to the tissue that causes some minor bleeding and nonintact mucosa, so the probe may come in contact with sterile sites. She notes that sterile probe covers are avail-able in the facility and are recommended for use by the probe manufacturer and the Centers for Disease Control and Prevention.2 A probe cover also will help prevent the

probe from becoming grossly contaminated and more dif-ficult to clean.2,20

The interdisciplinary team schedules a meeting for one month later to review compliance with the processes established for manual chemical high- level disinfec-tion. Team members also will provide an update on the process for transporting of TEE probes to the SPD for reprocessing and the possibility of moving to automated reprocessing.

KEY TAKEAWAYS DISCUSSIONThe key takeaways from the AORN “Guideline for man-ual chemical high- level disinfection” address preparing semicritical items for high- level disinfection, using HLDs in accordance with the disinfectant and device manufac-turers’ IFU, maintaining a safe environment of care for personnel who handle and use chemical HLDs, and doc-umenting high- level disinfection processes. These take-aways do not cover the entire guideline. Rather, they help the reader focus on important or new information that should be implemented into perioperative practice.

Preparation of Semicritical ItemsIn the scenario, the anesthesia technicians were not cor-rectly cleaning and transporting the TEE probes before processing. Items for which the device manufacturer rec-ommends precleaning should be precleaned at the point of use. Moistening and removing organic soils at the point of use helps reduce the formation of biofilm that could prevent effective high- level disinfection.7 After preclean-ing, the items must be transported to the decontamination area in a closed container to prevent exposure of person-nel to blood, body fluids, or other infectious organisms. The items should be kept damp, and the container must be leak proof, puncture resistant, large enough to contain the contents, and labeled with a biohazard label.21

Items for which the device manufacturer recommends precleaning should be precleaned at the point of use.

Soiled instruments should not be cleaned in a hand-wash-ing sink because the instrument could contaminate the

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sink and faucet and subsequently infect the hands of personnel.22 Personnel should adhere to the item man-ufacturer’s IFU for cleaning, rinsing, and drying the item before high- level disinfection and then inspect the item to make sure there is no residual soil that could prevent effective high- level disinfection. Soiled items should be recleaned, and any defective or damaged item should be removed from service.7 High- level disinfection should not be performed in areas near potential sources of contam-ination. A barrier should separate the area where clean-ing occurs from the area where high- level disinfection is occurring.7

Use of HLDsEach HLD has unique requirements, and if the manu-facturer’s IFU are not followed, it may affect the dis-infection process and the performance of the device. Personnel should verify the compatibility of the HLD with the item to be processed and use a test strip or another US Food and Drug Administration– cleared test-ing device specific to the disinfectant to ensure that the activated HLD is in the concentration recommended by the HLD manufacturer.11,18,23 Personnel should store test strips in accordance with the manufacturer’s IFU and should test them for efficacy because the test strips may degrade over time and not provide accurate results.11,18 If the test strip indicates the concentration of the active ingredient is insufficient or the HLD solution has precip-itates or appears cloudy on inspection, personnel should discard the solution. Personnel should verify the tem-perature of the activated HLD before use to ensure that the solution is at the temperature recommended by the HLD manufacturer.

Safe Environment of CareHigh- level disinfection should be performed in an area controlled and maintained to support HLD processes. In the scenario, the room the technicians used for high- level disinfection was a decontamination room that other team members accessed to transport carts to the SPD. Keeping the doors closed and posting signs warning of HLDs in use can help prevent unauthorized personnel from entering the area and potentially exposing themselves to chemical vapors.

Health hazards associated with HLDs range from minor irritation of mucous membranes to chemical burns, and

also may include headaches, ocular irritation, nasal mem-brane irritation, contact dermatitis, occupational asthma, and allergic reactions.7 Health care organizations have a responsibility to minimize health care workers’ expo-sure to chemical vapors. An interdisciplinary team in the health care organization should select US Food and Drug Administration– cleared HLDs based on an evaluation of the potential health hazards associated with the disinfec-tant chemicals and the compatibility of the HLDs and the HLD manufacturers’ IFU with existing processes, prod-ucts, and equipment used for high- level disinfection in the facility.

The health care facility should maintain 10 air changes per hour in rooms where manual chemical high- level disinfec-tion occurs and should monitor exposure levels in areas where there is potential for hazardous amounts of chemi-cal vapors to be dispersed into the air

• after initial use of the HLD;

• whenever there is a significant change in protocol, work practices, or caseload;

• after major heating, ventilation, or air- conditioning equipment repairs or disruptions; and

• when personnel have concerns about or symptoms of overexposure.

Health care organizations have a responsibility to minimize health care workers’ exposure to chemical vapors.

Personnel should wear personal protective equipment during manual high- level disinfection and dispose of HLD solution in accordance with federal, state, and local regulations and the disinfectant manufacturer’s IFU.7

Education facilitates the development of knowledge, skills, and attitudes about safe practices.7 In collaboration with an educator and nurse managers, the infection pre-ventionist provided education and competency evalua-tion on the steps for reprocessing TEE probes. Education for processing personnel should including precleaning at the point of use; transporting the probes; preparing the items for high- level disinfection according to the item

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manufacturer’s IFU; performing manual chemical high- level disinfection according to device and HLD manu-facturers’ IFU; following safety precautions, including knowing the hazards related to HLD chemicals and wear-ing personal protective equipment; and accurately docu-menting the process.24

DocumentationThe anesthesia technicians were not consistently doc-umenting information about the disinfection process. The health care organization should maintain records of manual chemical high- level disinfection processes to help ensure that parameters for correct high- level disinfection have been met, enable retrieval of HLD solutions in the event of a recall, and establish trace-ability and accountability.7 A log for documenting man-ual chemical high- level disinfection should include the following:

• date and time of high-level disinfection,

• HLD solution lot number,

• HLD solution shelf-life date,

• results of solution test strip testing,

• HLD solution temperature,

• HLD exposure time,

• unique device identification number,

• identity of the person performing high-level disinfection,

• identity of the patient on whom the device was used, and

• identity of the physician and procedure in which the device was used.

CONCLUSIONThe Joint Commission has noted that processes for high- level disinfection equipment and devices are fre-quently found to be inadequate, especially in decen-tralized areas.25 Most surgical instruments are now being reprocessed in the SPD, including cleaning,

Resources for Implementation

• Guideline Essentials: manual chemical

high-level disinfection. AORN, Inc. https://

www.aorn.org/essentials/high-level-disin-

fection [AORN member/guideline subscriber

access only]. Accessed July 12, 2018.

• Guideline implementation topics: high-level

disinfection. AORN, Inc. https://www.aorn.org/

guidelines/guideline-implementation-topics/

sterilization-and-disinfection/high-level-disin

fection. Accessed July 12, 2018.

• AORN Syntegrity. http://www.aorn.org/synteg

rity. Accessed July 12, 2018.

• ORNurseLink. http://www.ornurselink.org/

home [member access only]. Accessed July 12,

2018.

Editor’s note: Syntegrity is a registered trademark

and ORNurseLink is a trademark of AORN, Inc,

Denver, CO.

What Else Is in the Guideline?

Read the AORN “Guideline for manual chem-

ical high- level disinfection”1 to learn what the

evidence says about the following:

• How should high-level disinfectants

(HLDs) be stored in the health care facility?

(Recommendation III.)

• What actions should personnel take if it is

necessary to add activated HLD solution to an

existing container of the activated HLD (eg, the

solution has evaporated, there is insufficient

volume of solution to immerse the device)?

(Recommendation IV.e.1.)

• What actions should personnel take if a portion

of the medical device cannot be immersed in the

HLD solution? (Recommendations VI.k.1-VI.k.2.)

• How often should rinse water and rinsing

containers be changed? (Recommendation

VI.o.2.)

• How should items processed by high-level

disinfection be stored? (Recommendations

VII.b.1.-VII.b.3.)

• What are the elements of a chemical spill

control plan? (Recommendation VIII.b.1.)

• How should personnel dispose of activated

HLDs? (Recommendations VIII.i.-VIII.i.6.)

REFERENCE

1. Guideline for manual chemical high- level

disinfection. In: Guidelines for Perioperative

Practice. Denver, CO: AORN, Inc;

2018:883- 906.

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decontamination, and sterilization or automated high- level disinfection, but for various reasons, manual chemical high- level disinfection may still occur in some ORs. In the scenario, the infection preventionist evalu-ated the high- level disinfection process used by anes-thesia technicians and found numerous practices that could result in suboptimal disinfection and potentially cause harm to patients or personnel. In the SPD, the high- level disinfection process can be standardized and performed by personnel who have the resources to correctly perform high- level disinfection, where-as in the OR, there are competing responsibilities in many cases. As in the scenario, process improvement initiatives are not always easy to accomplish and may require transitional phases—for example, from manual chemical high- level disinfection to the use of automat-ed reprocessors and eventually, as technology changes, to sterilization. Personnel can refer to the “Guideline for manual chemical high- level disinfection” for assis-tance in implementing safe processes for manual chem-ical high- level disinfection to help protect patients and personnel.

REFERENCES 1. Spaulding EH, Lawrence CA, Block SS, Reddish

GF. Chemical disinfection of medical and surgi-cal materials. In: Lawrence CA, Block SS, Reddish GF, eds. Disinfection, Sterilization, and Preservation. Philadelphia, PA: Lea & Febiger; 1968:517-531.

2. Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Washington, DC: Centers for Disease Control and Prevention; 2008. https://www.cdc.gov/infection control/pdf/guidelines/disinfection-guidelines.pdf. Updated February 15, 2017. Accessed July 12, 2018.

3. Rutala WA, Weber DJ. Disinfection, sterilization, and antisepsis: an overview. Am J Infect Control. 2016;44(5 suppl):e1-e6. https://doi.org/10.1016/j.ajic.2015.10.038.

4. Rutala WA, Weber DJ. Reprocessing semicritical items: current issues and new technologies. Am J Infect Control. 2016;44(5 suppl):e53-e62. https://doi.org/10.1016/j.ajic.2015.12.029.

5. Rutala WA, Weber DJ. Cleaning, disinfection, and sterilization in healthcare facilities. In: APIC Text of

Infection Control and Epidemiology. Arlington, VA: Association for Professionals in Infection Control and Epidemiology; 2016.

6. McDonnell G, Burke P. Disinfection: is it time to re-consider Spaulding? Hosp Infect. 2011;78(3):163-170.

7. Guideline for manual chemical high-level disinfec-tion. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2018:883-906.

8. Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2018:799-882.

9. Ofstead CL, Wetzler HP, Snyder AK, Horton RA. Endoscope reprocessing methods: a prospective study on the impact of human factors and automa-tion. Gastroenterol Nurs. 2010;33(4):304-311.

10. Ubhayawardana DL, Kottahachchi J, Weerasekera MM, Wanigasooriya IW, Fernando SS, De Silva M. Residual bioburden in reprocessed side- view endo-scopes used for endoscopic retrograde cholangiopan-creatography (ERCP). Endosc Int Open. 2013;1(1):12-16.

11. Guideline for Use of High-Level Disinfectants & Sterilants in the Gastroenterology Setting. Chicago, IL: Society of Gastroenterology Nurses and Associates, Inc; 2017.

12. Best practices for the safe use of glutaraldehyde in health care. Occupational Safety and Health Administration. http://www.osha.gov/Publications/ 3258-08N-2006-English.html. Published 2006. Ac- cessed July 12, 2018.

13. Cohen NL, Patton CM. Worker safety and glutaral-dehyde in the gastrointestinal lab environment. Gastroenterol Nurs. 2006;29(2):100-104.

14. ECRI. Ethylene oxide, formaldehyde, and glutaralde-hyde. In: Operating Room Risk Management. Plymouth Meeting, PA: ECRI; June 2012:1A.

15. Pala G, Moscato G. Allergy to ortho- phthalaldehyde in the healthcare setting: advice for clinicians. Expert Rev Clin Immunol. 2013;9(3):227-234.

16. Nayebzadeh A. The effect of work practices on per-sonal exposure to glutaraldehyde among health care workers. Ind Health. 2007;45(2):289-295.

17. Weber DJ, Consoli SA, Rutala WA. Occupational health risks associated with the use of germi-cides in health care. Am J Infect Control. 2016; 44(5):e85-e89. https://doi.org/10.1016/j.ajic.2015. 11.030.

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18. ANSI/AAMI ST58:2013 Chemical Sterilization and High-Level Disinfection in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2013.

19. The NHSN Standardized Infection Ratio (SIR). Centers for Disease Control and Prevention. National Healthcare Safety Network. https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf. Updated March 2018. Accessed August 8, 2018.

20. Rutala WA, Gergen MF, Sickbert-Bennet E. Effectiveness of a hydrogen peroxide mist (Trophon) system in inactivating healthcare pathogens on sur-face and endocavitary probes. Infect Control Hosp Epidemiol. 2016;37(5):613-614.

21. 29 CFR 1910.1030: Bloodborne pathogens. US Government Publishing Office. https://www.ecfr.gov/cgi-bin/text-idx?SID=a71fad4cc5d7ca4d71154a2 c80a4f88f&mc=true&node=se29.6.1910_11030&rgn=div8. Accessed July 12, 2018.

22. Guideline for hand hygiene. In: Guidelines for Periop-erative Practice. Denver, CO: AORN, Inc; 2018:29-50.

23. High- level disinfection and sterilization: know your process. Jt Comm Perspect. 2014;34(2):9, 13, 15.

24. United States Department of Labor. Hazard communi-cation: toxic and hazardous substances. 29 CFR §1910. 1200. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10099. Revised March 26, 2012. Effective May 25, 2012. Accessed August 8, 2018.

25. Improperly sterilized or HLD equipment – a growing problem. Quick Safety. May 2017;(33). https://www.jointcommission.org/assets/1/23/qs_33a_2017.pdf. Accessed July 12, 2018.

Terri Link, MPH, BSN, CNOR, CIC, FAPIC, is the product manager for the Guideline Implementation Tools at AORN, Inc, Denver, CO. Ms Link has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

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EXAMINATION

Continuing EducationGuideline Implementation: Manual Chemical High- Level Disinfection1.5 www.aornjournal.org/content/cme

PURPOSE/GOALTo provide the learner with knowledge specific to implementing recommendations from the AORN “Guideline for manual chemical high- level disinfection.”

OBJECTIVES 1. Identify when items may be processed by manual chemical high-level disinfection. 2. Identify hazards associated with manual chemical high-level disinfection. 3. Describe practices for safe use of high-level disinfectants.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.

QUESTIONS 1. According to the Spaulding system, items that con-

tact mucous membranes are classified as a. critical. b. noncritical. c. semicritical. d. subcritical.

2. High-level disinfection eliminates all microbial life, including pathogenic microorganisms, bacterial spores, and prions.

a. true b. false

3. Some reusable semicritical items cannot be sterilized. a. true b. false

4. Semicritical reusable devices that are manufacturer- validated for automated high-level disinfection should be mechanically processed instead of manually pro-cessed because mechanical high-level disinfection

1. helps protect personnel from exposure to poten-tially harmful disinfectant chemicals.

2. is more cost effective. 3. is more efficient.

4. can be more easily monitored for quality and consistency.

a. 1 and 4 b. 2 and 3 c. 1, 3, and 4 d. 1, 2, 3, and 4

5. When a reusable semicritical item cannot be mechan-ically processed and manual chemical high-level disin-fection is the only processing method recommended by the manufacturer, the item may be processed by manual chemical high-level disinfection.

a. true b. false

6. After precleaning, the items to be transported to the decontamination area for manual chemical high-level disinfection must be placed in a closed container that is

1. labeled with a biohazard label. 2. large enough to contain the contents. 3. leak proof. 4. puncture resistant.

a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

http://doi.org/10.1002/aorn.12373 © AORN, Inc, 2018

AORN Journal  409  

October 2018, Vol. 108, No. 4 Guideline Implementation: Manual Chemical High-Level Disinfection

7. Personnel should discard an activated high-level disinfectant solution if

1. the concentration of the active ingredient is insufficient.

2. the solution has precipitates. 3. the solution is clear. 4. the solution is cloudy.

a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, and 4

8. Health hazards associated with high-level disinfec-tants include

1. allergic reactions. 2. impaired cognition. 3. occupational asthma. 4. ocular and nasal membrane irritation.

a. 1 and 4 b. 2 and 3 c. 1, 3, and 4 d. 1, 2, 3, and 4

9. The health care facility should maintain _____ air exchanges per hour in rooms where manual chemical high-level disinfection occurs.

a. 5 b. 10 c. 15 d. 20

10. In areas where there is potential for hazardous amounts of chemical vapors to be dispersed into the air, the health care facility should monitor exposure levels

1. after initial use of the high-level disinfectant. 2. after major heating, ventilation, or air- conditioning

equipment repairs or disruptions. 3. when personnel have concerns about or symp-

toms of overexposure. 4. whenever there is a significant change in protocol,

work practices, or caseload. a. 1 and 4 b. 2 and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4

410  AORN Journal

LEARNER EVALUATION

Continuing EducationGuideline Implementation: Manual Chemical High- Level Disinfection1.5 www.aornjournal.org/content/cme

This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed

here for your convenience. To receive continuing edu-cation credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/con-tent/cme. Rate the items as described below.

OBJECTIVESTo what extent were the following objectives of this con-tinuing education program achieved?

1. Identify when items may be processed by manual chemical high-level disinfection.

Low 1. 2. 3. 4. 5. High

2. Identify hazards associated with manual chemical high-level disinfection.

Low 1. 2. 3. 4. 5. High

3. Describe practices for safe use of high-level disinfectants.

Low 1. 2. 3. 4. 5. High

CONTENT 4. To what extent did this article increase your knowl-

edge of the subject matter? Low 1. 2. 3. 4. 5. High

5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High

6. Will you be able to use the information from this article in your work setting?

1. Yes 2. No

7. Will you change your practice as a result of read-ing this article? (If yes, answer question #7A. If no, answer question #7B.)

7A. How will you change your practice? (Select all that apply)

1. I will provide education to my team regarding why change is needed.

2. I will work with management to change/imple-ment a policy and procedure.

3. I will plan an informational meeting with physi-cians to seek their input and acceptance of the need for change.

4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice.

5. Other: _________________________________________________________________

7B. If you will not change your practice as a result of reading this article, why? (Select all that apply)

1. The content of the article is not relevant to my practice.

2. I do not have enough time to teach others about the purpose of the needed change.

3. I do not have management support to make a change.

4. Other: _________________________________________________________________

http://doi.org/10.1002/aorn.12373 © AORN, Inc, 2018