Much modern medical equipment is labeled “disposable.” When resources are scarce, the luxury of not reusing serviceable medical equipment cannot be sustained. On the other hand, safety regarding equipment reuse is paramount. Patients should not be put at risk either through introducing infections from previously used equipment or by using malfunctioning equipment. This chapter discusses the guidelines and techniques for reusing, cleaning, and sterilizing medical equipment.

Major governments do not agree on their recommendations regarding the reuse of single-use devices (SUDs). The US policy across several agencies is that SUDs can be reused.

A US government panel of experts stated that in resource-scarce situations, equipment and supplies “will be rationed and used in ways consistent with achieving the ultimate goal of saving the most lives (e.g., disposable supplies may be reused).” However, they also said guidelines are needed on “how to use and reuse common supplies and equipment, such as gloves, gowns, and masks.”¹

The US Food and Drug Administration (FDA) found “no data to indicate that people are being injured or put at increased risk by the reuse of SUDs,”² while acknowledging that many SUDs are commonly reused. Among these are many types of equipment, including those used in dentistry, orthodontics, otolaryngology, and laparoscopy. Specific equipment includes needles, scalpels, forceps, trocars, saw blades, staplers, drills, scissors, masks, syringes, gowns, and biopsy devices.³ The problems found with reusing SUDs include a “loss of elasticity in inflatable balloons, persistence of blood and biofilms, loss of original lubricants and resultant effect on catheter threading, and crystallization of liquid x-ray contrast material.”³ The FDA recently advised that “single-use sterile devices that do not have reprocessing instructions should not be reprocessed.” They did not comment on resource-poor situations.⁴

The US Centers for Disease Control and Prevention (CDC) states that “in general, reusable medical devices or patient-care equipment that enters normally sterile tissue or the vascular system or through which blood flows should be sterilized before each use.”⁵ Except in rare and special instances, items that do not ordinarily touch the patient or that touch only intact skin are not involved in disease transmission and generally do not necessitate disinfection between uses on different patients. Special rules apply when patients are infected or colonized with drug-resistant or highly virulent microorganisms. In these cases, the CDC recommends that noncritical items be dedicated to one patient or patient cohort (someone with the same contagious illness) or that this equipment be subjected to low-level disinfection between patient uses. Reusable items that touch mucous membranes should, at a minimum, receive high-level disinfection between patients.⁵

The US Government Accounting Office (GAO) concluded that there is no evidence that reprocessed SUDs create an elevated health risk for patients. Testifying before the US Congress, Dr. Kenneth Kizer, a former undersecretary for health at the US Department of Veterans Affairs, said, “Single-use labeling is a real scam for a lot of devices, and by not using reprocessed devices where possible, it is wasteful and not environmentally responsive, since these items have to be disposed of as biomedical waste.”⁶

Members of the European Community have multiple conflicting policies on reusing SUDs, with some allowing it, others regulating it, and some banning it.⁷

The infection risk that medical equipment poses to patients can be stratified according to its use into (a) high risk, (b) intermediate risk, and (c) low risk. Each group, under normal circumstances, has different decontamination requirements.

1. 
   

   High-risk items (sterilization required) come into close contact with breaks in the skin or mucous membranes or are introduced into a normally sterile body area. These include surgical instruments, needles, endoscopes used in sterile body cavities and their irrigation systems and biopsy accessories, and urinary or other catheters.⁴

   
   
2. 
   

   Intermediate-risk items (disinfection required) come into close contact with mucous membranes or are items contaminated with particularly virulent or readily transmissible organisms. These include most respiratory equipment, for example, laryngoscope blades, endotracheal and tracheostomy tubes, and oropharyngeal and nasal airways.

   
   
3. 
   

   Low-risk items (cleaning required) come into contact only with normal intact skin. These include stethoscopes, other physical examination equipment, stretchers and wheelchairs, and electrocardiogram (ECG) and electroencephalography (EEG) leads.⁸

Cleaning, disinfection, and sterilization all decontaminate medical equipment. Decontamination is the general term describing any method of reducing the risks of cross infection—passing microbes from one infected person to a previously uninfected person.⁸

Table 6-1 contains recommended processes for decontaminating and, then, cleaning different types of medical equipment that can easily be accomplished in most settings.

When using chlorine solutions, avoid prolonged exposure of the equipment, because this causes metal to rust and rubber and cloth to deteriorate. To avoid dulling the edges, do not sterilize needles or instruments with a cutting edge at temperatures >160°C (320°F).

Cleaning is the process of removing any visible dirt or secretions, including dust, soil, large numbers of microorganisms, and organic matter (e.g., blood, vomit) on which microorganisms grow. Cleaning must be done before equipment is disinfected or sterilized; not doing so can impede effective disinfection or sterilization.⁸

Especially in austere circumstances, “clean items are sufficient to prevent infection in the majority of cases. For the vast majority of minor cuts and lacerations, clean is fine.”⁹ Note that SUD needles cannot be cleaned adequately.

Method

Cleaning normally involves washing the equipment with detergent (soap) and water.⁸ Mix fresh dilute soap solutions (and other disinfectant solutions) every 24 hours and store them in a cool place: Bacteria may grow in dilute solutions (but not in concentrated solutions).

Clean equipment immediately after use. First, remove blood and other visible dirt by washing equipment thoroughly with warm water without soap. Then wash thoroughly with warm water and soap, rinse with water, and dry completely. Leave scissors and forceps open while drying.¹⁰ Clean surgical instruments with a small brush, such as a soft toothbrush.¹¹

Maintenance and Packing

Once the equipment is clean, perform any necessary maintenance (e.g., tighten screws, sharpen edges) and pack them for use or prepare them for disinfection or sterilization.

Disinfection is a process used to reduce the number of microorganisms, although not usually bacterial spores. The process does not necessarily kill or remove all microorganisms, but simply reduces their number to a level that is not harmful to health.⁸ The CDC recognizes three levels of disinfection: high, intermediate, and low.⁵

High-level disinfection methods kill all organisms, except when there are large numbers of bacterial spores, with a chemical germicide such as bleach or ethyl alcohol. Intermediate-level disinfection procedures kill mycobacteria, bacteria, and most viruses by using a chemical germicide registered as a “tuberculocide” by the US Environmental Protection Agency. Low-level disinfection kills some viruses and bacteria by using a chemical germicide such as soap.

Usefulness

While the effectiveness of disinfection depends on the method and the disinfectant that are used, some general principles apply⁸: