High-Level Disinfection (HLD) and Sterilization Boosterpak

High-Level Disinfection (HLD) and
Sterilization BoosterPak
Table of Contents
LEADERSHIP
®
RISK ASSESSMENT
STERILIZATION
ENVIRONMENT OF CARE
HIGH-LEVEL DISINFECTION
HR – COMPETENCY AND TRAINING
APPENDIX – STANDARDS
Goal of this BoosterPak
To ensure work practices are carried out following regulatory

standards and evidence-based guidelines for HLD and
Introduction
sterilization in order to minimize the potential risk of
infection transmission to patients.
Primary Standard Governing HLD and/or Sterilization

TARGETED AUDIENCE Processes for All Settings:
Standard IC.02.02.01: EP2: Performing intermediate,
Front-line staff
Reducing the risk of infections associated high-level disinfection and
conducting HLD
and sterilization with medical equipment, devices, sterilization of medical equipment,
processes and supplies devices, and supplies
Supervisor/Manager Other Standards Governing HLD and/or Sterilization

of front-line staff
Processes for Each Setting:
Standard HAP CAH AMB OBS

Infection IC.01.01.01    
Preventionists    
IC.01.03.01
IC.01.05.01    
IC.02.01.01    
APPLICABLE SETTINGS IC.02.02.01    
IC.02.03.01    
 Hospitals (HAP)/ IC.03.01.01    
Critical Access Hospitals HR.01.02.01   
(CAHs) HR.01.04.01    
   
 Ambulatory (AMB) HR.01.05.03
HR.01.06.01    
 Office-based Surgery
LD.01.03.01    
Practice Settings (OBS)
LD.03.01.01    
LD.03.03.01    
LD.03.06.01    
Become acquainted LD.04.01.05    
with these Standards LD.04.01.11    
EC.02.05.01    
EC.02.04.03    
See the Appendix for
NPSG.07.01.01    
Standards Explanation
NPSG.07.03.01  
NPSG.07.05.01    
Introduction | 1
BACKGROUND
Healthcare organizations accredited by The Joint Commission continue to discover
serious noncompliance issues with the Infection Prevention and Control Standard
IC.02.02.01. These breaches are specific to HLD of semi-critical devices and sterilization
of critical devices; both pose a potential risk of infection to patients.
During accreditation surveys, organizations that perform HLD and sterilization display
wide variations in their processes. Penalties from identifying HLD and/or sterilization
breaches that may pose an immediate threat to life (ITL) can include an adverse
accreditation decision.
Noncompliance with Standard IC.02.02.01 by Setting
IC.02.02.01 Noncompliance
2009-2015
This graph illustrates the annual percentages from years 2009-2015 (half-year) of
noncompliance with Standard IC.02.02.01 scored during accreditation surveys in the
above noted settings, specific to surveyor identified findings with high-level disinfection
and sterilization breaches. AMB= Ambulatory, CAH= Critical Access Hospitals, HAP=
Hospitals, OBS= Office-based Surgery Practice Settings
Introduction | 2
THE SPAULDING CLASSIFICATION
The Spaulding Classification defines the minimum levels of disinfection (or sterilization)
that should be employed according to the infection risk associated with a medical device.
The system is divided into three categories of medical equipment and devices and their
recommended levels of disinfection or sterilization, shown in the below chart.

Device Minimum
Patient
Examples Classification Disinfection
Contact
Level
Low Level or
Intact Skin Non-Critical Intermediate
Level Disinfection
Mucous
Membranes or High Level
Semi-Critical Disinfection
non-intact skin
Sterile areas
of the body, Critical Sterilization
vascular system
A. Source: Healthcare Purchasing News (June 2014)

Q.
Semi-critical Devices – come into contact with intact mucous membranes but do
not ordinarily penetrate sterile tissue. Examples:
l Some endoscopes based on patient contact and manufacturer instructions for use
A-Z l Laryngoscope blades
l Respiratory therapy equipment
DEFINITIONS
Critical Devices – enter normally sterile tissue or the vascular system. Examples:
l Surgical instruments
l Cardiac catheters
l Implants
l Some endoscopes based on patient contact and manufacturer instructions for use
High-level Disinfection (HLD) – the process of complete elimination of all

microorganisms in or on a device, except for small numbers of bacterial spores.
Examples:
l Glutaraldehyde
l Hydrogen Peroxide
l Ortho-phthaldehyde (OPA)
Introduction | 3
A.
Q.
A-Z
Sterilization – validated process used to render a product free of all forms of viable
DEFINITIONS microorganisms. Examples:
l Steam (preferred method for sterilization of critical instruments that are not damaged
by heat, steam, pressure or moisture):

– gravity-displacement steam
– pre-vacuum steam
l Ethylene oxide (EO)
l Hydrogen peroxide gas plasma
l Peracetic acid-chemical sterilization
Immediate Threat to Life (ITL) – A threat that represents the most immediate
risk, and has or potentially may have, serious adverse effects on the health or safety of
the patient. These threats are identified on site by the surveyor.
Q&A
A. Q. Why is an understanding of the Spaulding Classification important?
Q. A. The Spaulding Classification defines the minimum levels of disinfection or
sterilization required for the three different categories of medical devices based
on intended use. Always defer to manufacturer’s instructions for use for cleaning,
REVIEW disinfection, and sterilization recommendations.
QUESTIONS
A-Z Q. What is High Level Disinfection (HLD)?
A. High Level Disinfection is the process of complete elimination of all
microorganisms in or on a device, with the exception of small numbers of bacterial
spores.
Q. How does one determine whether to HLD or sterilize a device or piece

of equipment?
A. Manufacturer instructions for use instructs the user on recommendations for HLD
and/or sterilization.
 Incidences of non-compliance with Standard IC.02.02.01

are on the rise in Joint Commission accredited facilities.
Important Takeaways
 Reduce/eliminate infections due to improperly disinfected
or sterilized medical devices by strictly implementing and
following Standard IC.02.02.01, EP2, related Standards,
and elements of performance (EPs).
 To properly disinfect or sterilize devices and instruments,

you must know in which Spaulding Classification Category
they belong and follow manufacturer instructions for use.
Introduction | 4
Leadership
®
Standards Governing Leadership and
Associated Elements of Performance (EPs)
Leadership
STANDARD LD.01.03.01 – EP5
(DOES NOT APPLY TO OBS)
The governing body is ultimately accountable for the safety and quality of care,
treatment, and services.
EXAMPLES OF EP5: The governing body provides for the resources needed to maintain safe, quality
RESOURCES INCLUDE: care, treatment, and services.
Human Human resources are provided such as staffing orientation, training, and certification if
Resources  required to support central sterile processing and/or high-level disinfection processes.
Equipment resources such as endoscopes, sterilizers, and surgical instruments are

Equipment  purchased and maintained, repaired, and replaced per manufacturer.
Appropriate space and location to safely conduct decontamination, high-level

Location  disinfection, sterilization, and storage is provided and maintained.
STANDARD LD.03.01.01
Create and maintain a culture of safety and quality.
EP3: Leaders provide opportunities for all individuals to participate in safety and quality
initiatives.
EP4: Leaders develop a code of conduct that defines acceptable behavior and behaviors
that undermine a culture of safety.
EP5: Leaders create and implement a process for managing behaviors that undermine a
culture of safety.
EP8: All individuals, including staff and licensed independent practitioners, are able to
EXAMPLES INCLUDE: openly discuss issues of safety and quality.
Front-line Front-line staff feel safe and are supported to report breaches in high-level disinfection
Staff  or sterilization.
Speaking Up to stop an error with high-level disinfection or sterilization is encouraged

Speaking Up  and supported.
Leadership | 2
Leaders use hospital wide planning to establish structures and processes that focus on
safety and quality.
EP4: Leaders provide the resources needed to support the safety and quality of care,
EXAMPLES INCLUDE:
Achieving Achieving short and long-term goals with expected or anticipated growth of procedures
Goals  that involve high-level disinfection and/or sterilization – to include off-site locations.
Designing high-level disinfection and sterilization work processes that focus on safety
Designing  and quality to prevent breaches that could pose infectious risks to patients.

Those who work in the hospital are focused on improving safety and quality.
EP4: Those who work in the hospital are competent to complete their assigned
EXAMPLES INCLUDE:
responsibilities.
Training  High-level disinfection and sterilization are both complex multi-step processes
that rely on competent individuals to assure that safety and quality are continually
recognized as driving factors. Initial and on-going competency, training, and adhering
to manufacturer’s instructions for use and evidence-based guidelines are important to
patient safety.
The organization effectively manages its programs, services, sites, and departments.
EP1: Leaders of the program, service, site, or department oversee operations.
EP3: The organization defines in writing the responsibility of those with administrative
and clinical direction of its programs, services, sites, or departments.
EP4: Staff are held accountable for their responsibilities.
The organization makes space and equipment available as needed for the provision of
care, treatment, and services.
EP2: The arrangement and allocation of space supports safe, efficient, and effective care,
treatment and services.
EP4: The grounds, equipment, and special activity areas are safe, maintained, and
supervised. (No CAH)
EP5: The leaders provide for equipment,supplies, and other resources. (No OBS).
CEO, Directors, management/supervisors, Infection Preventionists (those with oversight

LEADERSHIP INCLUDES:  responsibilities).
Leadership | 3
LEADERSHIP
OR’s | Clinics | ICU’s, Units, Floors | Endoscopy

Central Sterile Processing | Dental | Sleep Apnea Study Centers
Leaders at the program, service, site, or department level are

responsible for the care, treatment, and services provided.
• L
eaders develop policies and procedures that utilize medical equipment, devices,
and supplies that require high-level disinfection (HLD) and sterilization prior to use
on patients.
• There should be clearly defined, written, managerial and/or supervisory oversight that
includes knowledge and training of (HLD) and/or sterilization at the leadership level
(this will provide safe and effective HLD and sterilization processes).
• M
anagerial staff have knowledge of and use evidence-based guidelines to develop
education, training, and competency for high-level disinfection and sterilization.
• F
ront-line staff that are responsible for performing HLD and/or sterilization
are initially and routinely monitored to assure that all steps are being conducted
thoroughly and accurately (according to both the manufacturer’s instructions for
use and evidence-based guidelines).
• S pecific job responsibilities are noted within the job qualifications of each individual/
role. These includes HLD and/or sterilization tasks or oversight:
– Upon hire;
– On an ongoing frequency, as determined by the department hospital policy, or in
accordance with law and regulation;
– When new devices, supplies, or equipment are purchased; and
EXAMPLES INCLUDE: – When there is a change in a staff member’s role.
An OR manager is now responsible for Central Sterile Supply (central sterile processing
OR Manager  receives both instruments and endoscopes for HLD and sterilization).
Outpatient An outpatient clinic manager is now responsible for dental clinics (a decentralized
Clinic Manager  location that conducts sterilization).
A central sterilization technician trained to perform sterilization processes is now

Technician  expected to perform cleaning and processing of endoscopes.
Leadership | 4
A.
Q.
Q&A
REVIEW Q. According to Standard: LD.04.01.05 and EP1, who in the organization
QUESTIONS manages the programs, services, sites, and departments?
A-Z A. The Leaders of the programs, services, sites, or departments oversee and manage
operations.
Q. How do front-line staff who perform HLD and sterilization processes know
they are performing their jobs correctly?
A. Front-line staff that are responsible for performing HLD and/or sterilization
are initially and regularly monitored to assure that all steps are being conducted
thoroughly and accurately.
Q. Where can you find an individual’s specific job responsibilities?

A. It can be found in the individual’s job qualifications.
 The organization defines in writing the responsibility of

those with administrative and clinical direction of its
Important Takeaways programs, services, sites, or departments.
 L
eadership is ultimately responsible for the care,
treatment, and services provided within the organization.
 To be sure that front-line staff are performing HLD and

sterilization processes thoroughly and accurately, they
are to be monitored initially and regularly.
RESOURCES/LINKS
The following links are provided courtesy of the International Association of Healthcare
Central Service Material Management (IAHCSMM):
Immediately available: No Cost Resources. To access IAHCSMM educational materials:

www.iahcsmm.org/education/online-lessons.html
(Please note: access to the articles is free; readers will need to pay a fee to take the associated CE exam.)
Leadership | 5
Risk Assessment
®
Primary Standard IC.01.03.01
Risk Assessment
The organization identifies risks for acquiring and
transmitting infections.
INCLUDE THE FOLLOWING COMPONENTS AS PART OF

YOUR RISK ASSESSMENT:
Identify all locations where all or part of High-level Disinfection
(HLD) and Sterilization processes are conducted in your organization
(centralized and de-centralized locations):
l Clinics
l Emergency Rooms
l OB-GYN Clinics
l ORs
l Central Sterile Processing
l Special Procedure Rooms
l Sleep Apnea Study Labs
l Endoscopy Rooms
Know where all scopes, probes, and devices requiring HLD and
Sterilization are located in your organization:
&
l Clinics
l Emergency Rooms
l OB-GYN Clinics
l ORs
l Central Sterilization Processing
l Special Procedure Rooms
l Sleep Apnea Study Centers
l Intensive Care Units
Identify. l Radiology and Respiratory
Review, maintain, and conduct competency verification training of

Know. front-line staff and those that have oversight for HLD and Sterilization
processes, including:
Review. l
l
Managers
Supervisors
Insure. l Infection Preventionists
Know the location and accessibility of manufacturer’s instructions-for-

use for devices, equipment, supplies, and products such as:
l Sterilizers
l Endoscopes
l High-level disinfectant/Test Strips
l Ultrasonic Washers
l Instruments and automated endoscopic reprocessors (AERs)
Risk Assessment | 2
Location and accessibility of current evidence-based guidelines for the
use of front-line staff (including links to resources and websites; some
may need to be purchased):
l AAMI:
– ANSI/AAMI ST58, Chemical sterilization and high-level disinfection in health
care facilities (preview at http://my.aami.org/store/detail.aspx?id=ST58)
– ANSI/AAMI ST79, Comprehensive guide to steam sterilization and sterility
assurance in health care facilities (preview at http://my.aami.org/store/detail.
aspx?id=ST79)
– ANSI/AAMI ST91, Flexible and semi-rigid endoscope processing in health care
facilities (preview at http://my.aami.org/store/detail.aspx?id=ST91)
Insure that organizational/departmental policies and procedures are

current, reflect evidence-based guidelines, and the staff have knowledge
and access to these documents:
l ssure that staff conduct and articulate procedures that reflect content stated in the
A
organizational/departmental Polices & Procedures Manual
Include key stakeholders involved in HLD and Sterilization processes in

your risk assessment:
l Infection Preventionists
l Environmental Services
l Facilities/ENG
l Managers/Supervisors
l Front-line Staff
l Directors
Example of a Risk Assessment Chart
Infection Control Program Risk Assessment

Program Probability Risk/ Current
Components Impact (Health, Financial, Legal, Regulatory) Systems Score
Expect it Likely Maybe Rare Never Loss of Temp Prolonged Moderate Minimal None Poor Fair Good Solid
life/limb/ loss of Length of Clinical/ Clinical/
function Function Stay Financial Financial
4 3 2 1 0 5 4 3 2 1 5 4 3 2 1
High-level
disinfection (HLD)
Endoscopy
GYN Clinic
Sterilization
OR
Dental
Labor & Delivery
A risk assessment is conducted before HLD and sterilization goals are determined. Both
HLD and sterilization if performed in your healthcare facility, should be included in
your Risk Assessment and Infection Prevention and Control Plan, based on risk.
The IC Risk assessment is an ongoing, continual process, as risks continually change –

as new products or pieces of equipment are purchased, new staff are hired, or a new
program or service is added.
Risk Assessment | 3
HLD and Sterilization Start with a Risk Assessment Process
IC.01.03.01
Risk Assessment  IC.01.04.01
Set Goals  IC.01.05.01
IC Plan

 IC.02.01.01
IC.03.01.01 Implementation
Evaluation of the IC Plan
DESCRIPTION OF THE GRAPHIC

IC.01.03.01 – Potential risks are related to HLD and sterilization – specify area or site
IC.01.04.01 – Goals are specific to identified risks related to minimizing the risk of
KEY TO THE GRAPHIC:
transmission of infection with endoscopes, ultrasounds probes, and implants as examples.
 IC.01.03.01 Risk Assessment –

l Include a time frame (monthly, quarterly, annually) for your goals
The organization identifies risks l Be specific ( location or site, HLD or sterilization)
for acquiring and transmitting l Measurable (100%, or based on last year’s result of 90%, increase incrementally)
infections. l Be realistic in goal setting based on former data and feasibility
 IC.01.04.01 Goal –
Based on the identified risks, IC.01.05.01 Have an IC Plan and IC.03.01.01 Evaluation of IC Plan
IC.02.01.01 Implementation of IC Plan l Implementation complete
the organization sets goals
to minimize the possibility of l Use of evidence-based guidelines l Goals met
transmitting infections. l Manufacturer’s instructions for use l Decrease in HLD and/or sterilization
 IC.01.05.01 Infection l Competency and training breaches

Control Plan – l Managerial or supervisory oversight
The organization has an infection l IC involvement

prevention and control plan.
 IC.02.01.01 Implementation –
The organization implements RISK ASSESSMENT SHOULD INCLUDE THE FOLLOWING:
its infection prevention and l What are your organization’s vulnerabilities with HLD and/or sterilization?
control plan. l What is your volume of reprocessing for HLD and/or sterilization?
 IC.03.01.01 Evaluation – – How many endoscope procedures do you conduct daily? Weekly?
The organization evaluates l Where are procedures being conducted in your facility? Include off-site, decentralized
the effectiveness of its infection locations in the risk assessment.
prevention and control plan.
l Staff turnover. Competency and training issues. Frequency. Adequacy – Does it reflect
details of the HLD and sterilization process? Documentation is kept up-to-date in

employee file.
l Oversight of HLD and sterilization. Is the supervisor or manager who oversees the
process of HLD and/or sterilization competent to monitor front-line staff performing

these processes?
l Quality monitoring. Following manufacturer instructions for use and evidence-based
guidelines for conducting HLD and sterilization.

– Sterilization – physical, chemical, and biological indicators.
– HLD – testing of HLD solution between each use, temperature of high-level
disinfectant, time based on manufacturer instructions for use of the product, and test
strips are used as indicated and not expired.
l Preventative maintenance of equipment and devices such as: sterilizers, automated
endoscopic reprocessors (AERs), ultrasonic cleaners, and endoscopes.
Risk Assessment | 4
A.
Q.
Q&A
Q. W
hat components should be included in a Risk Assessment for HLD and
REVIEW Sterilization?
QUESTIONS A. These are the seven components that were presented in this module:
A-Z
l Identify all locations where all or part of HLD and Sterilization processes are
conducted (centralized and de-centralized locations);

l Know where all scopes, probes, and devices requiring HLD and Sterilization are
located in your organization;

l Review, maintain, and conduct ongoing competency and training of front-line
staff, and those that have oversight for HLD and Sterilization processes;
l Know the location and accessibility of the manufacturer’s instructions-for-use for
devices, equipment, supplies, and products which are involved in the HLD or
sterilization process;
l Become familiar with the location and accessibility of current evidence-based
guidelines for front-line staff use;

l Insure that organizational/departmental policies and procedures are current,
reflect evidence-based guidelines, and that the staff have knowledge and access to
these documents; and
l Include key stakeholders involved in HLD and Sterilization processes in your risk
assessment process review.
Q. When are Risk Assessment goals concerning HLD and Sterilization determined?
A. The goals are determined/set after a Risk Assessment has been conducted.
Q. W
hat would a specific goal look like based on an HLD or Sterilization Risk
Assessment?
A. An example of a specific goal would be: By a specific date, 100% of surgical
instruments transported to central sterile processing will be pre-cleaned at the point-
of-use to prevent blood/body fluids/bioburden from hardening on the instruments
as per evidence-based guidelines.
 The Infection Control Risk assessment is an ongoing and

continual process.
 The IC Risk Assessment must include:

–A
ssessment (identification) of risks for acquiring and
transmitting infections related to high-level disinfection
Important Takeaways and sterilization processes;
–G
oals based on the results of the Risk Assessment are
to minimize the possibility of transmitting infections
to patients;
–D
evelopment and implementation of the infection
prevention and control plan; and
–E
valuation of the effectiveness of the organization’s
infection prevention and control plan annually and
whenever risks significantly change.
 All stakeholders must be included in any Risk Assessment

in order to create both an accurate and successful Infection
Control Plan. Stakeholders include directors, managers
supervisors and front line staff of multiple departments.
Risk Assessment | 5
RESOURCES/LINKS
“Using the Risk Assessment to Set Goals and Develop the Infection Prevention and
Control Plan.” Joint Commission Resources. Web. http://www.jcrinc.com/using-the-
risk-assessment-to-set-goals-and-develop-the-infection-prevention-and-control-
plan/
Risk Assessment | 6
Sterilization
®
Sterilization and The Spaulding Classification
Use sterilization on critical devices that enter sterile tissue

or the vascular system.
Sterilization
APPLICABLE MEDICAL DEVICES
Those devices included in the critical category of the Spaulding Classification (a device
that enters sterile tissue or the vascular system). Such devices should be sterilized, which
is defined as the destruction of all microbial life. Examples:
TARGETED AUDIENCE
Front-line staff
conducting sterilization
processes
Surgical Orthopedic Dental Invasive

Instruments Implants Instruments Catheters
Supervisor/Manager
of front-line staff
Primary Standard Governing HLD and Sterilization for All Settings:
Infection Standard IC.02.02.01: EP2: Performing intermediate,

Preventionists Reducing the risk of infections associated high-level disinfection and
with medical equipment, devices, sterilization of medical equipment,
and supplies devices, and supplies
APPLICABLE SETTINGS
 Hospitals (HAP)/ Important

Critical Access Hospitals l ll locations where sterilization is conducted in your organization and where
A
(CAHs) instruments, devices, and equipment used for procedures that require
reprocessing by sterilization are kept (centralized and de-centralized
 Ambulatory (AMB) locations, such as clinics, ERs, and L&Ds)
l Initial and on-going competency and training of front-line staff and those
Practice Settings (OBS) with oversight for sterilization processes
l Location and accessibility of manufacturers’ instructions- for-use
(sterilization related equipment, devices, and supplies)

l Location and accessibility of current sterilization evidence-based guidelines
for front-line staff use (know which guidelines have been selected and
Important Things where are they located)
l Make sure that sterilization policies and procedures are current, reflect
to Know:
sterilization evidence-based guidelines, and that staff have a working
knowledge and access to these documents
l Include key stakeholders in sterilization process (Infection Preventionist,
Environmental Services, Facilities/ENG, leadership, central sterile manager

or supervisor, OR manager and front-line staff)
l Contracted services for equipment/loaner instrumentation:
– How are these services tracked and monitored?

– Does equipment/loaner instruments arrive in sufficient time to reprocess?
Sterilization | 2
Reprocessing Process for Sterilization
Point of Use/ Transport to

Preparation for Inspect/
Removal of Processing Sterilization Storage
Cleaning/Cleaning Package
gross soil Area


Manual Automated
CHECKLIST FOR STERILIZATION PROCESS
Point-of-Use
q Procedure completed
q Pre-cleaning with a product recommended for pre-cleaning with manufacturer’s
POINT-OF-USE instructions-for-use followed, that is applied at point-of-use in the procedure room
or O.R. to remove blood, body-fluids, and bioburden from items that are to be
re-processed based on manufacturer’s instructions-for-use and evidence-based
guidelines
q Items labeled as single-use disposable are disposed of and not reprocessed
q Use of a foam, gel, spray solution, or moist towel indicated per manufacturer to
keep instruments and devices moist during transport prevents blood/body fluids/
bioburden from hardening on the equipment
Notes:
– Instruments, devices, and supplies are to be kept moistened to make it easier to
clean in the decontamination room. This is particularly true if instruments have
to wait to be cleaned because other areas are also transporting instruments to the
decontamination area
– Pre-cleaning is the initial step to the sterilization process
Transport to Decontamination Area

q Items are contained to protect the transporter and others from contents within
the container
q Items are to be kept moist during transport to prevent hardening of bioburden
q The type of container used is based on what is being transported
TRANSPORT
q All containers must be leak-proof, puncture-proof, and labeled as biohazardous
q Examples: bins with lids, impermeable bags, etc.
Sterilization | 3
Decontamination – General
q Observe and monitor for carts of contaminated instruments left unattended in
corridors and for instruments left soaking in containers in de-centralized locations for
extended periods of time
q Delaying the decontamination process can cause bioburden to dry on instruments,
DECONTAMINATION making them more challenging to clean
In the Decontamination Room

q Personal Protective Equipment (PPE) is worn and includes:
– Hair covering/cap
– Face mask/shield
– Fluid resistant gown
– Gloves used should be durable to prevent tearing and leaking of chemicals and/or
contaminated fluids when the user’s hands are under water
q Note a distinct flow and separation of dirty and clean processes that minimizes the
risk of cross-contamination
Decontamination
q Hinged items are opened to assure access to proper cleaning
q Cleaning:
– Manual or performed by hand
– Mechanical or automated process
– Combination of manual and automated based on manufacturer’s instructions for
use and evidence-based guidelines
Prepping and Packaging

q Examples of packaging materials:
– Woven, non-woven textile wrappers
– Rigid sterilization containers
– Paper/plastic pouches (peel packs)
PREPPING q Items are wrapped and placed in paper/plastic peel-pouches based on what it is and
manufacturer’s instructions-for-use (IFU)
q Double paper/plastic peel-pouches are utilized as indicated by the manufacturer
instructions-for-use, with evidence-based guidelines being followed. No folding
over of the inner paper/plastic peel pouch, as this may prevent the sterilant from
contacting the contents of the package
– Use the proper size pouch for the proper instruments
Sterilization
q Cleaning, maintenance, and record keeping/documentation of sterilizer(s) based on
manufacturer’s IFU
STERILIZATION
q Cycles of sterilizer – test all cycles that your sterilizer is capable of performing
regardless of the cycle you use most often:
– Gravity displacement
– Dynamic air-removal
Sterilization | 4
Sterilization – Steam
q Is the most commonly used process for sterilizing instruments, trays, and cassettes
q According to the CDC, steam under pressure is the process of choice whenever
possible as it is considered safe, fast, and the most cost-effective for health care
facilities
STERILIZATION
q Steam sterilizers come in many different sizes, and sterilizer cycles can vary among
manufacturers. The cycle a sterilizer runs can typically be found in the sterilizer
manual. The following are examples of standard cycle parameters (AAMI ST79,
AORN) for packaged instruments. (The cycle selected should be appropriate for the
device(s) being sterilized per the medical device manufacturer’s IFU for sterilization.)
– Gravity – 121°C/250°F for 30 minutes exposure and 15–30 minutes drying time
– Gravity – 132°C/270°F for 15 minutes exposure and 15–30 minutes drying time
– Gravity – 135°C/275°F for 10 minutes exposure and 30 minutes drying time
– Dynamic Air Removal – 132°C/270°F for 4 minutes exposure and 20–30 minutes
drying time
– Dynamic Air Removal – 135°C/275°F for 3 minutes exposure and 16 minutes
drying time
Sterilization – Other Commercially Available Sterilization Processes

q Chemical vapor
q Dry heat
q Ethylene oxide
q Vaporized hydrogen peroxide
q Ozone
Each of these processes offer advantages and disadvantages. The decision as to which
sterilization process the health care facility should choose lies with the instrument
manufacturer and what was validated in their instructions-for-use. For patient safety the
process must be compatible so as not to cause damage, and must be efficacious to ensure
sterility. For additional information refer to CDC Guidelines on HLD and Sterilization.
Reference on page 11.
Sterile Storage
q Limited access, traffic controlled area
q Ventilation, temperature, and humidity (refer to evidence-based guidelines)
STORAGE q Housekeeping – routine cleaning of this area

q Shelf life – event-related versus expiration/date related
– Assures sterility maintenance
– Inventory control
q Sterile storage area must be a well-ventilated area that provides protection against
dust, moisture, insects, and temperature and humidity extremes
q Store sterile items so the packaging is not compromised (e.g., punctured, bent)
q Sterilized items include the following records: lot number, load contents, temperature
and exposure time, reviewer initials, Bowie-Dick testing, chemical indicator and
biological indicator results as appropriate
Sterilization | 5
MONITORING
Table 6 – Sterilization Process Monitoring Recommendations

Routine load release Routine sterilizer Sterilizer qualification Periodic product
efficacy monitoring testing (after instal- quality assurance
lation, relocation, testing
malfunctions, major
repairs, sterilization
process failures)
Nonimplants Implants
Physical monitoring Physical monitoring Physical monitoring Physical monitoring Physical monitoring
of cycle of cycle of cycle of cycle of cycle
External and internal External and internal External and internal External and internal Placement of BIs and,
chemical indicator chemical indicator chemical indicator chemical indicator CIs within product test
monitoring of packages monitoring of packages monitoring of packages monitoring of packages samples
Optional monitoring of Monitoring of every Weekly, preferably daily For sterilizers larger than 2
the load with a PCD load with a PCD (each day the sterilizer cubic feet and for flash
containing one of the containing a BI and a is used), monitoring with sterilization cycles,
following: Class 5 integrating a PCD containing a BI. monitoring of three
– a BI indicator (The PCD may also consecutive cycles in an
– a BI and a Class 5 contain a CI.) empty chamber with a PCD
integrating indicator containing a BI. (The PCD
– a Class 5 integrating may also contain a CI.)
indicator
– a Class 6 emulating For sterilizers larger than For table-top sterilizers,
indicator 2 cubic feet and for table- monitoring of three
top sterilizers, monitoring consecutive cycles in a fully
is done in a fully loaded loaded chamber with a PCD
chamber. containing a BI. (The PCD
may also contain a CI.)
In flash sterilization cycles,
monitoring is done in an
empty chamber.
For dynamic-air-removal For dynamic-air-removal

sterilizers, daily Bowie- sterilizers, monitoring of
Dick testing in an empty three consecutive cycles in
chamber an empty chamber with a
Bowie-Dick test pack
Reprinted from ANSI/AAMI ST79:2010, A1:2010, A2:2011, A3:2012, & A4:2013 with permission of Association for the Advancement of Medical Instrumentation.
© 2013 AAMI www.aami.org. All rights reserved. Further reproduction or distribution prohibited. For more information and context, please view the full AAMI standard.
Sterilization | 6
Table 7 – Types and Applications for Use of Sterilization Monitoring Devices
Monitor Frequency of Use

Application
(release of sterilizer, package, load)
PHYSICAL MONITORS
Time, temperature, and pressure Should be used for every load of every sterilizer. Part of load release criteria.
recorders, displays, digital
printouts, and gauges
CHEMICAL INDICATORS (CIS)
External CIs Should be used on outside of every package unless the Part of load and package release criteria.
Class I (process indicators) internal CI is visible. Test of sterilizer for efficacy of air removal
Bowie-Dick-type indicators For routine sterilizer testing (dynamic-air-removal and steam penetration; part of release
Class 2 (Bowie-Dick) sterilizers only), should be run, within a test pack, each criteria for using sterilizer for the day.
day in an empty sterilizer before the first processed load. Part of release criteria for placing sterilizer
For sterilizer qualification testing (dynamic-air-removal into service after qualification testing.
sterilizers only), should be run, within a test pack, after
sterilizer installation, relocation, malfunction, and major
repairs and after sterilization process failures; test should
be run three times consecutively in an empty chamber
after BI tests.
Internal CIs Should be used inside each package. Part of package release criteria at use site.
Should be used in periodic product quality Part of release criteria for changes
assurance testing. made to routinely sterilized items, load
configuration, and/or packaging. Release
criteria should include BI results.
Class 3 (single-variable indicator) May be used to meet internal CI recommendation. Part of package release criteria at use
Class 4 (multi-variable indicator) site; NOT to be used for release of loads.
Class 5 (integrating indicator) May be used to meet internal CI recommendation. Part of package release criteria at use site.
Within a PCD, may be used to monitor nonimplant Part of load release criteria for nonimplant
sterilizer loads. loads.
Within a PCD, should be used to monitor each sterilizer Part of release criteria for loads containing
load containing implants. The PCD should also contain implants. Except in emergencies, implants
a BI. should be quarantined until BI results are
known.
Class 6 (emulating indicator) May be used to meet internal CI recommendation. Part of package release criteria at use site.
Within a PCD, may be used to monitor sterilizer loads. Part of load release criteria for nonimplant
loads.
Part of release criteria for loads containing
implants. Implants should be quarantined
until BI results are known, except in
emergency situations.
Biological indicators (BIs) Within a PCD, may be used to monitor nonimplant loads. Part of load release criteria.
Within a PCD, should be used in every load containing Part of release criteria for loads containing
implants. The PCD should also contain a Class 5 implants. Implants should be quarantined
integrating indicator. until BI results are known, except in
Within a PCD, should be used for weekly, preferably daily emergency situations.
(each day the sterilizer is used), routine sterilizer efficacy Part of release criteria for loads containing
testing. (The PCD may also contain a CI.) Should be run implants. Except in emergencies, implants
in a full load for wrapped items; for table-top sterilization, should be quarantined until BI results are
should be run in a fully loaded chamber; for flash known.
sterilization, should be run in an empty chamber.
Part of sterilizer/load release and recall
Within a PCD, should be used for sterilizer qualification criteria.
testing (after sterilizer installation, relocation, malfunction,
Part of release criteria for changes
major repairs, sterilization process failures). (The PCD
made to routinely sterilized items, load
may also contain a CI.)
configuration, and/or packaging.
Test should be run three times consecutively in an
empty chamber, except for table-top sterilizers, where
the test should be run three times consecutively in a
full load. Should be used for periodic product quality
assurance testing.
Reprinted from ANSI/AAMI ST79:2010, A1:2010, A2:2011, A3:2012, & A4:2013 with permission of Association for the Advancement of Medical
Instrumentation. © 2013 AAMI www.aami.org. All rights reserved. Further reproduction or distribution prohibited. For more information and context, Sterilization | 7
please view the full AAMI standard.
Quality Monitoring – Mechanical or Physical Indicator
q A visible monitor such as a printout, used to determine if critical sterilization
parameters for each cycle (time, temperature, and pressure) were met during
the process.
q The printout should be reviewed and signed at the end of each cycle verifying
MONITORING that all sterilization parameters were met.
Quality Monitoring – Chemical Indicator

q A chemical indicator is a monitoring device that is used to monitor one or more
critical parameters required for sterilization. This is typically noted by a color change
on a tape or strip that indicates the item has been exposed (or processed versus not
processed) to the sterilization process.
q This does NOT indicate that the item is sterile.
q A chemical indicator should be used inside each package to be sterilized and also on
the exterior of the package if the internal indicator is not visible from the outside.
q There are 6 classes of CIs. The Class 5 indicators are integrating indicators which
react to all three of the critical variables and are appropriate for all steam cycles.
A Class 5 indicator is used with a biological indicator (BI) for all implant loads.
q Dynamic air-removal test (Bowie-Dick test) is a diagnostic test performed daily
to determine adequacy of air removal from the chamber of a pre-vacuum steam
sterilizer. This test is not a test of sterilization.
Quality Monitoring – Biological Indicator

q These are monitoring devices commercially prepared with highly resistant spores that
tests the effectiveness of the sterilization method in use.
q This indicator demonstrates that conditions necessary to achieve sterilization were
met during the cycle being monitored.
q Steam sterilizers should be tested with a BI at least weekly and preferably daily.
q Consult manufacturer’s instructions for testing of other sterilizers such as for
ethylene oxide.
q All loads containing an implant should be monitored with a BI and the implant
should be quarantined until results of the BI are known.
Quality Monitoring – AAMI ST79:2010 and Amendments

q 10.7.2.3 Test procedure: Each day that Biological Indicator (BI) tests are run, at least
one BI that is from the same lot but has not been exposed to the sterilant should be
incubated as a control in each incubator to verify the pre-sterilization viability of the
test spores, the ability of the media to promote growth of the test spores, and the
proper incubation temperature. Upon completion of the incubation period, the test
and control results should be read and recorded.
q 10.6.2 Release criteria for non-implants: Load release should be an active decision
that is based on the evaluation of all available data from the sterilization process for
the particular load. The decision to release a load should be made by an experienced
and knowledgeable person at the conclusion of the sterilization cycle. Loads that
do not meet the criteria for release should be clearly identified so that they are not
mistakenly distributed and used on a patient.
Sterilization | 8
Quality Monitoring – Per AAMI ST79:2010 (continued)
q 10.6.3 Release criteria for implants:
– As with all cycles, an experienced and knowledgeable person should review the
sterilizer chart or printout at the end of the sterilization cycle, as well as the
results of other indicators that have been used to monitor the sterilization process.
MONITORING The load should be quarantined until the results of the BI testing are available
(CDC, 2008).
– Releasing implants before the BI results are known is unacceptable and should be
the exception, not the rule.
q When documented medical exceptions dictate (e.g., the need for trauma-related
orthopedic screw-plate sets), it may be necessary to release an implantable device
before the BI results are known. In this case, the release of the device before the BI
results are known should be documented; the BI result obtained later should also be
documented. (See Annex L for examples of an implant log and an exception form.)
It is critical that this documentation be fully traceable to the patient.
q Emergency situations should be defined in written guidance, developed in
consultation with infection prevention and control, the surgeon, the OR manager,
and risk management. Steps should be taken to reduce the frequency of emergency
releases of implantable items. For example, ongoing periodic reviews of the exception
forms and implant logs could reveal consistent patterns of events that are causing
emergency release and that could be improved upon or reduced.
Annex L (Informative) – Example of Documentation of Premature Release of Implants
Implantable Devices Load Record
Date Description Dept. Time Sterilizer # Load # Date/time Date/ Early Date/time Released by
of implants sterilized BI in time and release? released (full name)
(specify incubator BI result to OR
AM/PM)
Reprinted from ANSI/AAMI ST79:2010, A1:2010, A2:2011, A3:2012, & A4:2013 with permission of Association for the Advancement of Medical Instrumentation.
© 2013 AAMI www.aami.org. All rights reserved. Further reproduction or distribution prohibited. For more information and context, please view the full AAMI standard.
Quality Monitoring – Event-related or Timed Expiration

q The shelf life of a packaged sterile item may be event related as stated by the
organization in their policy and procedure, based on evidence-based guidelines and
manufacturer’s instructions for use.
q If the integrity of the packaging is compromised, such as being wet or torn, then the
item must be repackaged and reprocessed before use; otherwise the item may be used
if no event has occurred to compromise the integrity of the packaging.
q Some organizations may use time storage which means that the label on the sterile
package is applied at sterilization with an expiration date; when the expiration date
occurs, the package must be reprocessed.
Quality Monitoring – Immediate Use Steam Sterilization (IUSS)

q Defined: Immediate use is the shortest possible time between a sterilized item’s
removal from the sterilizer and its aseptic transfer to the sterile field. Immediate Use
Steam Sterilization (IUSS) is for items not intended to be stored and used later.
q Consider the following before IUSS: Can the item undergo IUSS? Review and
adhere to manufacturer’s instructions for use regarding cycle type, temperature
setting, exposure time, and drying times.
Sterilization | 9
q IUSS does not imply that reprocessing steps are acceptably omitted, such as
appropriate cleaning and transport.
q Items are placed in approved/validated containers/trays for IUSS.
q Why is IUSS being conducted? – out of convenience, limited instruments/equipment
for the number of cases/procedures being conducted: these are reasons that are
MONITORING NOT supported by evidence based guidelines and should be addressed to eliminate
this practice.
q Loaner practices – receipt of loaner instruments too close to the scheduled case/
procedure time (review contract and address directly with vendor).
Reference: http://www.apic.org/Resource_/TinyMceFileManager/Position_Statements/
Immediate_Use_Steam_Sterilization_022011.pdf
A.
Q.
Q&A
REVIEW
QUESTIONS Q. What is the definition of critical devices, according to the Spaulding
A-Z Classification?
A. Those devices that are included in the critical category of the Spaulding Classification
are devices that enter sterile tissue or the vascular system. Such devices should be
sterilized, which is defined as the destruction of all microbial life.
Q. When a procedure is over, why should you pre-clean the instruments as soon as
possible and not delay the transport to the decontamination area?
A. Omitting or delaying pre-cleaning may cause bioburden to dry on instruments,
making them more challenging to clean and sterilize.
Q. What are the three types of indicators used to monitor sterilization parameters?
A. Mechanical or physical indicators, chemical indicators, and biological indicators. All
three parameters serve a purpose in quality monitoring of the sterilization process.
 Become familiar with the Spaulding Classification and

understand which instruments fall within the critical
category. Once you know this, you will be able to determine
Important Takeaways which instruments/devices must undergo sterilization as
opposed to HLD.
 Regardless of your position, learn all of the steps in the

sterilization process from Point-of-Use to the end of the
process, when the instruments are stored in the Sterile
Storage Room.
 Understand what Immediate Use Steam Sterilization (IUSS)

is and the criteria used to determine if devices can undergo
this method of sterilization.
Sterilization | 10
RESOURCES/LINKS
“2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities.”
Centers for Disease Control and Prevention (2008)
2015 AORN Guidelines for Perioperative Practice
Association for Professionals in Infection Control. APIC Text of Infection Control and
Epidemiology. 4th Edition. 2014. Print
“Checklist for Cleaning, Disinfection and Sterilization of Instruments and Flexible

Scopes:” Agency for Healthcare Research and Quality. http://ascsafetyprogram.org/
about-the-program/press-release?download=136:c2-checklist
“Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care

Facilities.” ANSI/AAMI ST79:2010 & A1:2010 & A2:2011 & A3:2012 & A4:2013
(Consolidated Text)
“Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for

Safe Care:” Centers for Disease Control and Prevention. http://www.cdc.gov/HAI/
settings/outpatient/checklist/outpatient-care-checklist-observations.html

Sterilization | 11
Environment of Care
®
Environment of Care
Standards Governing the Environment
of Care Standards
Applicable Standards that apply and are related to sterilization and/or high-level
disinfection (HLD) processes include the following::
STANDARD EC.02.04.03
The organization inspects, tests, and maintains medical equipment.
EP4: The organization conducts performance testing of and maintains all sterilizers
APPLICABLE SETTINGS
These activities are documented.
 Hospitals (HAP)/
Critical Access Hospitals EXPLANATION OF STANDARD
(CAHs) Identify, monitor, and document (maintain a log) all sterilizers for cleaning,
maintenance, and repairs. This includes all de-centralized or off-site locations with table-
 Ambulatory (AMB)
top sterilizers. Adhere to manufacturer’s instructions-for-use.
This may include working with other departments such a Facilities/ENG/Plant
Practice Settings (OBS)
Operations and/or contracted staff to assure compliance.
If an alternative equipment maintenance strategy is used, see standard EC.02.04.01 EP
4 through 7 for assessment and implementation instructions.
STANDARD EC.02.05.01
The organization manages risks with its utility systems.
APPLICABLE SETTINGS
EXPLANATION OF EP15 AND EP6
 EP15 (Manuals): In areas designed to control airborne contaminants (such as biological agents, gases,
Hospitals and Critical fumes, and dust), the ventilation system provides appropriate pressure relationships,
Care Hospitals air-exchange rates, and filtration efficiencies.
 EP6 (Manuals): Note: Areas designed for control of airborne contaminants include spaces such as:
Ambulatory and Office-based
l Operating rooms
Surgery Practice Settings
l Special procedure rooms (where a sterile procedure field is required)
l Caesarean Delivery rooms
l Rooms for patients diagnosed with or suspected of having airborne communicable
diseases (for example, pulmonary or laryngeal tuberculosis)
l Patients in “protective environment” rooms (for example, those receiving bone
marrow transplants)
l Laboratories
l Pharmacies
l Sterile supply rooms
The purpose of providing and maintaining controlled conditions in the OR, special
procedure rooms, Caesarean delivery rooms, airborne infection isolation rooms,
laboratories, pharmacies, and sterile storage rooms is to reduce the risk of airborne
contamination.
Environment of Care | 2
Room temperature, humidity, and ventilation should adhere to local, state, and federal
policies and regulations.
For further information, see Guidelines for Design and Construction of Health Care
Facilities, 2010 edition, administered by the Facility Guidelines Institute and published
by the American Society for Healthcare Engineering (ASHE)
PER EC.02.05.01 EP 15 (HAP AND CAH); PER EC.02.05.01

EP 6 (AHC AND OBS)
l The organization is expected to comply with the specified filtration, room
pressurization, and air exchange rates listed in the ventilation table as determined by
the rules and regulations adopted by the organization’s controlling authority for health
care construction and operations (typically their state health department or licensing
entity).
l I f the organization’s authority is silent, then TJC recognizes Guidelines for Design
and Construction of Hospitals and Health Care Facilities, 2010 edition, where the
ASHRAE I70, Ventilation Table 7-1 has been adopted.
l ther guidelines such as those published by AORN or AAMI, can be utilized by
O
the organization; again, this is only if the controlling authority is silent on the issue.
Organizations are to make the TJC surveyors aware of these requirements at the time
of their survey.
l There are clinics in which high level disinfection and table top sterilization may be
performed. Many of these areas do not have separate rooms for decontamination and
disinfection. They have, however, been set up to work in a one directional manner to
accommodate the dirty to clean layout of the room. This practice and process may
be acceptable as long as it reflects a dirty to clean process based on evidence-based
guidelines, and supporting departmental policy and procedure, with no risk of cross
contamination.
l dditionally, if the controlling authority (i.e., state health department or licensing
A
entity) is silent at the time for design – especially for the air exchanges, filtration, and
pressure relationships that would be required – then the organization must be able to
provide documentation that this space meets state regulations or 2010 FGI guidelines.
l There are no ventilation requirements for spaces where sterilization and/or
decontamination occurs in office-based surgery practices or general outpatient
facilities that are not ambulatory surgery centers (ASCs).
l or high-level disinfection of semi-critical devices, refer to ventilation recommendations
F
noted in ASHRAE 170-2008. Table 7-1. All other ventilation expectations would
follow those based on the chemical used (i.e., the Safety Data Sheet requirements).
GUIDELINES FOR STERILIZATION
Design requirements are not the same as clinical practice recommendations. Each has
a distinct purpose and intent. The ASHRAE/ASHE standards and FGI guidelines are
intended to establish the minimum design requirements and criteria that must be met
to construct an HVAC system that will support clinical functions during the life of a
building. The AAMI and AORN guidelines are intended to guide the daily operation of
the HVAC system and clinical practice once the health care facility is occupied.
Joint Interim Guidance: HVAC in the Operating Room and Sterile Processing
Department
FGI 2010 Guidelines
Design Parameters
Function of Pressure Minimum Minimum All Room Air Air Recirculated RH (k), Design Temperature
Space Relationship Outdoor Total Exhausted by Means of % (I), ºF/ºC
to Adjacent ach ach Directly to Room Units
Areas (n) Outdoors (j) (a)
Q&A
A. Q. How would you explain Standard EC.02.04.03 to a new employee?
Q. A. The organization identifies, monitors, and documents (maintain a log) all sterilizers
for cleaning, maintenance, and repairs. This includes all de-centralized or off-site
locations with table-top sterilizers. Adhere to manufacturer’s instructions-for-use.
REVIEW
Q. Standard EC.02.05.01 states: the organization manages risks with its utility
QUESTIONS
A-Z systems. Why is it important to maintain controlled conditions via the
ventilation system, especially in certain areas such as the O.R. and special
procedure rooms?
A. The purpose of providing and maintaining controlled conditions in the OR, special
procedure rooms, Caesarean delivery rooms, airborne infection isolation rooms,
laboratories, pharmacies, and sterile storage rooms is to reduce the risk of airborne
contamination.
Q. If a clinic does not have a separate room in which they perform high level
disinfection or table top sterilization, what is one of the most important rules
they must follow in order for this to be acceptable?
A. This practice and process may be acceptable as long as it reflects a dirty to clean
process based on evidence-based guidelines and supporting departmental policy and
procedure, with no risk of cross contamination.
 According to Standard EC.02.04.03, EP4: health care
facilities must identify, monitor, and document (maintain
a log) all sterilizers for cleaning, maintenance, and
repairs. This includes all de-centralized or off-site locations
Important Takeaways with table-top sterilizers. Adhere to manufacturer‘s
instructions-for-use.
 Standard EC.02.05.01, EP15 and EP6 addresses the

health care facility’s ventilation system. It’s important to
understand how the ventilation system works to reduce
airborne contaminants:
• In areas designed to control airborne contaminants
(such as biological agents, gases, fumes, and dust),
the ventilation system must provide appropriate
pressure relationships, air-exchange rates, and filtration
efficiencies.
• W
hen functioning properly, the ventilation system
plays an essential role in minimizing the spread of
contaminants and infection.
 Health care organizations are expected to comply with

the specified filtration, room pressurization, air exchange
rates, temperature ranges and relative humidity ranges
listed in the ventilation table as determined by the rules
and regulations adopted by the organization’s controlling
authority for health care construction and operations
(typically their state health department or licensing entity).
RESOURCES
AORN 2015 Guidelines for Perioperative Practice – Guideline for Sterilization
Guidelines for Design and Construction of Health Care Facilities, 2010 edition,
administered by the Facility Guidelines Institute and published by the American Society
for Healthcare Engineering (ASHE)
State licensing rules
High-level Disinfection
®
High-level Disinfection
High-level Disinfection (HLD)
Use HLD on semi-critical devices that come into

contact with mucous membranes and/or non-intact skin.
APPLICABLE MEDICAL DEVICES

Devices that are included in the semi-critical category of the Spaulding Classification
(Devices that come into contact with intact mucous membranes but do not ordinarily
penetrate sterile tissue). Examples:
TARGETED AUDIENCE
Front-line staff
conducting HLD
processes
Endoscope* Bronchoscope Laryngoscope Anorectal
Blades Catheters
Supervisor/Manager
of front-line staff
PRIMARY GUIDE FOR HLD IN ALL SETTINGS
Standard IC.02.02.01
Infection
Reducing the risk of infections associated with medical equipment, devices, and supplies
Preventionists
EP2: Performing intermediate, high-level disinfection and sterilization of medical
equipment, devices, and supplies
APPLICABLE SETTINGS
 Hospitals (HAP)/ Important

Critical Access Hospitals
l ll locations where HLD is conducted in your organization
A
(CAHs)
(centralized and de-centralized locations)
 Ambulatory (AMB) l here all scopes, probes, and devices requiring HLD are located
W
 Office-based Surgery (clinics, ERs, ICUs, Sleep Study Centers, etc.)
Practice Settings (OBS) l Initial and on-going competency and training of front-line staff, and
those that have oversight for HLD processes
l Location and accessibility of manufacturer’s instructions-for-use
(HLD related equipment, devices, and supplies)
Important Things l Location and accessibility of current HLD evidence-based guidelines
to Know
for front-line staff use
l Make sure that HLD policies and procedures are current, reflect
HLD evidence-based guidelines, and that staff have knowledge and
access to documents
l Include key stakeholders in HLD process (Infection Preventionist,
Environmental Services, Facilities/ENG, leadership, front-line staff)
and managers/supervisors
High-level Disinfection | 2
THE STEPS NECESSARY TO THOROUGHLY CLEAN AND HIGH-LEVEL DISINFECT
IMMERSIBLE GI FLEXIBLE ENDOSCOPES
Remember: Follow OSHA Bloodborne GI flexible endoscopes normally come in contact with intact mucous membranes and
Pathogen Regulations and Standard are classified by CDC guidelines as semicritical medical devices minimally requiring
precautions when Handling high level disinfection. Chemicals used to achieve HLD are capable of sterilization but
Contaminated Endoscopes when used at shorter contact times will destroy all vegetative bacteria, viruses, fungi,
mycobacteria and some but not all spores. Only chemicals cleared by the FDA as
All the steps of precleaning, leak testing,
high-level disinfectants or sterilants should be used for reprocessing endoscopes. Follow
cleaning, and rinsing must occur to
the manufacturer instructions for use for high-level disinfectants. This includes
prepare the endoscope for either a manual
immersion or contact time, temperature of the high-level disinfectant, and required
or automated disinfection process.
documented quality monitoring parameters.
SGNA High-Level Disinfection Cleaning Chart
1 PRECLEANING
Immediately
Wipe exterior of scope Suction scope with endoscope Clear the air and water Place fluid-tight video cap
with endoscopic detergent. detergent until fluid is clear channels according on scope and bring scope
and end by suctioning air to to the manufacturer’s to reprocessing area in
Note: Use a detergent covered container.
clear fluid from scope. Flush instruction.
formulated for use with
endoscopes. Do not use auxiliary water channel even
household or dish detergent. if it was not used.
Note: Two channel endoscope require aspiration of detergent through both channels.
2 LEAK TESTING
Leak test the endoscope according
to the manufacturer’s instructions.
Note: If a leak is detected, follow the
manufacturer’s instructions for decon-
Detach all removable parts tamination to avoid further damage.
except for fluid-tight video cap.
3 MANUAL CLEANING
Attach cleaning adapters to

endoscope. Immerse and
Brush all accessible soak the endoscope and
channels. its internal channels for the
Scrub, brush, soak For the suction valve Immerse and thor- period specified by the label.
Note: Clean brush Flush detergent solution
and rinse all remov- depress button to oughly clean exterior each time it exits
able parts in fresh clean valve channel of the endoscope in distal tip and umbilical through all of the following
endoscope detergent. opening. endoscope deter- cord. Brushing should channels (suction, biopsy,
gent using a lint free be repeated until no air/water, accessory and
sponge or cloth. debris is visible on the elevator wire) until clear of
brush. debris.
SGNA High-Level Disinfection Cleaning Chart (continued)

4 RINSE AFTER CLEANING 5 DISINFECTANT/STERILANT
Rinse the Endoscope Purge all channels with Immerse the cleaned, rinsed and air-purged endoscope
and removable parts air. Note: Dry the exterior and all removable parts in a high-level disinfectant or
thoroughly under run- of the endoscope with sterilant. Using the cleaning adapters, fill all channels with
ning water to remove a soft, lint-free cloth to the high-level disinfectant or sterilant until no air bubbles
residual detergent. prevent dilution of the are seen.
Flush all channels with HLD used in subsequent Note: If an automated reprocessor is used, place the endo-
water. steps. scope in the reprocessor and attach all channel adapters
according to the manufacturer’s instructions, Place valves
and other removable parts into the soaking basin of the
reprocessor unless the reprocessor has a dedicated space
for the accessories, reprocess these items separately.
RINSE AFTER HIGH-LEVEL

6 DISINFECTANT 7 DRYING
Thoroughly rinse all surfaces

and channels of the endo-
scope and its removable
parts with water to remove
all traces of the High-level
disinfectant or sterilant.
Note: If an automated reproces-
sor is used, ensure that rinsing
is performed by the machine.
Purge all channels Flush all channels with

with air. 70-80% alcohol to
Note: Avoid excessively facilitate drying. Purge all
high air pressure. channels with air.
8 STORAGE
Hang endoscopes vertically in a clean, well-ventilated

and dust-free area.
Note: Caps, valves and other detachable components
removed per manufacturer’s instructions.
CHECKLIST FOR CLEANING, HIGH-LEVEL DISINFECTION, AND/
GENERAL  OR STERILIZATION OF INSTRUMENTS AND FLEXIBLE SCOPES
q Copy of manufacturers’ current instructions for cleaning, disinfection, and/or

sterilization available for each instrument or scope
q Copy of manufacturers’ current instructions for use of sterilizer/automated endoscopic
reprocessor (AER)
q Cleaning instructions for scopes posted in cleaning area
q Copy of manufacturers’ instructions for each cleaning product, disinfectant, high-level
disinfectant, and designated test strips for the high-level disinfectant
q Appropriate personal protective equipment (PPE) available and used during
processing- (Head/hair covering, mask/face shield, goggles, utility gloves, and fluid
resistant gown)
q Flow of instruments is from dirty to clean with no cross-contamination (from clean to
dirty or dirty to clean)
q Staff should know by the clearly designated location what stage of the HLD process
a scope or instrument is in, whenever there is doubt if a step has been conducted or
completed, reprocess the device (start over)
q Instruments, equipment, and supplies labeled “single use disposable” are not
reprocessed or reused (ex. brushes)
q Written policies and procedures for HLD of scopes and probes are to include
preventative maintenance and storage, must be current, and front-line staff must have
knowledge of and access to these documents
q Competency evaluations should be completed for each employee on hire and
considerations for annual review as recommended by evidence-based guidelines; also
include random observations. Determine frequency of competency and training based
on staff turnover, purchasing new equipment or products, or a breach in the process
has been identified
q Processing log maintained: scope #, test strip results, immersion, initialed, and dated;
may refer to and use HLD manufacturer provided log form
ENDOSCOPIC
REPROCESSING
 High-level Disinfection (HLD) – Manual Process:
q Point-of-Use: Scope immediately wiped down at point of use (in the procedure
room) and channels flushed with enzymatic, detergent
q Transport: Scope is safely transported to the cleaning area/decontamination room
in a leak-proof, puncture resistant container/device labeled as biohazardous which is
POINT-OF-USE based on evidence-based guidelines, manufacturer instructions for use
q Decontamination:
– Scope is leak tested; if fails, finish processing, remove from service, and send for repair
– All
accessories are removed for cleaning or discarded if disposable – following
manufacturer’s instructions-for-use
TRANSPORT
– Scope and accessories immersed in measured enzymatic detergent
– Cleaning solution is changed after each scope is cleaned, based on manufacturer
instructions for use
– All channels and accessories thoroughly brushed with manufacturer recommended
DECONTAMINATION brushes
q High Level Disinfectant (HLD) solution and concentration monitored and
documented and dated as per manufacturer instructions for use
q If test strip fails while checking HLD minimum effective concentration, discard
& replace HLD; if problem with test strips, use different bottle – always check
expiration dates
q Test strips should be dated upon opening with the discard date as per manufacturer
instructions for use, and quality control conducted per label instructions
q High-level disinfectant used is FDA-approved; used per label directions (contact
time) all items completely submerged
q Temperature of the HLD meets HLD label instructions
q Soak time meets manufacturer’s label instructions
q Scopes rinsed 3 times with sterile water or tap water as per manufacturer’s
instructions-for-use; flushed with alcohol and compressed air after high-level
disinfection
q Scopes thoroughly dried before storage – there should be no staining at the base of
the storage cabinet which may reflect an inadequate drying process; may consider
reprocessing the scope
q Scopes vertically hung in a manner that prevents contamination; scope attachments
are dried and stored separately
q Scopes reprocessed per evidence-based guidelines, manufacturer, and organizational
policy
ENDOSCOPIC  High-level Disinfection (HLD) – Using an Automated Endoscope

REPROCESSING Reprocessor (AER)
q Point-of-Use: Scope is immediately wiped down at point of use (procedure room)
and channels flushed with enzymatic, detergent after procedure
q Transport: Scope is safely transported to the cleaning area/decontamination room
in a leak-proof, puncture resistant container/device labeled as biohazardous which is
POINT-OF-USE based on evidence-based guidelines, manufacturer instructions for use
q Decontamination:
– Leak test if AER doesn’t do this; if fails, finish processing, remove from service, send
for repair
TRANSPORT
– Manual cleaning, brushing is performed
q HLD solution concentration is checked and documented; changed if test strip fails
q Test strips dated with discard date as per manufacturer instructions for use and
quality control per label
DECONTAMINATION q Scope connection instructions posted near the AER; proper connectors used
q Scope and accessories connected correctly to AER
q Cycle run, meets HLD contact time and temperature
q AER set for triple rinse in accordance with manufacturer’s IFU
q On completion of cycle, if AER doesn’t include a drying process, flush channels with
alcohol and compressed air
q Scopes vertically hung in a manner that prevents contamination; scope attachments
are dried and stored separately
PREVENT INFECTIONS
Recommendations to prevent infections in outpatient settings: http://www.cdc.gov/
HAI/settings/outpatient/outpatient-care-guidelines.html
HLD Record Keeping – Sample Log Sheet for HLD Quality Monitoring

Date Test Strip Bottle First Opened: Do Not Use After (Date): Bottle Lot #:
QC Test Results: QC Test Date:
Tested By (Initials): Location/Dept:
Date Date Date Time Solution MEC Tested By Temp in ºF Comments

Solution Solution Solution Solution Test Results (Initials) Before Use
Opened Expires Tested Tested (circle one)
Pass Fail
Q&A
A. Q. What is meant by “flow of instruments or devices,” and in which direction
Q. should this always occur?
A. The term “flow of instruments or devices” pertains to the cleaning of instruments;
the flow is always from dirty to clean, with no risk of cross contamination.
REVIEW
Q. What are the steps involved when decontaminating scopes using the manual
QUESTIONS
A-Z HLD process?
A. Scope is leak tested; if fails, follow manufacturer instructions for a failed leak test,
remove from service, and send for repair.
– All accessories are removed for cleaning or discarded if disposable – following
manufacturer’s instructions-for-use
– Scope & accessories are fully immersed in measured enzymatic, detergent
– Cleaning solution changed after each scope is cleaned per manufacturer
– All channels and accessories thoroughly brushed with manufacturer brush(es)
Q. When using an AER, how many rinses should scopes go through?

A. The AER should be set for triple rinses based on manufacturer’s instructions-for-use
and evidence-based guidelines.
 Become familiar with the Spaulding Classification and

understand which instruments or devices fall within the
semi-critical category. When you know this and follow
the manufacturer instructions for use, you will be able to
Important Takeaways determine which instruments/devices undergo HLD
 W hen transporting a “dirty” scope from the procedure
room, always make sure that it is safely moved to
the cleaning area/decontamination room in a leak
proof, puncture resistant container/device labeled as
biohazardous as per evidence-based guidelines
 Always change the cleaning solution after each scope.
DON’T re-use the solution. When changing the solution
always measure accurately, don’t approximate
RESOURCES/LINKS
“2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities.” (2008)
“2016 AORN Guidelines for Perioperative Practice. Guideline for Processing Flexible
Endoscopes.
(Consolidated Text)
“Chemical Sterilization and High-level Disinfection in Healthcare Facilities.” • ANSI/
AAMI ST58:2013 (2013)
“Flexible and Semi-rigid Endoscope Processing in Health Care Facilities.” • ANSI/AAMI
ST91:2015 (2015)
SGNA 2016. Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal
Endoscopes: http://www.sgna.org/Portals/0/Standards%20for%20reprocessing%20
endoscopes_FINAL_2016.pdf

HR – Competency
and Training
HR – Competency and Training | 1

Standards That Apply to HR –
HR – Competency
Competency and Training
and Training
HR.01.02.01 HR.01.04.01 HR.01.05.01 HR.01.06.01



Defines Staff Provides Participate Staff are

Qualifications Orientation in Ongoing Competent
to Staff Education and to Perform Their
Training Responsibilities
RESPONSIBILITIES
l High-level disinfection and sterilization – complex processes (with multiple
important steps) that require front-line staff and those responsible for its oversight
to be competent and trained initially and on an ongoing basis as defined by
the organization
l Training and competencies – to be documented and maintained in the employee
record or file
l New products, devices, and equipment – continually being added along with new
front-line staff, supervision, and services. It is critical to the positive outcome of a
patient’s procedure that instruments are sterilized and endoscopes and probes are
high-level disinfected (as recommended by the device manufacturer and evidence-
based guidelines)

A.
Q.
Q&A
Q. How often should front-line staff and supervisors responsible for HLD and
REVIEW sterilization processes receive training in order to maintain their competency
QUESTIONS status?
A-Z
A. They must be trained initially and on an ongoing basis at least every three years, or
as defined by organizational policy, law, and regulation.
Q. Where should training records of individual staff members be stored?

A. Records documenting a staff member’s and supervisor’s training and competency
must be stored in their employee record or file.
Q. W
hy must instruments be sterilized and endoscopes and probes undergo
HLD procedures, as recommended by the device manufacturer and evidence-
based guidelines?
A. This is done in order to insure the positive outcome of a patient’s procedure to
minimize the risk of transmitting an infectious agent to the patient.
 HLD and sterilization are complex processes that require

front-line staff and those responsible for its oversight to
Important Takeaways be competent and trained not only initially, but on an
ongoing basis as defined by the organization.
 Records documenting a staff member’s training and

competency must be stored in their employee record
or file.
 It is critical to the positive outcome of a patient’s

procedure that instruments are sterilized and endoscopes
and probes are high-level disinfected (as recommended by
the device manufacturer and evidence-based guidelines).
RESOURCES/LINKS
“2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities.”
Centers for Disease Control and Prevention (2008)
2016 AORN Guidelines for Perioperative Practice. Guideline for Processing Flexible
Endoscopes.
SGNA 2016. Standards of Infection Prevention in Reprocessing Flexible

Gastrointestinal Endoscopes: http://www.sgna.org/Portals/0/Standards%20for%20
reprocessing%20endoscopes_FINAL_2016.pdf

Association for Professionals in Infection Control. APIC Text of Infection Control and
Epidemiology. 4th Edition. 2014. Print:
l
Chapter 31 Cleaning, Disinfection, and Sterilization
l
Chapter 55 Endoscopy
l
Chapter 106 Sterile Processing
“CDC Patient Notification Toolkit.” CDC. Web. 2013.

http://www.cdc.gov/injectionsafety/pntoolkit/
“This toolkit is intended to be used after a healthcare facility or health department has made the decision to conduct
a patient notification.”

(Consolidated Text)
“Multisociety Guideline on Reprocessing Flexible Gastrointestinal Endoscopes (2011).”

American Society for Gastrointestinal Endoscopy (ASGE) (2011).
“Chemical Sterilization and High-level Disinfection in Healthcare Facilities.” • ANSI/

AAMI ST58:2013 (2013)
“Flexible and Semi-rigid Endoscope Processing in Health Care Facilities.” • ANSI/AAMI

ST91:2015 (2015)


Appendix – Standards
®
Appendix – Standards
Standards Relating to HLD and/or
Sterilization Processes
IC.01.01.01
The organization assigns responsibility for the daily management of infection prevention
and control activities.
IC.01.03.01
Requires organizations to identify risks for acquiring and transmitting infections.
IC.01.05.01
The organization has an infection prevention and control plan.
IC.02.01.01
The hospital implements its infection prevention and control plan.
IC.02.02.01
The organization reduces or eliminates the risk of infections associated with medical
equipment, devices, and supplies.
IC.02.03.01
The organization works to prevent the transmission of infectious disease among patients,
licensed independent practitioners, and staff.
IC.03.01.01
The organization evaluates the effectiveness of its infection prevention and control plan
annually and whenever risks significantly change.
HR.01.02.01
The organization’s leaders allocate needed resources for the infection prevention and
control program.
HR.01.04.01
The hospital orients its staff to the key safety content before staff provides care,
treatment, and services. Completion of this orientation is documented.
HR.01.05.03
Staff participate in ongoing education and training.
HR.01.06.01
Staff are competent to perform their responsibilities.
LD.01.03.01 – OBS (Office-Based Surgery Setting)

Practice leaders are ultimately accountable for the safety and quality of care, treatment,
or services.
LD.01.03.01 – Hospital (HAP)

Appendix – Standards | 2
LD.01.03.01 – Ambulatory (AMB)
Governance is ultimately accountable for the safety and quality of care, treatment, or
services.
LD.01.03.01 – Critical Access Hospitals (CAH)


Leaders create and maintain a culture of safety and quality throughout the practice.

Leaders create and maintain a culture of safety and quality throughout the hospital.

Leaders create and maintain a culture of safety and quality throughout the organization.

Leaders create and maintain a culture of safety and quality throughout the critical access
hospital.

Leaders use practice-wide planning to establish structures and processes that focus on
safety and quality.

Leaders use hospitalwide planning to establish structures and processes that focus on
safety and quality.

Leaders use organizationwide planning to establish structures and processes that focus
on safety and quality.

Leaders use critical access hospitalwide planning to establish structures and processes
that focus on safety and quality.

Those who work in the practice are focused on improving safety and quality.

Those who work in the hospital are focused on improving safety and quality.

Those who work in the organization are focused on improving safety and quality.

Those who work in the critical access hospital are focused on improving safety and
quality.
LD.04.01.05
The organization effectively manages its programs, services, sites, or departments.
LD.04.01.11
The organization makes space and equipment available as needed for the provision of
care, treatment, and services.
EC.02.04.03
The organization inspects, tests, and maintains medical equipment.
EC.02.05.01
The organization manages risks associated with its utility systems.
NPSG.07.01.01
Comply with either the current Centers for Disease Control and Prevention (CDC)
hand hygiene guidelines or the current World Health Organization (WHO) hand
hygiene guidelines.
NPSG.07.03.01
Implement evidence-based practices to prevent health care–associated infections due to
multidrug-resistant organisms in acute care hospitals.
NPSG.07.05.01
Implementing evidence-based practices for preventing surgical site infections.

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High-Level Disinfection (HLD) and

HR – COMPETENCY AND TRAINING

To ensure work practices are carried out following regulatory

Primary Standard Governing HLD and/or Sterilization

Supervisor/Manager Other Standards Governing HLD and/or Sterilization

Standard HAP CAH AMB OBS

APPLICABLE SETTINGS IC.02.02.01    

 Hospitals (HAP)/ IC.03.01.01    

Critical Access Hospitals HR.01.02.01   

Become acquainted LD.04.01.05    

with these Standards LD.04.01.11    

Noncompliance with Standard IC.02.02.01 by Setting

A. Source: Healthcare Purchasing News (June 2014)

A-Z l Laryngoscope blades

l Respiratory therapy equipment

High-level Disinfection (HLD) – the process of complete elimination of all

by heat, steam, pressure or moisture):

l Hydrogen peroxide gas plasma

l Peracetic acid-chemical sterilization

Q. How does one determine whether to HLD or sterilize a device or piece

 Incidences of non-compliance with Standard IC.02.02.01

 To properly disinfect or sterilize devices and instruments,

Equipment resources such as endoscopes, sterilizers, and surgical instruments are

Appropriate space and location to safely conduct decontamination, high-level

Speaking Up to stop an error with high-level disinfection or sterilization is encouraged

STANDARD LD.03.06.01 – EP4

EP1: Leaders of the program, service, site, or department oversee operations.

EP4: Staff are held accountable for their responsibilities.

CEO, Directors, management/supervisors, Infection Preventionists (those with oversight

OR’s | Clinics | ICU’s, Units, Floors | Endoscopy

Leaders at the program, service, site, or department level are

A central sterilization technician trained to perform sterilization processes is now

Q. Where can you find an individual’s specific job responsibilities?

 The organization defines in writing the responsibility of

 To be sure that front-line staff are performing HLD and

Immediately available: No Cost Resources. To access IAHCSMM educational materials:

INCLUDE THE FOLLOWING COMPONENTS AS PART OF

Identify. l Radiology and Respiratory

Review, maintain, and conduct competency verification training of

Insure. l Infection Preventionists

Know the location and accessibility of manufacturer’s instructions-for-

Insure that organizational/departmental policies and procedures are

Include key stakeholders involved in HLD and Sterilization processes in

Example of a Risk Assessment Chart

Infection Control Program Risk Assessment

The IC Risk assessment is an ongoing, continual process, as risks continually change –

DESCRIPTION OF THE GRAPHIC

 IC.01.03.01 Risk Assessment –

 IC.01.05.01 Infection l Competency and training breaches

The organization has an infection l IC involvement

details of the HLD and sterilization process? Documentation is kept up-to-date in

process of HLD and/or sterilization competent to monitor front-line staff performing

guidelines for conducting HLD and sterilization.

endoscopic reprocessors (AERs), ultrasonic cleaners, and endoscopes.

conducted (centralized and de-centralized locations);

located in your organization;

guidelines for front-line staff use;

l Hydrogen peroxide gas plasma

l Peracetic acid-chemical sterilization

Q. How does one determine whether to HLD or sterilize a device or piece

 Incidences of non-compliance with Standard IC.02.02.01

 To properly disinfect or sterilize devices and instruments,

 The organization defines in writing the responsibility of

 To be sure that front-line staff are performing HLD and

 IC.01.03.01 Risk Assessment –

 IC.01.05.01 Infection l Competency and training breaches

 The Infection Control Risk assessment is an ongoing and

 The IC Risk Assessment must include:

 All stakeholders must be included in any Risk Assessment

STORAGE q Housekeeping – routine cleaning of this area

 Become familiar with the Spaulding Classification and

 Regardless of your position, learn all of the steps in the

 Understand what Immediate Use Steam Sterilization (IUSS)

 Standard EC.02.05.01, EP15 and EP6 addresses the

 Health care organizations are expected to comply with

q Copy of manufacturers’ current instructions for cleaning, disinfection, and/or

 Become familiar with the Spaulding Classification and

Q. Where should training records of individual staff members be stored?

 HLD and sterilization are complex processes that require

 Records documenting a staff member’s training and

 It is critical to the positive outcome of a patient’s