Infection Control in Optometric Practice

Transcription

1 Infection Control in Optometric Practice William D. Townsend, O.D., FAAO Advanced Eye Care - Canyon, TX Adjunct Professor, UHCO - Houston, TX Why Infection Control in Optometry? Changes in national standards Changes in legal climate Changes in disease entities HIV Hepatitis C Tuberculosis MRSA Changes in Optometry CL ushered in a new era Procedures, instruments, sharps Body fluids; tears, blood Hospital privileges Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care All healthcare settings, regardless of the level of care provided, must make infection prevention a priority and must be equipped to observe Standard Precautions. The 2007 CDC and HICPAC Guideline for Isolation Precautions was a first attempt to provide recommendations that can be applied in all 1

2 Realistic Goals for Infection Control: How Far Do We Go? Optometrists practice in a nonsterile environment, not an operating room! 1. Protect the patient from clinic-acquired infection 2. Protect the staff and doctors from infectious agents 3. Meet infection control standards established by government and healthcare industry 4. Avoid unnecessary cost, effort Know Your Enemies- Microorganisms Free living, capable of respiration, reproduction Bacteria No cell nucleus No cell organelles Cell wall Genetic info- single DNA strand Fungi True cell nucleus True cell organelles Cell wall Non-motile Protozoa (Acanthamoeba) True cell nucleus True cell organelles Cell membrane Bacteria Shape-important for classification Cocci- round, so less affected by drying Diplo- pairs Strepto- chains Staphylo- clusters Bacillus- rods Spiral- improved motility Helix- elongated spirals 2

3 capsule cell wall cytoplasmic membrane ribosomes pili cytoplasm nucleoid flagella Bacterial Structure Capsule- coating for protection Cell wall- structural Absent in animal cells Targeted by some antibiotics Gives staining characteristics Cytoplasm Chromatin material (nucleoid) Ribosomes for protein synthesis Lipids for energy Flagella- motility Microbial Survival Tactics: Endospores, Cysts, Enzymes Conversion from vegetative to encapsulated forms Bacteria- spores Amoeba- cysts Fungi- alter form depending on environment Encapsulated forms MUCH more difficult to kill Boiling- NO, Alcohol- NO The ability to kill spores is the gold standard in infection control! Endospore Formation Clostridial Species Clostridium botulinum- botulism Clostridium tetani tetanus Clostridium perfringens- gangrene Bacillus Species Bacillus anthrasis- anthrax Bacillus cereus- diarrheal syndrome Viruses Are they living? Incapable of respiration, reproduction Rely on host cell to replicate Genetic elements- not cells Structure Core of genetic material; DNA or RNA Covering of protein Viability outside host cell varies with species Basically, not really a living organism! 3

4 Size of Protozoa, Bacteria, Viruses Viral Replication Viruses incapable of independent reproduction Virus attaches to host cell Virus injects genetic material into host cell Host cell replicates thousands of viral particles Viruses released into environment Infect adjacent cells The infection spreads exponentially Viral Infection & Replication Important Viruses In Eye Care Herpes simplex- cold sore, keratitis, uveitis, retina Herpes zoster- shingles, HZ ophthalmicus Adenoviruses Epidemic keratoconjunctivitis- EKC Pharyngoconjunctival fever- PCF Pox viruses- molluscum contagiosum Transmission: asymptomatic viral shedding. 4

5 Important Viruses In Eye Care Hepatitis B Hepatitis C Papova viruses- lid warts Enterovirus- hemorrhagic conjunctivitis Human immunodeficiency virus- HIV & AIDS Increased risk for : Fungal infection Bacterial infection Fungal infection Cytomegalovirus (CMV) retinitis Protozoa (Example: Acanthamoeba) Vegetative (normal) form Capable of forming cysts Increased resistance to hostile conditions Cause severe corneal infection that are highly resistant to treatment Present in distilled, tap water in virtually all communities Present in soil, hot tubs, HVAC units Federal Register, June 2002 Confused about terminology? EPA's preliminary determination is that no regulatory action is appropriate for the contaminants Acanthamoeba, aldrin, dieldrin, hexachlorobutadiene, manganese, metribuzin, naphthalene, Suddenly sodium, it is and OK to sulfate. have amoebae in our water supply! 5

6 Antiseptics..a substance that inhibits the growth and development of microorganisms without necessarily killing them. For use on skin, tissue Not for inanimate objects substances that are applied to non-living objects to destroy microorganisms Used to destroy microorganisms on surfaces, i.e. countertops, face shields Disinfectant Disinfection Versus Sterilization The golden standard in infection control Spores more difficult to kill than vegetative forms. Spore destruction is the pivotal criteria in IC Can any given method kill spores? If no, disinfection If yes, sterilization Infection Control Terminology Sterilization- all life forms killed Spores Cysts Vegetative forms Viruses Fungi Politicians Disinfection- all life forms killed except spores & cysts 6

7 Infection Control Terminology cidal Indicates death of specific life form Virucidal- kills viruses Sporicidal- kills spores Tuberculocidal- kills bacteria that cause tuberculosis Fungicidal- kills fungi Spaulding Classification Based on type of tissue object will enter. Critical- enters sterile tissue or vascular tissue Example Spud, burr, spatula, scalpel, scissors Spaulding Classification Semicritical- touches mucous membranes Example: forceps, lacrimal dilators, lacrimal cannulas, tonometer probes Noncritical- touches skin Example: cilia forceps, stethoscopes, occluders, face shields, head rests Infection Control: Basic Procedures Hand washing- #1 form of infection control Gloving Solution/drug sterility Surface disinfection Tonometer disinfection Sharps disposal Basic Procedures are Important Procedures! 7

8 Hand Washing in Health Care Workers: The cornerstone of infection control English Spanish French Hand Washing in Health Care Workers: The cornerstone of infection control Duration of hand scrubbing by HCW seconds seconds Negative factors Dr. vs. nurse Male vs. female Working during week vs. weekend shift Lack of role model, encouragement Hold each other accountable! Hand Washing #1 means of preventing nosocomial infection Use a liquid disinfectant soap Never use bar soaps Rinse well Shake off hands w/ fingers pointing down NO cloth towels, only paper towels Turn off water w/ paper towel & dispose Hands must be dry prior to patient Hand Washing Sing Happy Birthday (to yourself) 8

9 Pathogen Survival on Surfaces Viruses Adenoviruses: 3-8 weeks at room temperature Hepatitis A: 4 hours Hepatitis B: 7 days Herpes simplex: 8 weeks HIV: 4-5 days (numbers very reduced in hours) Influenza virus: 2-4 days Bacteria Pseudomonas aeruginosa: 7 hours Methicillin-resistant Staph aureus (MRSA): 2 days Surface Disinfection When? After every patient Always after red eyes At the end of every day Which agent? Alcohol pads for face shields Let the patient see you do it! Use cotton balls and bottled alcohol-save $$! Disinfectant spray for counters Isopropyl alcohol (60%) all surfaces Hypochlorite (1/1000 concentration) 995 ml distilled water, 5 ml bleach Frugality in Infection Control Gloving Non-sterile gloves in red eyes Sterile gloves in invasive procedures Keep gloves in all treatment areas Proper sizing important, so make various sizes available if needed Wash hands after de-gloving Glove while cleaning 9

10 Solution/Drug Sterility Once opened, it isn t sterile Never touch dropper to eye Do expiration date inspections Small bottles of CL solution in exam rooms Date CL solutions when put in each room Replace all CL solution bottles each month Tonometer Probe Disinfection After every patient Alcohol swabs- degrades plastic tonometer probe Hydrogen peroxide (3%) 10 minutes- wipe off Sodium hypochlorite 500 ppm (0.0005%) Within 10 minutes of application, destroys herpes simplex virus, adenovirus 8, and enterovirus 70 Soaking units for disinfection Tonometer Probe Disinfection Disinfection of Tonometer Tips Contaminated With Adenovirus 8 Wiped With dry wipe wipe w/ water wipe w/ isopropyl alcohol wipe w/ hydrogen peroxide wipe w/ povidone-iodine Results Soaked 5 Minutes In water isopropyl alcohol hydrogen peroxide povidone-iodine Dry wiped tips positive for active virus Tips soaked in water positive for active virus No viable virus recovered from tips wiped w/ water or any of the disinfectants Threlkeld AB.et al Efficacy of a disinfectant wipe method for the removal of adenovirus 8 from tonometer tips. Ophthalmology. Dec

11 Tonopen Compares favorably with Goldmann Disposable tip covers- great for infection control Does not reqire patient be seated at slit lamp Technique easily mastered by techs More costly than Goldmann Breaks when you (your tech) drops them Disposable, protects from contamination, small STDs Sharps Disposal Biohazard disposal companies easy to find; just ask your dentist or PCP Never recap needles Micropuncture needles Cannulas Scalpels Spuds CPR Microshield: Are you & your staff CPR certified? Considerations in Infection Control: Instrument Maintenance Disinfection or Sterilization? Which would you want for your eye? Heat or Chemical? Long-term effects of chemical disinfectionsterilization on stainless steel Corrosion Dulling Storage of instruments after disinfection or sterilization? 11

12 Non-disposable Instruments Disinfection / Sterilization Use disposable whenever possible Soaking & cleaning of instruments Disinfection / sterilization Storage Monitoring stored instruments Who is responsible for maintaining the system? Soaking & Cleaning Instruments Reduces bacteria on instrument surfaces Loosens, removes protein, blood Presoak 3% H 2 O 2 for minimum 10 minutes Ultrasound vs. scrubbing Scrub w/ heavy gloves Rinse w/ saline Chemical Disinfection/Sterilization Systems Relatively inexpensive Ideal for plastics, rubber Chemicals must be rinsed off instruments after cycle is complete- with what? Storage after disinfection or sterilization? Chemical Systems Alcohols- do not sterilize Chlorines- do not sterilize Phenols- do not sterilize Quaternary alcohols- do not sterilize Hydrogen peroxide- sterilizes in very high concentration Glutaraldehyde- high concentrations, temperature dependent Stinks! 12

13 Gluteraldehyde Activated by alkalinizing agent Alters bacterial, viral RNA & DNA Unpleasant 2% Sterilant- 37 o for 6 hrs. Disinfectant- 37 o for 2 hrs. Examples Cidex Plus 28-day Solution (Johnson & Johnson) Metricide 28 (Metrex Research Corp.) MaxiCide (Henry Schein Inc.) Replace every month Chemical Disinfection/ Sterilization Gluteraldehyde systems Phenols The original disinfecting agent Disrupt cell wall and precipitate proteins Some viruses, spores unaffected by phenols Commonly combined with glutaraldehyde Quaternary Ammonium /Alcohol Compounds Safest, fastest products on the market today Higher concentration of alcohol = faster kill time Available delivery forms Traditional ready-to-use liquid Convenient pre-saturated towelettes Disinfect but DO NOT STERILIZE 13

14 Chemical Disinfection/Sterilization OK for many applications in Optometry, but. Issues to consider How do you store after disinfection or disinfection? How often do you re-treat instruments? Heat Sterilization Kills by coagulating enzymes and proteins Dry heat Becoming the standard with many dentists Old systems were slow New heat sterilizers very fast Autoclaving Heat/Chemical combination Dry Heat Conventional Heat instruments at 320 for minutes Inefficient Inexpensive Rapid heat transfer Very popular in dentistry Expensive but very efficient Source- contact a dental supply for prices and information Dry Heat Disinfection & Sterilization 14

15 Autoclaving Saturated steam under pressure Boiling water does not kill spores 270 F for 4 minutes at 150 psi Total cycle 35 minutes Storage Instruments wrapped prior to sterilization Instruments dated, stored in see-through packages Expense moderate to high Newer office units smaller, less expensive Autoclaves: Cost $600 to $3000 Refurbished autoclaves available from dental suppliers Two Reasons Why It's So Hard To Solve An Arkansas Murder: 1. All the DNA is the same. 2. There are no dental records. Heat/Chemical (Chemiclave) Unsaturated chemical vapor under low pressure, high heat 270 at psi for minutes Chemicals (Vaposterile) include water, ethyl alcohol, and formaldehyde Moderate cost Instruments can be pre-packaged Disadvantages; unpleasant odor and incompatible with some plastics 15

16 Chemiclaves Unsaturated chemical vapor method is a lowhumidity process Instrument Storage No time-consuming drying phase is needed Use a solution containing alcohol, tend to be much less corrosive to instruments. Not-so-pleasant odor Used, refurbished chemiclaves available from dental suppliers 69 Diagnostic Contact Lens Disinfection Largely a non-issue due to disposables Non-disposables require disinfection Appropriate method depends on water content Diagnostic Contact Lens Disinfection Cleaning diagnostic lenses Proper cleaning reduces bacterial load on lenses by 99.99% Best accomplished by manual cleaning with bactericidal cleaner (Miraflow) Leach et al found that after cleaning with Miraflow, no bacteria were present on lenses 16

17 Diagnostic Contact Lens Disinfection Low water content lenses Always use heat when possible Contamination rate Heat 5% Chemical 67% Does not damage low water content lenses With time, heat treated lenses become contaminated in vials (Callendar et al) Re-treat with heat every month if possible Diagnostic Contact Lens Disinfection High water content lenses Heat reduces life of lens Meticulous cleaning with bactericidal cleaner Use system with maximum kill (Hydrogen peroxide, Optifree PureMoist, Biofinity) Re-treatment of lenses monthly Who Will Be King (Queen) Designate an infection control commissioner Must be self starter Must be consistent & persistent Everyone in the office is answerable including doctors Implementing Infection Control In Your Office Tomorrow Doctors, educate yourself first Educate a key infection control person Educate your entire staff Write a plan of action for each facet of infection control Basic procedures Instrument sterilization Contact lens disinfection Conduct staff training sessions Initiate and maintain a system 17

18 Implementation Of Infection Control In Your Office Designate an infection control person Dependable, meticulous, self-starter What level of disinfection / sterilization you want? Which system you want to use? Heat vs. Chemical Purchase the required materials Train and model- be a role model Maintain the system! Develop quality assurance controls Conclusion Optometry is becoming more involved in procedures that require infection control We are held to the same standard as other health care professionals If optometry fails to implement infection control we may be discovered - Ask any dentist The time to start an infection control program in your office is now! Let me know if I can help! drbilltownsend@gmail.com 18