policies and protocols for infection control, the prevention of infection, the ability to demonstrate extreme measures are taken to prevent the cause of infection in and around the workplace. This protocol is geared more towards the surgical setting but can be customized to meet any health care setting as most of them are universal precautions based policies.
High Level Disinfection Using Policy # 0122 Liquid Chemical Sterilant Effective: Reviewed: Revised: 1. POLICY. 1.1 The facility will utilize recommended practices for high level disinfection of heat-sensitive instruments and equipment used for patient procedures. 2. PROCEDURE. Items to be disinfected should be categorized as one of the following: 2.1 Critical item: Instruments or other objects that are introduced directly into the human body, either into or in contact with the bloodstream or normally sterile areas of the body. These items should be rendered sterile. Examples: surgical instruments, cutting endoscopic accessories that break the mucosal barrier, cardiac and urinary catheters, needles. (This includes arthroscopes and laparoscopes.) 2.2 Semi-critical item: Items that come in contact with non-intact skin or mucous membranes. These items should be high-level disinfected. Examples: respiratory therapy equipment, bronchoscopes, gastrointestinal endoscopes, and cystoscopes. 2.3 Non-critical: Instrument or items that come in contact with the patient, but in most instances only with unbroken skin. These items should receive low or intermediate-level cleaning. Examples: bedpans, blood pressure cuffs, crutches, linens, and furniture. 3. DEFINITIONS 3.1 Chemical disinfectant/germicide: A generic term for a government- registered agent that destroys microorganisms. Germicides are classified as sporicides, general disinfectants, hospital disinfectants, sanitizers, and others. Note: Manufacturer’s instruction must be followed for each product regarding disinfection/sterilization parameters, temperature for use, ventilation requirements and testing and recording of efficacy prior to use. 3.2 Decontaminations: Any physical or chemical process that serves to reduce the number of microorganisms on any inanimate object to render that object safe for subsequent handling. Page 1 of 2 3.3 Disinfection: A process that destroys some forms of microorganisms, excluding bacterial spores. 3.4 Hospital disinfectant: A chemical germicide with label claims for effectiveness against Salmonella choleraesuis, Staphylococcus aureus, and Pseudonomas aeruginosa. Hospital disinfectants may be either a low-level, intermediate-level, or high-level disinfectants. 3.5 High-level disinfectant: A process that destroys microorganism, with the exception of high numbers of bacterial spores, High-level disinfectants has the capability of inactivation of hepatitis B virus, and HIV, and Mycobacterium tuberculosis. High-level disinfectants do not inactivate the virus-like prion the causes Crautzfeldt-Jakob disease. 3.6 Intermediate-level disinfectant: A process that inactivates Mycobacterium tuberculosis, vegatative bacteria, most virus, and most fungi, but does not necessarily kill bacterial spores. 3.7 Low-level disinfectant: A process that kills most bacteria, some viruses, and some fungi, but cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores. The level of disinfection required is based on the nature of the item and the manner in which it is to be used. Page 2 of 2
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