Court Opinion

ID: 4052794
Source: CourtListenerOpinion
Date Created: 2016-09-29 02:07:40.224409+00
Date Added: 2024-06-11T14:27:05.462987
License: Public Domain

ACCEPTED
                                                                                12-14-00220-CV
                                                                   TWELFTH COURT OF APPEALS
                                                                                 TYLER, TEXAS
                                                                            9/4/2015 3:01:53 PM
                                                                                      Pam Estes
                                                                                         CLERK

                                      ORAL ARGUMENT REQUESTED

                    No. 12-14-00220-CV                       FILED IN
                                               12th COURT OF APPEALS
     _______________________________________________
                                                            TYLER, TEXAS
                                                        9/4/2015 3:01:53 PM
              COURT OF APPEALS                                PAM ESTES
                                                                Clerk
                            for the

             TWELFTH DISTRICT OF TEXAS

                       Tyler, Texas
     _______________________________________________

          EAST TEXAS MEDICAL CENTER GILMER
                                  Appellant,

                               v.

                      BIRDER PORTER
                                            Appellee.
     _______________________________________________

                Appeal from Cause No. 697-13
               th
            115 District Court, Upshur County, Texas
            Honorable Lauren Parish, Presiding Judge
     _______________________________________________

APPELLANT’S SUPPLEMENTAL BRIEF ON APPLICATION OF
        ROSS v. ST. LUKE’S EPISCOPAL HOSPITAL
    _______________________________________________

                      Russell G. Thornton
          THIEBAUD REMINGTON THORNTON BAILEY LLP
                      Two Energy Square
               4849 Greenville Avenue, Suite 1150
                     Dallas, Texas 75206
                  (214) 954-2200 – Telephone
                  (214) 754-0999 – Telecopier

          ATTORNEYS FOR DEFENDANT – APPELLANT
            EAST TEXAS MEDICAL CENTER GILMER

                      September 4, 2015
                                         TABLE OF CONTENTS

INDEX OF AUTHORITIES ....................................................................................iv

SUMMARY OF ARGUMENT ................................................................................ 2

ARGUMENT ............................................................................................................6

         I.       Limited Scope and Application of Ross ............................................... 6
         II.      Appellee’s Claim Is An HCLC Under Ross ......................................... 7
         III.     Substantive Nexus to Health Care Exists ...........................................16

CONCLUSION .......................................................................................................21

PRAYER .................................................................................................................24

CERTIFICATE OF COMPLIANCE ......................................................................25

CERTIFICATE OF SERVICE ...............................................................................26

APPENDIX ........................................................................................... INDEX TAB

         1.       Ross v. St. Luke’s Episcopal Hosp., 462 S.W.3d 496 (Tex. 2015)

         2.       Loaisiga v. Cerda, 379 S.W.3d 248 (Tex. 2012)

         3.       Yamada v. Friend, 335 S.W.3d 192 (Tex. 2010)

         4.       42 C.F.R., §§482.1 and 482.11

         5.       42 C.F.R., §482.21

         6.       42 C.F.R., §§482.41 and 482.42

         7.       25 TEX. ADMIN. CODE, §133.1

         8.       25 TEX. ADMIN. CODE, §133.41

         9.       25 TEX. ADMIN. CODE, §133.142

                                                            i
10.   TEXAS HEALTH & SAFETY CODE, Chapter 241

11.   Excerpts from the CMS State Operations Manual, Appendix A,
      Survey Protocol, Regulations and Interpretive Guidelines for
      Hospitals. (This is a 510-page document, a complete copy of which is
      available      at       –      https://www.cms.gov/Regulations-and-
      Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf)

12.   Centers for Medicare & Medicaid Services, Hospital Infection Control
      Worksheet       (accessed      from    and    available     at     –
      https://www.cms.gov/Medicare/Provider-Enrollment-and-
      Certification/SurveyCertificationGenInfo/Downloads/Survey-and-
      Cert-Letter-15-12-Attachment-1.pdf)

13.   Rutala WA, Weber DJ, and the Healthcare Infection Control Practices
      Advisory Committee, Guideline for Disinfection and Sterilization in
      Healthcare Facilities, 2008, U.S. Department of Health and Human
      Services, Centers for Disease Control and Prevention (2008)

14.   Sehulster LM, Chinn RYW, Ardino MJ, Carpenter J, et al., Guidelines
      for Environmental Infection Control in Health-Care Facilities, U.S.
      Department of Health and Human Services, Centers for Disease
      Control and Prevention (2003)

15.   Occupational Safety & Health Administration, Hospital eTool
      (accessed       from       and         available at       –
      https://www.osha.gov/SLTC/etools/hospital/)

16.   Occupational Safety & Health Administration, Housekeeping,
      Hospital   eTool (accessed      from and       available at –
      https://www.osha.gov/SLTC/etools/hospital/housekeeping/housekeepi
      ng.html)

17.   Occupational Safety & Health Administration, Healthcare Wide
      Hazards Slips, Trips and Falls, Hospital eTool (accessed from and
      available                          at                               –
      https://www.osha.gov/SLTC/etools/hospital/hazards/slips/slips.html)

                                 ii
18.   Joint    Commission   Standards,   Chapter   EC.01.01.01;
      Chapter EC.02.01.01

                            iii
                                         INDEX OF AUTHORITIES

TEXAS SUPREME COURT CASES

Garland Community Hosp. v. Rose,
156 S.W.3d 541 (Tex. 2004) .............................................................................19, 20

Harris Methodist Fort Worth v. Ollie,
342 S.W.3d 525 (Tex. 2011) ...................................................................................16

Loaisiga v. Cerda,
379 S.W.3d 248 (Tex. 2012) .............................................................................16, 19

Ross v. St. Luke’s Episcopal Hosp.,
462 S.W.3d 496 (Tex. 2015) ...........................................................6, 7, 8, 16, 19, 22

Texas West Oaks Hospital, L.P. v. Williams,
371 S.W.3d 171 (Tex. 2012) ...................................................................................16

Yamada v. Friend,
335 S.W.3d 192 (Tex. 2010) .............................................................................17, 20

TEXAS COURTS OF APPEALS CASES

Baylor All Saints v. Martin,
340 S.W.3d 529 (Tex. App.—Fort Worth 2011, no pet.) .......................................18

Christus Health Southeast Texas v. Lanham,
2007 Tex. App. LEXIS 1103 (Tex. App.—Beaumont)(Jan. 11, 2007)(no pet.)(mem.
op.) ..........................................................................................................................19

Denton Regional Medical Center v. LaCroix,
947 S.W.2d 941 (Tex. App.—Fort Worth 1997, writ dism’d by agr.) ...................18

Hightower v. Baylor University Medical Center,
348 S.W.3d 512 (Tex. App.—Dallas 2011, pet. denied) ........................................18

                                                               iv
Kraus v. Alamo Nat’l Bank,
586 S.W.2d 202 (Tex. Civ. App.—Waco 1979), aff’d on o.g., 616 S.W.2d 908
(Tex. 1981) ..............................................................................................................18

Methodist Hospital of Dallas v. King,
365 S.W.3d 847 (Tex. App.—Dallas 2012, no pet.) ..............................................18

Sanchez v. Martin,
378 S.W.3d 581 (Tex. App.—Dallas 2012, no pet.) ..............................................18

FEDERAL STATUTORY PROVISIONS

42 C.F.R.., §482.1(a)(1) ............................................................................................9

42 C.F.R.., §482.11(a) ...............................................................................................9

42 C.F.R., §482.21(e)(1) ...........................................................................................9

42 C.F.R., §482.21(e)(3) ...........................................................................................9

42 C.F.R., §482.41(a) ................................................................................................9

42 C.F.R., §482.41(c)(2) ...........................................................................................9

42 C.F.R., § 482.42 .................................................................................................10

TEXAS STATUTORY PROVISIONS

25 TEX. ADMIN. CODE, §133.1(a) ...........................................................................10

25 TEX. ADMIN. CODE, §133.41(g) .........................................................................10

25 TEX. ADMIN. CODE, §133.142 ............................................................................10

TEXAS HEALTH & SAFETY CODE, §241.002 ............................................................10

TEXAS HEALTH & SAFETY CODE, §241.026(a)(3) ...................................................10

                                                             v
TEXAS HEALTH & SAFETY CODE, §241.026(a)(5) ...................................................10

MISCELLANEOUS MATERIALS

CMS State Operations Manual, Appendix A, Survey Protocol, Regulations and
Interpretive Guidelines for Hospitals ................................................................11, 12

Centers for Medicare & Medicaid Services, Hospital Infection Control Worksheet
.................................................................................................................................11

Joint Commission Standards, Chapter EC.01.01.01 ...............................................14

Joint Commission Standards, Chapter EC.02.01.01 ...............................................15

Occupational Safety & Health Administration, Healthcare Wide Hazards Slips,
Trips and Falls, Hospital eTool ........................................................................13, 14

Occupational Safety & Health Administration, Hospital eTool ............................13

Occupational Safety & Health Administration, Housekeeping, Hospital eTool 13, 14

Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory
Committee, Guideline for Disinfection and Sterilization in Healthcare Facilities,
2008, U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention (2008) .......................................................................................12, 13

Sehulster LM, Chinn RYW, Ardino MJ, Carpenter J, et al., Guidelines for
Environmental Infection Control in Health-Care Facilities, U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention (2003)
 ...........................................................................................................................12, 13

                                                                vi
                           No. 12-14-00220-CV
          ___________________________________________________

                              COURT OF APPEALS

                                        for the

                         TWELFTH DISTRICT OF TEXAS

                              Tyler, Texas
          ___________________________________________________

                 EAST TEXAS MEDICAL CENTER GILMER
                                         Appellant,

                                          v.

                                BIRDER PORTER
                                              Appellee.
          ___________________________________________________

                       Appeal from Cause No. 697-13
                    th
               115 Judicial District Court, Upshur County, Texas
                   Honorable Lauren Parish, Presiding Judge
          ___________________________________________________

TO THE TWELFTH COURT OF APPEALS:

      Appellant East Texas Medical Center Gilmer, defendant in Cause No. 697-

13 in the 115th Judicial District Court of Upshur County, Texas, Honorable

Lauren Parish presiding, pursuant to this Court’s August 4, 2015 order,

respectfully submits its Supplemental Brief on Application of Ross v. St. Luke’s

Episcopal Hospital. Appellee is Birder Porter, Plaintiff in the district court.

                                          1
                          SUMMARY OF ARGUMENT

      On August 6, 2015, the Twelfth Court of Appeals ordered Appellant East

Texas Medical Center Gilmer (“ETMCG”) to submit additional briefing “on

whether Birder Porter’s claim is a ‘health care liability claim’ in light of Ross v. St.

Luke’s Episcopal Hosp., No. 13-0439, 2105 WL 2009744 (Tex. May 1, 2015) and

its progeny” within 30 days (emphasis in Order). Pursuant to this order, ETMCG

submits this Supplemental Brief on Application of Ross v. St. Luke’s Episcopal

Hospital.

      Based on existing pertinent Texas Supreme Court authority, including Ross

v. St. Luke’s Episcopal Hosp., 462 S.W.3d 496 (Tex. 2015), Appellee’s claim

against ETMCG is a health care liability claim (“HCLC”), as defined in Chapter 74

of the TEXAS CIVIL PRACTICE & REMEDIES CODE (“Chapter 74”).

      Review of the Ross opinion shows that it is not controlling here because

there were two situations absent from Ross that are present here. The Texas

Supreme Court was forced to address and evaluate whether Ross’ claims were

health care liability claims (“HCLC”) in Ross because St. Luke’s Episcopal

Hospital did not argue that the incident at hand occurred in an area where patients

might be when receiving medical services, and because St. Luke’s did not argue

that the area where the incident occurred was subject to any particular maintenance

                                           2
or cleanliness standards related to the provision of health care or related to patient

safety.

      In contrast to Ross, Appellee admits that this incident occurred in the

ETMCG emergency room and that she was in the emergency room that day

seeking medical services. Thus, in contrast to Ross, it cannot be disputed that the

underlying incident occurred in a location patients could be when receiving

medical services. Also in contrast to Ross, is the fact that the ETMCG emergency

room is subject to a number of cleanliness and maintenance standards that are

related to the provision of health care and related to patient safety. For these

reasons, Ross really does not apply to this appeal.

      Appellee’s claim is an HCLC even if this Court applies Ross and evaluates

this matter pursuant to the guidance provided in Ross. Two key points came out of

Ross in connection with evaluating whether or not a claim like this is an HCLC.

One, Ross provided seven non-exclusive factors for courts to consider in

evaluation of whether a claim is an HCLC. Five of these sevens factors are present

here when one applies the legal framework within which hospitals like ETMCG

have to operate and the facts of this case to the seven factors set forth in Ross.

      More importantly, however, is the fact that in Ross the Texas Supreme Court

held that when evaluating whether a safety-based claim is an HCLC the “pivotal

issue” is whether or not the standards on which the claim are based implicates a

                                           3
hospital’s duties as a health care provider, as well as the fact that the Texas

Supreme Court did not abrogate its prior decisions regarding the general

considerations courts must apply when evaluating whether a claim is an HCLC.

Specifically, disposition of this appeal is also controlled by the Texas Supreme

Court’s opinions, in Harris Methodist Fort Worth v. Ollie, 432 S.W.3d 525 (Tex.

2011), Texas West Oaks Hospital, L.P. v. Williams, 371 S.W.3d 171 (Tex. 2012),

Loaisiga v. Cerda, 379 S.W.3d 248 (Tex. 2012), Yamada v. Friend, 335 S.W.3d
192 (Tex. 2010), and Garland Community Hosp. v. Rose, 156 S.W.3d 541 (Tex.

2004).

      Ollie establishes that a slip-and-fall can be an HCLC. Texas West Oaks

Hospital establishes that that a safety-based HCLC – like this matter – does not

have to be directly related to the provision of health care. Loaisiga and Yamada

establish that an HCLC exists if the underlying facts could support a claim that the

defendant health care provider departed from safety standards related to health

care, even if that specific allegation is not made. Rose establishes that accepted

standards of health care exist if a hospital’s conduct is governed by federal and

state law, as well as regulatory guidelines.

      The CODE OF FEDERAL REGULATIONS and the TEXAS ADMINISTRATIVE CODE

place cleanliness and maintenance requirements on hospitals like ETMCG

pertinent to the claim Appellee asserts against ETMCG.         In addition, federal

                                           4
guidelines and guidelines from The Joint Commission (an entity that accredits and

certifies hospitals like ETMCG) also place cleanliness and maintenance

requirements on hospitals like ETMCG that are pertinent to Appellee’s claim.

Because these accepted standards that relate to health care could provide the basis

of a claim against ETMCG under the facts alleged, Appellee’s claim against

ETMCG is an HCLC based on existing stare decisis from the Texas Supreme

Court.

         As such, even if the Court determines that Ross is controlling or applicable,

Appellee’s claim against ETMCG is an HCLC. It is for these additional reasons

that the decision of the trial court should be reversed and that Appellee’s claims

against ETMCG should be dismissed with prejudice.

                                           5
                                    ARGUMENT

I.    LIMITED SCOPE AND APPLICATION OF ROSS:

      A careful consideration and reading of Ross reveals two circumstances that

significantly distinguish it from this case and render Ross inapplicable here. In

Ross, the Texas Supreme Court stated it was required to address the question of

whether Ross’s claims against St. Luke’s were HCLCs because of two factors

absent from that matter that are present here. First, St. Luke’s did not claim “that

the area where Ross fell was a patient care area or an area where patients possibly

would be in the course of the hospital’s providing services to them.”         Ross,
462 S.W.3d at 503. Second, St. Luke’s did not argue that the area of the hospital

where Ross fell “had to meet particular cleanliness or maintenance standards

related to the provision of health care or patient safety.” Id.

      Because there was no claim the incident occurred in an area where patients

might be and because there was no reference to any particular maintenance

standards specifically applicable to St. Luke’s and related to patient safety, the

Texas Supreme Court in Ross was forced to address “the question of whether

Ross’s claims are nevertheless HCLCs, as the hospital would have us hold.” Id. at

503-504. (emphasis added). The situation in Ross is not the situation here.

      First, Appellee not only admits that she fell in the ETMCG emergency room,

she admits that she was in the ETMCG emergency room at that time because she

                                           6
was “seeking treatment” (CR 23). Second, as shown below, ETMCG is required

“to meet particular cleanliness or maintenance standards related to the provision of

health care or patient safety” set forth in federal law, Texas law, federal agency

regulations, and requirements of The Joint Commission, an accrediting and

certification agency. For these reasons, Appellee’s claim is an HCLC. The Tyler

Court of Appeals has no need to go further to evaluate under Ross why,

“nevertheless,” Appellee’s claim is an HCLC.

II.      Appellee’s Claim Is An HCLC Under Ross:

      Even if this matter is evaluated under the guidance provided in Ross, Appellee’s

claim against ETMCG is an HCLC. In Ross, the Texas Supreme Court provided

seven non-exclusive factors to be used by courts in evaluation of whether a claim

was an HCLC. Id. at 505.

      In Ross, the Texas Supreme Court also reduced evaluation of whether a safety

standards-based claim is an HCLC down to whether or not there is “a substantive

nexus between the safety standards allegedly violated and the provision of health

care.” Id. at 504. The Texas Supreme Court went on to state “the pivotal issue in a

safety standards-based claim is whether the standards on which the claim is based

implicate the defendant’s duties as a health care provider, including its duties to

provide for patient safety.” Id. at 505.

                                           7
      A.     Seven Non-Exclusive Factors:

      Five of the seven non-exclusive considerations provided in Ross that can be

used to determine whether or not a safety standards claim is an HCLC exist here.

These five factors are whether the alleged negligence (1) occurred in connection

with tasks related to protecting patients from harm, (2) occurred in a location that

patients might be, (3) occurred in connection with seeking or receiving health care,

(4) is based on safety standards arising from professional duties owed by a health

care provider, and (5) occurred in connection with a failure “to take action

necessary to comply with safety-related requirements set for health care providers

by governmental or accrediting agencies.” Id. at 505.

      Factors (2) and (3) are present here because Appellee admits her fall

occurred in the ETMCG emergency room and that she was in the emergency room

“seeking treatment” at the time (CR 23). Factors (1), (4), and (5) are present here

because – as shown below – the maintenance of ETMCG’s premises is subject to

requirements set by federal law, Texas law, federal regulations, and accrediting

agency regulations that relate to the provision of health care and patient safety.

             1.     Federal Law Requirements:

      Under federal law, the Centers for Medicare & Medicaid Services (“CMS”)

have promulgated standards that must be met for participating hospitals. See,

                                          8
42 C.F.R., §§482.1(a)(1), 482.11(a)(Appendix 4).         Subpart C of this statute

provides specific hospital functions that are conditions for participation.

      Pertinent to this case are Sections 482.21, 482.41, and 482.42 of Subpart C.

Section 482.21 requires not only that hospitals have “an ongoing program for

quality improvement and patient safety,” but also that “clear expectations for

safety are established by hospital executives.”       42 C.F.R., §482.21(e)(1), (3)

(Appendix 5, page 2).

      Section 482.41 of Title 42 of the CODE            OF   FEDERAL REGULATIONS

establishes requirements related to the “physical environment” of a hospital. The

first sentence of this regulation requires that hospitals be “maintained to ensure the

safety of the patient…” Within this regulation, it is specifically required that “the

physical plant and overall hospital environment must be developed and maintained

in such a manner that the safety and well-being of patients are assured.” 42 C.F.R.,

§482.41(a)(Appendix 6, page 1). Hospitals must also “be maintained to ensure an

acceptable level of safety and quality.” 42 C.F.R., §482.41(c)(2)(Appendix 6, page

2).

      Section 482.42 of the CODE OF FEDERAL REGULATIONS requires an infection

control program also be in place and followed. 42 C.F.R., §482.42 (Appendix 6,

page 2). One cannot dispute that a hospital’s infection control program relates to

both the provision of health care and patient safety.        The significance of an

                                          9
infection control program and its relevance to maintenance of the floors at

ETMCG will be shown below.

            2.     Texas Law Requirements:

      Texas law imposes requirements on hospitals in order for them to be

licensed to operate.   25 TEX. ADMIN. CODE, §133.1(a) (Appendix 7); TEXAS

HEALTH & SAFETY CODE, §241.002 (Appendix 10, page 1).          Under this set of

laws, Texas hospitals are required to “provide a sanitary environment to avoid

sources and transmission of infections and communicable diseases.” 25 TEX.

ADMIN. CODE, §133.41(g)(Appendix 8, page 21) See also, TEXAS HEALTH &

SAFETY CODE, §241.026(a)(3)(Appendix 10, page 9). Hospitals are also required

to appoint a safety committee and safety officer and to take steps to promote

general safety in the facility. 25 TEX. ADMIN. CODE, §133.142 (Appendix 9).

      Texas law also requires that hospitals comply with “federal laws affecting

the health, safety, and rights of hospital patients.” TEXAS HEALTH & SAFETY

CODE, §241.026(a)(5)(Appendix 10, page 9). As such, Texas law requires that

hospitals like ETMCG follow the CODE        OF   FEDERAL REGULATION provisions

discussed above.

                                       10
                 3.      CMS Surveys and Applicable CDC and OSHA Regulations
                         and Guidelines:

        CMS performs unannounced surveys of participating hospitals to determine

if they are in compliance with federal law (Appendix 11, pages 3-4). 1                                      In

evaluation of whether a facility is properly maintained, as required under C.F.R.,

§482.41, surveyors must “verify that the condition of the hospital is maintained in

a manner to assure the safety and well being of patients (e.g., condition [of]

ceilings, walls, and floors, presence of patient hazards, etc.)” (Appendix 11,

page 7) (emphasis added).

        In evaluation of the infection control program required by 42 C.F.R.,

§482.42, hospital surveyors must determine if the hospital “[m]aintains a sanitary

environment” and if the hospital has and follows an infection control program

(Appendix 11, pages 10-11, 14). Facility housekeeping and maintenance must be

included in and monitored as part of a proper infection control program (Appendix

11, page 17). CMS provides surveyors a worksheet to track a hospital’s infection

control compliance (Appendix 12). The CMS infection control worksheet requires

surveyors to specifically evaluate and assess a hospital’s housekeeping services

like cleaning floors in patient care areas (Appendix 12, page 16).                                    Under

1
  See, 2015 CMS State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines
for Hospitals (Appendix 11)(excerpts only are provided of this 510-page document in Appendix 11)(a complete
copy of this document is available at - https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf).

                                                      11
Rule 201(b)(2) of the TEXAS RULES OF EVIDENCE, ETMCG requests the Court take

judicial notice of these regulatory compliance materials.

           When        evaluating a facility’s infection control program, surveyors are

instructed that such a program should be conducted in accordance with nationally

recognized practices and guidelines, such as practices and guidelines promulgated

by the Centers for Disease Control and Prevention (“CDC”) and the U.S.

Occupational Health and Safety Administration (“OHSA”) (Appendix 11,

pages 13, 17). Surveyors are also informed that hospital emergency departments

provide special challenges in infection control (Appendix 11, page 18). ETMCG

requests that under Rule 201(b)(2), the Court take judicial notice of the fact that the

Centers for Disease Control and the Centers for Medicare & Medicaid Services are

agencies within the United States Department of Health & Human Services.2

ETMCG also requests that judicial notice be taken of the fact that OSHA is an

agency of the United States Department of Labor. 3

           The CDC has promulgated two sets of guidelines that apply to infection

control in hospitals like ETMCG. These are (1) the Guideline for Disinfection and

Sterilization in Healthcare Facilities 2008 (Appendix 13) and (2) the Guidelines for

Environmental Infection Control in Health-Care Facilities, published in 2003

(Appendix 14).

2
    See, HHS Organizational Chart (available at – http://www.hhs.gov/about/agencies/orgchart/index.html).
3
    See, Department of Labor agencies (available at – http://www.dol.gov/dol/organization.htm)

                                                         12
        The CDC Guidelines recognize that hospital floors are a source of

microorganism and blood-borne pathogen contamination (Appendix 13, page 23,

29). Significantly, the Guidelines also recognize that removal of these pathogens

“is a component in controlling health-care-associated infections” (Appendix 13,

page 29). Both Guidelines address cleaning hospital floors in order to prevent

them from serving as a source of health-care associated infections (Appendix 13,

pages 11, 12, 23, 30; Appendix 14, pages 74-75). The CDC also cautions that

improper mopping procedure in a hospital “actually can spread heavy microbial

contamination throughout the health-care facility” (Appendix 13, page 12).

        Based on these underlying facts and concerns, the CDC Guidelines provide

floor   care   recommendations     “to   reduce   rates   of   health-care-associated

infections…” (See, Appendix 13, page 83).         These recommendations address

(1) when hospital floors should be cleaned, (2) the specific types of solutions to be

used, (3) how frequently the floor mopping solution should be changed, and (4) the

decontamination of mops (Appendix 13, pages 84-85; Appendix 14, pages 133-

135).

        A summary of OSHA guidelines applicable to health care facilities like

ETMCG is available on line through its “Hospital eTool” (Appendix 15). Specific

items addressed by OSHA through its Hospital eTool include “Housekeeping”

(Appendix 16) and “Slips, Trips and Falls” (Appendix 17). Similar to the CDC

                                         13
guidelines, the OSHA guidelines require hospitals maintain a sanitary environment

and they provide recommendations about when floors should be cleaned and how

they should be cleaned (Appendix 16, 17). Based on these materials, one cannot

dispute that floor care at a hospital like ETMCG is related to the provision of

health care and patient safety; specifically it is related to infection control.

           ETMCG requests that under Rule 201(b)(2) of the TEXAS RULES                      OF

EVIDENCE, the Court take judicial notice of these applicable CDC and OSHA

guidelines.

                   4.      Joint Commission Regulations and Guidelines:

           The Joint Commission also places safety-based requirements on hospitals

related to health care and patient safety.                           ETMCG requests that under

Rule 201(b)(2) of the TEXAS RULES OF EVIDENCE, the Court take judicial notice of

the fact that The Joint Commission is a nationwide accrediting and certification

agency. 4

           Under Joint Commission standards, hospitals are evaluated in regard to

management of “[t]he environmental safety of patients and everyone else who

enters the hospital’s facilities,” as well as “[t]he security of everyone who enters

the hospital’s facilities.”             Joint Commission Standard, Chapter EC.01.01.01,

Elements of Performance 3 and 4)(Appendix 18, page 1). The Joint Commission

4
    See, http://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx.

                                                       14
also evaluates whether a hospital “identifies safety and security risks associated

with the environment of care that could affect patients, staff and other people

coming to the hospital’s facilities,” whether a hospital “takes action to minimize or

eliminate identified safety and security risks in the physical environment,” and

whether a hospital “maintains all grounds…”           Joint Commission Standard,

Chapter EC.02.01.01, Elements of Performance 1, 3 and 5 (Appendix 18, page 3).

             5.    Conclusion:

   After consideration and review of the laws, regulations, agency guidelines and

accreditation guidelines applicable to ETMCG in maintaining its facilities in

general and its floors specifically, one cannot question that ETMCG was required

to meet particular cleanliness and maintenance standards related to the provision of

health care and patient safety in its emergency room where Appellee fell. When

the existence of these applicable laws, regulations and guidelines is combined with

the fact that Appellee fell in an area where patients could be receiving treatment at

ETMCG and with the fact that Appellee was in the ETMCG emergency room that

day seeking treatment; it is clear Appellee’s claim against ETMCG is an HCLC

under the seven non-exclusive factors provided by the Texas Supreme Court in

Ross.

                                         15
III.   Substantive Nexus to Health Care Exists:

       When the Texas Supreme Court in Ross cited to its earlier opinion in Harris

Methodist Fort Worth v. Ollie, 342 S.W.3d 525 (Tex. 2011) – a slip-and-fall case –

without abrogating that opinion, the Court recognized and affirmed that a slip-and-

fall at a hospital like ETMCG can still be an HCLC. Ross, 462 S.W.3d at 502. See

also, Ollie, 342 S.W.3d at 527. In Ross, the Texas Supreme Court also expressly

recognized its holding in Texas West Oaks Hospital, L.P. v. Williams, 371 S.W.3d
171 (Tex. 2012) that a safety-based HCLC did not need “to be directly related to

the provision of health care” and that this part of its holding in Texas West Oaks

Hospital is still good law “entitled to stare decisis treatment.” Ross, 462 S.W.3d

at 502. See also, Texas West Oaks Hosp., 371 S.W.3d at 186.

       In Ross, the Texas Supreme Court also recognized and reiterated its holding

in Loaisiga v. Cerda, 379 S.W.3d 248 (Tex. 2012), when it stated that “if the facts

underlying a claim could support claims against a physician or health care provider

for departures from accepted standards of medical care, health care, or safety or

professional or administrative services directly related to health care, the claims are

HCLCs regardless of whether plaintiff alleged the defendants were liable for

breach of the standards.” Ross, 462 S.W.3d at 503 (emphasis in original)(citing

Loaisiga v. Cerda, 379 S.W.3d 248, 255 (Tex. 2012)).

                                          16
      Finally, in Ross the court did not abrogate or modify its earlier opinion in

Yamada v. Friend, 335 S.W.3d 192 (Tex. 2010).           This is significant in the

evaluating and deciding this appeal because the Texas Supreme Court in Yamada

held that “claim-splitting” was not allowed by claimants in an effort to circumvent

application of Chapter 74 of the TEXAS CIVIL PRACTICE & REMEDIES CODE. In

particular, in Yamada the Texas Supreme Court held that in circumstances where

there is one set of operative facts, a claimant cannot elect to pursue a claim not

covered by Chapter 74 if that claim also falls within the ambit of Chapter 74.

Specifically, the Texas Supreme Court stated in Yamada:

      When the underlying facts are encompassed by provisions of the TMLA
      [Chapter 74] in regard to a defendant, then all claims against that defendant
      based on those facts must be brought as health care liability claims.
      Application of the TMLA cannot be avoided by artfully pleading around it
      or splitting claims into both health care liability claims and other types of
      claims such as ordinary negligence claims.

Id. at 193-94.

      These holdings and rulings by the Texas Supreme Court are significant in

the evaluation and resolution of this appeal because ETMCG has shown above that

federal and state law, as well as federal and Joint Commission regulations, apply to

the maintenance of its floors and that these requirements relate to the provision of

health care and patient safety because they involve infection control. As such,

based on the underlying facts of this case and these applicable laws and

regulations, Appellee could have elected to pursue an HCLC against ETMCG

                                        17
based on its alleged failure to comply with these laws and regulations. For that

reason, based on the above Texas Supreme Court authority, Appellee’s claim

against ETMCG is an HCLC.

      Support for ETMCG’s position on this point also comes from two additional

facts established by Texas case law. First, under Texas law the statutes and

regulations that apply to ETMCG in maintenance of its floors and premises

provide evidence of the standard of care applicable to ETMCG. See, Denton

Regional Medical Center v. LaCroix, 947 S.W.2d 941, 951 n.7 (Tex. App.—Fort

Worth 1997, writ dism’d by agr.)(Joint Commission guidelines can be viewed as

providing evidence of a hospital’s standard of care). See also, Kraus v. Alamo

Nat’l Bank, 586 S.W.2d 202, 208 (Tex. Civ. App.—Waco 1979), aff’d on o.g., 616
S.W.2d 908 (Tex. 1981)(similar holding regarding OSHA regulations).

      Second, and even more significant, is the fact that CMS, CDC and Joint

Commission guidelines and regulations have been cited and utilized by claimants

to establish the standard of applicable to hospitals and breaches of that standard of

care in Chapter 74 expert reports. See, Sanchez v. Martin, 378 S.W.3d 581, 593

(Tex. App.—Dallas 2012, no pet.)(use of CDC guidelines); Methodist Hospital of

Dallas v. King, 365 S.W.3d 847, 851 (Tex. App.—Dallas 2012, no pet.)(use of

CMS and Joint Commission requirements); Hightower v. Baylor University

Medical Center, 348 S.W.3d 512, 517, 518 (Tex. App.—Dallas 2011, pet.

                                         18
denied)(use of CDC guidelines); Baylor All Saints v. Martin, 340 S.W.3d 529, 533-

34 (Tex. App.—Fort Worth 2011, no pet.); Christus Health Southeast Texas v.

Lanham, 2007 Tex. App. LEXIS 1103 *4 (Tex. App.—Beaumont)(Jan. 11,

2007)(no pet.)(mem. op.)(use of Joint Commission standards).

      Finally, in 2004 the Texas Supreme Court held that accepted standards of

health care exist and are at issue when a hospital’s conduct is governed by a

combination of existing federal law, state law and Joint Commission regulations.

See, Garland Community Hosp. v. Rose, 156 S.W.3d 541, 546 (Tex.

2004)(existence of applicable federal and state law, as well as Joint Commission

guidelines make a negligent credentialing claim against a hospital an HCLC

because “accepted standards of…health care” are involved). As shown above,

ETMCG’s actions at issue here are governed by applicable federal and state law

and Joint Commission guidelines.       For this reason, ETMCG’s conduct here

involves accepted standards of health care.

      Not only does this authority bolster ETMCG’s position that Appellee alleges

an HCLC against it under Ross, this authority establishes without question that

under the facts of this case Appellee could have asserted an HCLC against

ETMCG based on violation of these accepted standards of health care and safety

directly related to its duties as a hospital. In light of the Texas Supreme Court’s

holdings and rulings in Ross, Loaisiga, Yamada, and Rose, there can be no doubt

                                        19
that Appellee’s claim against ETMCG is an HCLC. See, Ross, 462 S.W.3d at 502-

203; Loaisga, 379 S.W.3d at 255 (claim is an HCLC if the underlying facts could

support a claim of departure from accepted standards of safety); Yamada, 335
S.W.3d at 193 (one set of facts cannot give rise to both an HCLC and an ordinary

negligence claim); Rose, 156 S.W.3d at 546 (network of applicable federal and

state law and Joint Commission regulations create applicable existing standards of

health care). For these reasons, Appellee’s claim against ETMCG is an HCLC.

                                       20
                                      CONCLUSION

      In its recent decision in Ross, the Texas Supreme Court provided trial courts

and courts of appeals guidance to assist in the evaluation of whether a safety-based

claim against a hospital like ETMCG is an HCLC under Chapter 74. In Ross, the

Texas Supreme Court provided seven non-exclusive factors for courts to use in

determining whether such a claim is an HCLC. Five of the Texas Supreme Court’s

seven non-exclusive factors are present here when one considers the underlying

circumstances and facts. As such, Appellee’s claim against ETMCG is an HCLC.

      The fact of the matter is, however, that Ross is really not applicable to this

matter because the very reasons the Texas Supreme Court had to evaluate Ross and

come up with the above-referenced seven non-exclusive factors to determine if the

claims there were HCLCs are not present here. Specifically, in Ross there was no

claim that the incident occurred in an area where patients might be receiving

treatment and there was no claim that certain cleanliness and maintenance

standards were applicable to location of the incident that arose out of the defendant

hospital’s duties as a health care provider. That is not the situation here.

      First, Appellee admits her fall occurred in the ETMCG emergency room.

One cannot question that the emergency room at ETMCG is a location where

patients might be receiving treatment at ETMCG. Second, ETMCG has shown

that there are a number of cleanliness and maintenance standards applicable to its

                                          21
premises that relate to the provision of health care and patient safety. These

standards involve infection control and come from federal law, Texas law, federal

regulatory agency regulations and guidelines, and accrediting entity guidelines.

Finally, unlike in Ross, Appellee was in the ETMCG emergency room at the time

of this incident “seeking” medical care. She was not at the hospital as a visitor.

      Most important, however, is the fact that the Texas Supreme Court in Ross

did not abrogate or modify its prior opinions in Texas West Oaks Hospital,

Loaisiga, Ollie, Yamada, and Rose. In fact, the Texas Supreme Court directly

stated that its holding in Texas West Oaks that safety-related HCLCs did not need

to be directly related to the provision health care was still good law and entitled to

stare decisis, and reiterated its holding in Loaisiga that if the facts underlying a

claim could support a claim that a physician or health care providers departed from

accepted standards of safety, the claim was an HCLC regardless of whether or not

plaintiff specifically alleged liability based on a breach of those standards. Ross,
462 S.W.3d at 502, 503-504.        These actions are important not only because

Appellee’s claim can be an HCLC even though it is not directly related to the

provision of health care, but more significantly because the touchstone issue in

determining whether or not Appellee’s claim is an HCLC remains whether, based

on the underlying facts, a claim could be made that ETMCG departed from

accepted standards of safety.

                                         22
      ETMCG has established through existing case law the fact that Appellee

could have elected to proceed with an HCLC against ETMCG. Appellee could

have asserted an HCLC against ETMCG based on its failure to comply with

applicable federal and state law, as well as federal agency regulations and

guidelines and accrediting organization guidelines. Existing Texas case law shows

us that these laws, regulations and standards have previously been used to establish

the standard of care applicable to a hospital like ETMCG in similar situations and

that existence of these laws and guidelines create accepted standards of health care

applicable to hospitals like ETMCG. Since Appellee could have maintained an

HCLC against ETMCG based on this applicable federal law, state law, and

regulatory guidelines, one cannot dispute and must conclude based on existing

Texas Supreme Court authority that Appellee’s claim against ETMCG is an HCLC

under Chapter 74 of the TEXAS CIVIL PRACTICE & REMEDIES CODE.

      For these reasons the trial court erred in denying ETMCG’s Chapter 74

motion to dismiss. Accordingly, the Twelfth Court of Appeals should reverse the

trial court’s denial of ETMCG’s motion to dismiss and should dismiss Appellee’s

claims against ETMCG with prejudice.

                                        23
                                      PRAYER

      Because the trial court erred in denying Appellant East Texas Medical Center

Gilmer’s Motion to Dismiss, Appellant requests that this Twelfth District Court of

Appeals:

      1.    Reverse the trial court’s denial of East Texas Medical Center Gilmer’s
            Motion to Dismiss (CR 36, Appendix “A”);

      2.    Dismiss with prejudice Appellee’s claim against East Texas Medical Center
            Gilmer, and:

      3.    Remand this matter to the trial court for further proceedings consistent with
            the above actions.

                                        Respectfully Submitted,

                                        THIEBAUD REMINGTON THORNTON BAILEY, LLP

                                        By:/s/Russell G. Thornton
                                          RUSSELL G. THORNTON
                                          State Bar Card No. 19982850
                                           4849 Greenville Avenue
                                           Suite 1150
                                           Dallas, Texas 75206
                                           (214) 954-2200
                                           (214) 754-0999 (Fax)
                                           rthornton@trtblaw.com

                                          24
                      CERTIFICATE OF COMPLIANCE

      Pursuant to TEXAS RULES      OF   APPELLATE PROCEDURE 9.4(i)(3) Appellant

certifies that its Supplemental Brief on Application of Ross v. St. Luke’s Episcopal

Hospital, filed on September 4, 2015, in the Twelfth Court of Appeals, contains

4,793 words.

                                     /s/Russell G. Thornton
                                     RUSSELL G. THORNTON

                                         25
                        CERTIFICATE OF SERVICE

      The undersigned certifies that on the 4th day of September, 2015, a true and

correct copy of the foregoing document was delivered to counsel listed below:

      VIA E-SERVE &/OR CMRRR:
      Mr. Michael Bernoudy
      THE BERNOUDY LAW FIRM
      2400 W. Grand Avenue
      Marshall, Texas 75670
      mlbjr@bernoudylawfirm.com

                                    /s/Russell G. Thornton
                                    RUSSELL G. THORNTON

                                       26
APPENDIX
APPEND IX - ''1 ''
                                                                                                                 Page 1

            LexisNexis®
                                                1 of1098 DOCUMENTS

                  LEZLEA ROSS, PETITIONER, v. ST. LUKE'S EPISCOPAL HOSPITAL, RE-
                                           SPONDENT

                                                      NO. 13-0439

                                           SUPREME COURT OF TEXAS

                   462 S.W.3d 496; 2015 Tex. LEX1S 361; 58 Tex. Sup. J. 766; 58 Tex. Sup. J. 802

                                             November 5, 2014, Argued
                                            May 1, 2015, Opinion Delivered

PRIOR HISTORY:            [**1] ON PETITION FOR               ory after she slipped and fell near the lobby exit doors.
REVIEW FROM THE COURT OF APPEALS FOR                          The issue is whether her suit is a health care liability
THE FOURTEENTH DISTRICT OF TEXAS.                             claim under the Texas Medical Liability Act. See TEX.
Ross v. St. Luke's Episcopal Hosp., 459 S.W.3d 617,          [**2] CIV. PRAC. & REM. CODE ch. 74. The trial court
2013 Tex. App. LEXIS 2796 (Tex. App. Houston 14th             and court of appeals concluded that it is. We hold that it
Dist., Mar. 19, 2013)                                         is not, because the record does not demonstrate a rela-
                                                              tionship between the safety standards she alleged the
                                                              hospital breached--standards for maintaining the floor
COUNSEL: For The Texas Trial Lawyers Association              inside the lobby exit doors--and the provision of health
(TTLA), Amicus Curiae: Michael G. Guajardo, Guajardo          care, other than the location of the occurrence and the
& Marks, LLP, Dallas TX; Peter M. Kelly, Kelly,               hospital's status as a health care provider.
Durham & Pittard, L.L.P., Houston TX.
                                                                  We reverse and remand to the trial court for further
                                                              proceedings.
For Ross, Lezlea, Petitioner: Harold Kenneth 'Ken'
Tummel, Tummel & Casso, Edinburg TX; Sean Michael
                                                               [*499] I. Background
Reagan, Leyh Payne & Mallia PLLC, Houston TX.
                                                                   Lezlea Ross accompanied a friend who was visiting
For St. Luke's Episcopal Hospital, Respondent: Charles        a patient in St. Luke's Episcopal Hospital. Ross was
Creighton Carr II, Manning, Gosda & Arredondo, L.L.P .,       leaving the hospital through the lobby when, as she ap-
Houston TX; Elizabeth Dale Burrus, Kroger I Burrus,           proached the exit doors, she slipped and fell in an area
Houston TX; Gregory Alan Schlak, Manning, Gosda &             where the floor was being cleaned and buffed She sued
Arredondo, L.L.P., Houston TX; Lauren Nelson, Kroger!         St. Luke's and Aramark Management Services, a com-
Burrus, Houston TX; Marsha A. Bradley, Kroger I Bur-          pany that contracted with the hospital to perform
rus, Houston TX.                                              maintenance services, on a premises liability theory.
                                                              Aramark is not a party to this appeal.
JUDGES: JUSTICE JOHNSON delivered the opinion
                                                                   After Ross filed suit we decided Texas West Oaks
of the Court. JUSTICE LEHRMANN filed a concurring
opinion, in which JUSTICE DEVINE joined. JUSTICE
                                                              Hospital, L.P. v. Williams, 371 S.W3d 171 (Tex. 2012).
                                                              There we held, in part, that when a safety stand-
BROWN did not participate in the decision.
                                                              ards-based claim is made against a health care provider,
                                                              the Texas Medical Liability Act (TMLA), TEX. CIV.
OPINION BY: Phil Johnson
                                                              PRAC. & REM. CODE ch. 74, does not require the safety
                                                              [**3] standards to be directly related to the provision of
OPINION
                                                              health care in order for the claim to be a health care lia-
     [*498] In this case a visitor to St. Luke's Episco-      bility claim (HCLC). Williams, 371 S. W3d at 186. Re-
pal Hospital sued the hospital on a premises liability the-   lying on Williams, the hospital asserted that Ross's claim
                                                                                                                   Page 2
                                      462 S.W.3d 496, *; 2015 Tex. LEXIS 361, **;
                                         58 Tex. Sup. J. 766; 58 Tex. Sup. J. 802

was an HCLC and moved for dismissal of her suit be-                Ross asserts that this Comt has jurisdiction because
cause she failed to serve an expert report. See TEX. C!v.      the court of appeals 1 opinion in this case conflicts with
PRAC. &REM. CODE§ 74.351(a), (b) (requiring dismissal          Good Shepherd Medical Center-Linden, Inc. v. Twilley,
of an HCLC if a claimant fails to timely serve an expert       422 S.W.3d 782 (Tex. App.--Texarkana 2013, pet. de-
report); Williams, 371 S.W.3d at 186.                         nied). In that case, Bobby Twilley, the director of plant
                                                               operations for a medical center, asserted premises liabil-
     The trial court granted the motion to dismiss. The
                                                               ity claims against his employer after he fell from a ladder
court of appeals affim1ed. Ross v. St. Luke's Episcopal
                                                               and also tripped over a mound of hardened cement. Id. at
Hasp., 459 S.W.3d 617, 2013 Tex. App. LEXIS 2796
                                                               783. The medical center moved for dismissal under the
(Tex. App.--Houston [14th Dist.] 2013). The appeals
                                                               TMLA because Twilley failed to file an expert report. I d.
court concluded that under Williams it is not necessary
                                                               at 783-84. The trial court denied the motion and the
for any connection to exist between health care and the
                                                               medical center appealed, arguing that even though
safety standard on which a claim is based in order for the
                                                               Twilley's claims were unrelated to the provision of health
claim to come within the TMLA. Id. at         , 2013 Tex.
                                                               care, under Williams they still fell within the ambit of the
App. LEXIS 2796.
                                                               TMLA. The court of appeals interpreted Williams as
    Ross asserts that the lower courts erred because           holding that a safety standards-based claim need not be
claims based on departures from "accepted standards of         directly related to the provision of health care to be an
safety" do not come within the provisions of the TMLA          HCLC. Id. at 789. The court stated, however, that it did
unless there is at least some connection between the           not understand Williams to hold that a safety standards
standards underlying the allegedly negligent actions and       claim falls under the TMLA when the claim is com-
the provision of health care, even if they are not directly    pletely untethered from health care. I d. The appeals court
related. She then argues that her claims are not HCLCs         concluded that at least an indirect relationship between
because the hospital's alleged negligence is completely        the claim and health care is required and, because
unrelated to the provision of health care.                     Twilley's [**6] claims did not have such a relationship,
                                                               an expert report was not required. I d. at 785.
     The hospital [**4] responds with three arguments.
It first urges that we lack jurisdiction. See TEX. Gov'T           In this case the court of appeals held that under Wil-
CODE§ 22.001(a)(2), (3), (6). It next asserts that even if     liams u a connection between the act or omission and
we have jurisdiction, Ross waived the issue of whether         health care is urmecessary for purposes of determining
her claim is an HCLC because she failed to properly            whether Ross brings an HCLC." Ross,             S. W.3d at
brief and urge it in the court of appeals. Third, the hospi-   , 2013 Tex. App. LEXIS 2796. The hospital asserts that
tal addresses the merits by asserting that the court of ap-    the decision of the court of appeals and Twilley do not
peals correctly held that a safety standards-based claim       conflict. But, for purposes of our jurisdiction, one court
need not be related to health care to fall within the          holds differently from another when there is incon-
TMLNs provisions, but in any event Ross 1s claims are          sistency in their decisions that should be clarified to re-
related to accepted standards of patient safety because        move unnecessary uncertainty in the law. TEX Gov'T
she fell inside the hospital.                                  CODE§ 22.001 (e). As other courts of appeals have noted,
                                                               Ross and Twilley are inconsistent in their interpretations
     We first address our jurisdiction. See Rusk State
                                                               of Williams and the TMLA, leaving uncertainty in the
Hasp. v. Black, 392 S.W.3d 88, 95 (Tex. 2012) (noting
                                                               law regarding whether a safety standards-based claim
that if a court does not have jurisdiction, its opinion ad-
                                                               must be related to health care. See, e.g., Weatheiford
dressing any issues other than its jurisdiction is adviso-
                                                               Tex. Hasp. Co. v. Smart, 423 S.W.3d 462, 467-68 (Tex.
ry).
                                                               App.--Fort Worth 2014, pet. filed); DHS Mgmt. Servs.,
                                                               Inc. v. Castro, 435 S.W.3d 919, 922 & n.3 (Tex.
II, Jurisdiction
                                                               App.--Dallas 2014, no pet). That being so, we have ju-
     Texas Civil Practice and Remedies Code §                  risdiction and move to the hospital's waiver claim,
51.014(a)(10) permits an appeal from an interlocutory
order granting relief sought by a motion to dismiss an         III. Waiver
HCLC for failure to file an expert report. Generally, the
                                                                   The hospital argues that Ross waived any challenge
court of appeals' judgment is final on interlocutory ap-
                                                               to her claim being classified as an HCLC by failing to
peals. See TEX. Gov'T CODE § 22.225(b)(3). However,
                                                               argue the point or cite relevant authority in tl1e court of
we have jurisdiction if the justices of the court of appeals
                                                               appeals. We disagree.
disagree on a question of law material to the decision, or
if a court of appeals holds differently from a prior [**5]         A brief in the court of appeals "must contain a clear
decision [*500] of another court of appeals or this            and concise argument for the contentions made, [**7]
Court. 1d. § 22.225(c).                                        with appropriate citations to authorities and to the rec-
                                                                                                                  Page 3
                                      462 S.W.3d496, *; 2015 Tex. LEXIS 361, **;
                                         58 Tex. Sup. J. 766; 58 Tex. Sup, J, 802

ord." TEX R. APP. P. 38.1(1). Failure to provide citations             the claimant's claim or cause of action
or argument and analysis as to an appellate issue may                  sounds in tort or contract.
waive it. See ERJ Consulting Eng'rs, Inc. v. Swinnea, 318
S.W.3d 867, 880 (Tex. 2010).
                                                               TEX C!V. PRAC. & REM. CODE § 74.00l(a)(l3). This
     In her court of appeals brief, Ross discussed the
                                                               Court construed 11 Safety" under the prior statute accord-
purpose of the TMLA and asserted that classifying her
                                                               ing to its common meaning as nthe condition of being
claim as an HCLC would conflict with the Government
                                                               'untouched by danger; not exposed to danger; secure
Code. See TEX Gov'TCODE § 311.021(3) (providing that
                                                               [**9] from danger, harm or loss.ur Diversicare Gen.
when a statute is enacted, there is a presumption that "a
                                                               Partner, Inc. v. Rubio, 185 S.W.3d 842, 855 (Tex. 2005)
just and reasonable result is intended"). The court of ap-
                                                               (quoting BLACK'S LAW DICTIONARY 1336 (6th ed.
peals implicitly determined that Ross's citations and ar-
                                                               1990)). We also recognized that the Legislature's inclu-
gument were enough to avoid waiver because it ad-
                                                               sion of the word "safety" in the statute expanded the
dressed the issue. See Republic Undenvriters Ins. Co. v.
                                                               statute's scope beyond what it would be if the statute
Mex-Tex, Inc., 150 S.W.3d 423, 427 [*501] (Tex.
                                                               only included the terms medical care and health care. Id.
2004) (concluding that an argument in the court of ap-
                                                               The Court explained its disagreement with the position
peals was not waived and noting that "we have instructed
                                                               of Chief Justice Jefferson who, in a concurring opinion,
the courts of appeals to construe the Rules of Appellate
                                                               argued that some of the patient's claims arising from an
Procedure reasonably, yet liberally, so that the right to
                                                               assault by another patient were premises liability claims:
appeal is not lost by imposing requirements not abso-
                                                                            Rubio is not complaining about an un-
lutely necessary to effect the purpose of a rule" (quoting
                                                                        locked window that gave an intruder ac-
Verburg/ v. Dorner, 959 S.W.2d 615, 616-17 (Tex.
                                                                        cess to the facility or a rickety staircase
1997))). We agree with the court of appeals that Ross did
                                                                        that gave way under her weight. All of her
not waive the issue.
                                                                        claims arise from acts or omissions that
                                                                       are inseparable from the provision of
IV. Health Care Liability Claims
                                                                       health care. We do not distinguish Rubio's
     The merits of the appeal require us to review the                 health care claims from premises liability
lower courts' construction of the TMLA. Under such                     claims "simply because the landowner is a
circumstances our review is de novo, Williams, 3 71                    health care provider" but because the gra-
S. W.3d at 177, and our goal [**8] is to give effect to                vamen of Rubio's complaint is the alleged
legislative intent. Certified EMS, Inc. v. Potts, 392                   failure of Diversicare to implement ade-
S. W.3d 625, 631 (Tex. 2013). In determining that intent                quate policies to care for, supervise, and
we look first and foremost to the language of the statute.             protect its residents who require special,
City of Rockwall v. Hughes, 246 S.W.3d 621, 625 (Tex.                  medical care.
2008). We construe a statute's words according to their
plain and common meaning unless they are statutorily
defined otherwise,. a different meaning is apparent from       Id. at854.
the context, or unless such a construction leads to absurd
                                                                    The Legislature added the phrase "or professional or
or nonsensical results. See Tex. Lottery Comm 'n v. First
                                                               administrative services directly [**10] related to health
State Bank of DeQueen, 325 S.W.3d 628, 635 (Tex.
                                                               care" to the definition [*502] of health care liability
2010). Determining legislative intent requires that we
                                                               claim in 2003. Compare Act of May 30, 1977, 65th Leg.,
consider the statute as a whole, reading all its language in
                                                               R.S., ch. 817, § 1.03(a)(4), 1977 Tex. Gen. Laws 2039,
context, and not reading individual provisions in isola-
                                                               2041, repealed by Act of June 2, 2003, 78th Leg., ch.
tion. See Union Carbide Corp. v. Synatzske, 438 S.W.3d
204, § 10.09, 2003 Tex. Gen. Laws 847, 884 (absence of
39, 51 (Tex. 2014).
                                                               language), with TEX CIV. PRAC. & REM. CODE §
    The TMLA defines a health care liability claim as:         74.00l(a)(l3) (language added). After that statutory
                                                               amendment we addressed the "safety" part of the defini-
          a cause of action against a health care              tion in Omaha Healthcare Ctr., L.L.C. v. Johnson, 344
       provider or physician for treatment, lack               S. W.3d 392 (Tex. 2011), and Harris Methodist Fort
       of treatment, or other claimed departure                Worth v. Ollie, 342 S.W.3d 525 (Tex. 2011). Although
       from accepted standards of medical care,                the claims in both cases alleged general negligence, they
       or health care, or safety or professional or            were HCLCs because the underlying nature of the claims
       administrative services directly related to             involved violations of safety standards directly related to
       health care, which proximately results in               the provision of health care, including protecting pa-
       injmy to or death of a claimant, whether                tients. Johnson, 344 S.W.3d at 394-95 (nursing home
                                                                                                                        Page 4
                                       462 S.W.3d 496, *; 2015 Tex. LEXIS 361, **;
                                          58 Tex. Sup. J. 766; 58 Tex. Sup. J. 802

patient's death caused by a brown recluse spider); Ollie,        medical care, treatment, or confinement" TEX. C!V. PRAC.
342 S.W.3d at 527 (post-operative patient's slip and fall       & REM. CODE§ 74.001 (a)(10)), and that if the facts un-
on a wet bathroom floor). But given that the claims were         derlying a claim could support claims against a physician
based on injuries to patients and were directly related to       or health care provider for departures from accepted
the provision of health care, we did not address the issue       standards of medical care, health care, or safety or pro-
of whether safety standard-based claims must be directly         fessional or administrative services directly related to
related to health care in order for them to be HCLCs.            health care, the claims [**13] were HCLCs regardless
Johnson, 344 S.W.3d at 394 n.2; Ollie, 342 S. W.3d at           of whether the plaintiff alleged the defendants were lia-
527 n.2.                                                         ble for breach of the standards. See Loaisiga, 379 S.W.3d
                                                                 at 255. But that being so, we further explained:
     The next year we considered whether a psychiatric
technician's claims for injuries in an altercation with a
                                                                           we fail to see how the Legislature
patient were HCLCs. Williams, 371 S.W.3d at 181. In
                                                                        could have intended the requirement of an
reaching our decision [**II] we specifically and sepa-
                                                                        expert report to apply under circumstanc-
rately analyzed both whether the claims were based on
                                                                        es where the conduct of which a plaintiff
the health care provider's allegedly departing from
                                                                        complains is wholly and conclusively in-
standards for health care, and whether they were also
                                                                        consistent with, and thus separable from,
based on its allegedly departing from standards for safe-
                                                                        the rendition of 11 medical care, or health
ty. Id. at 180-86. Regarding the safety standards issue,
                                                                        care, or safety or professional or adminis~
we reviewed the definition of HCLC and determined that
                                                                        trative services directly related to health
the phrase "directly related to health care" modified the
                                                                        care" even though the conduct occurred in
terms immediately before it--professional or administra-
                                                                        a health care context. See TEX. C!V. PRAC.
tive services--but not the word safety. Id. at 185. We said
                                                                        & REM. CODE§ 74.001(a)(J3); see also
that "Williams'[s] claims are indeed for departures from
                                                                        TEX. Gov'T CODE § 311.021 ("In enacting
accepted standards of safety. We conclude that the safety
                                                                        a statute, it is presumed that ... a just and
component of HCLCs need not be directly related to the
                                                                        reasonable result is intended .... ").
provision of health care and that Williams'[s] claims
against West Oaks implicate this prong of HCLCs." Id.
at 186. Because we also concluded that Williams's
                                                                 Id. at 257. Our reasoning led to the conclusion that a
claims were HCLCs because they were for departures
                                                                 patient's claim against a medical provider for assault
from health care standards, our decision that his claims
                                                                 during a medical examination is not an HCLC if the only
were HCLCs rested on alternative holdings that are both
                                                                 possible relationship between the alleged improper con-
entitled to stare decisis treatment: the claims were for
                                                                 duct and the rendition of medical services or health care
departures from health care standards and they were for
                                                                 was the setting in which the conduct took place. !d.
departures from safety standards. Id.; see State Farm
Mut. Auto. Ins. Co. v. Lopez, 156 S.W.3d 550, 554 (Tex.              In this case, the hospital advances two positions in
2004) (distinguishing alternative holdings from dictum).         support of the lower courts' rulings and its assertion that
                                                                 Ross's claim is (**14] an HCLC. First, it addresses slip
     The [**12]     purpose of the TMLA's expert report
                                                                 and fall claims generally, and says that any slip and fall
requirement is not to have claims dismissed regardless of        event within a hospital is directly related to health care
their merits, but rather it is to identify and deter frivolous
                                                                 because it necessarily is related to the safety of patients.
claims while not unduly restricting a claimant's rights.
                                                                 Second, it focuses on Ross 1s claim specifically and ar-
Scoresby v. Santillan, 346 S.W.3d 546, 554 (Tex. 2011).
                                                                 gues that her claim is related to health care because she
And the Legislature did not intend for the expert report
                                                                 alleges the hospital breached standards applicable to
requirement to apply to every claim for conduct that oc-
                                                                 maintaining a safe environment for patients. We disagree
curs in a health care context. See Loaisiga v. Cerda, 3 79
                                                                 with both positions.
S. W.3d 248, 258 (Tex. 2012). For example, in Loaisiga
patients claimed that a doctor improperly touched them                As to the hospital's first contention, even though the
during the course of medical exams and thereby assault-          claims in Loaisiga were by a patient and the nature of the
ed them. 379 S. W.Jd at 253. The trial court concluded           claims differ from Ross's safety standards-based claim,
that the claim was not an HCLC and the court of appeals          the principle we explicated there applies here. A safety
affirmed. Id. at 254. We pointed out that the statutory          standards-based claim does not come within the TMLA's
definition of "health care" is broad ("any act or treatment      provisions· just because the underlying occurrence took·
performed or furnished, or that should have been per-            place in a health care facility, the claim is against a
formed or furnished, by any health care provider for, to,        health care provider, or both. See Loaisiga, 379 S.W.3d
or on behalf of a patient [*503] during the patient's            at 257.
                                                                                                                         Page 5
                                         462 S.W.3d 496, *; 2015 Tex. LEXIS 361, **;
                                            58 Tex. Sup. J. 766; 58 Tex. Sup. J. 802

     As to its second contention, Ross alleged that the             CODE§ 31l.021 ("In enacting a statute, it is presumed
hospital failed to exercise reasonable care in making the           that ... a just and reasonable result is intended .... ");
floor safe. The standards Ross says the hospital breached           Synatzske, 438 S.W.3d at 54 (declining to attribute to the
regarding maintenance of its floor may be the same as               Legislature an intent to require a meaningless, arbitrary
the hospital1s standards for maintaining a safe environ-            procedural hurdle for injured persons to bring suit).
ment inpatient care areas--but those may [**15] also be
the same standards many businesses generally have for                      I Hi/co Elec. Co-op. v. Midlothian Butane Gas
maintaining their floors. And the hospital does not claim,                 Co., Ill S. W.3d 75, 81 (Tex. 2003) ("[T]he rule
nor does the record show, that the area where Ross fell                    of ejusdem generis ... provides that when words
was a patient care area or an area where patients possibly                 of a general nature are used in connection with
would be in the course of the hospital's providing health                  the designation of particular objects or classes of
care services to them. Nor does the hospital reference                     persons or things, the meaning of the general
support in the record for the position that the area had to                words will be restricted to the particular designa-
meet particular cleanliness or maintenance standards                       tion."); see also ANTONIN SCALIA & BRYAN A.
related to the provision of health care or patient safety.                 GARNER, READING LAW: THE INTERPRETATION
See Ollie, 342 S.W.3d at 527 ("[S]ervices a hospital pro-                 OF LEGAL TEXTS 199 (20 12) ("Where general
vides its patients necessarily include those services re-                  words follow an enumeration of two or more
quired to meet patients' fundamental needs such as clean-                  things, they apply only to persons or things of the
liness ... and safety."). Which leads to the question of                   same general kind or class specifica11y men-
whether      [*504]     Ross's claims are nevertheless                     tioned.11).
HCLCs, as the hospital would have us hold.
                                                                         Thus, we conclude that for a safety standards-based
     The TMLA does not specifically state that a safety             claim to be an HCLC there must be a substantive nexus
standards-based claim fa11s within its provisions only if           between the safety standards allegedly violated and the
the claim has some relationship to the provision of health          provision of [**18] health care. And that nexus must be
care other than the location of the occurrence, the status          more than a "but for" relationship. That is, the fact that
of the defendant, or both. But the Legislature must have            Ross, a visitor and not a patient, would not have been
intended such a relationship to be necessa1y, given the             injured but for her fa11ing inside the hospital is not a suf-
legislative intent explicitly set out in the TMLA and the           ficient relationship between the standards Ross a1leges
context [** 16] in which "safety" is used in the statute.           the hospital violated and the hospital's health care activi-
We said as much in Loaisiga. 379 S.W.3d at 257. Even                ties for the claim to be an HCLC. As we recognized in
though the statute's phrase "directly related to health             Loaisiga, "[i]n some instances the only possible rela-
care11 does not modify its reference to safety standards,           tionship between the conduct underlying a claim and the
that reference occurs within a specific context, which              rendition of medical services or healthcare will be the
defines an HCLC to be "a cause of action against a health           healthcare setting (i.e., the physical location of the con-
care provider or physician for [a] treatment, [b] lack of           duct in a health care facility), the defendant's status as a
treatment, [c] or other claimed departure from accepted             doctor or health care provider, or both." 379 S.W.3d at
standards of medical care, or health care, or safety. 11 TEX.       256. But although the mere location of an injury in a
C!V. PRAC. & REM. CODE§ 74.00l(a)(l3). Where the                    health care facility or in a health care setting [*505]
more specific items, [a] and [b], are fo11owed by a                 does not bring a claim based on that injury within the
catcha11 "other," [c], the doctrine of ejusdem generis              TMLA so that it is an HCLC, the fact that the incident
teaches that the latter must be limited to things like the          could have occurred outside such a facility or setting
former.' And here, the catcha11 "other" itself refers to            does not preclude the claim from being an HCLC. The
standards of 11 medical care' 1 or 11 health care 11 or "safety."   pivotal issue in a safety standards-based claim is whether
Considering the purpose of the statute, the context of the          the standards on which the claim is based implicate the
language at issue, and the rule of ejusdem generis, we              defendant's duties as a health care provider, including its
conclude that the safety standards refeiTed to in the defi-         duties [**19] to provide for patient safety.
nition are those that have a substantive relationship with
                                                                         As this case demonstrates, the line between a safety
the providing of medical or health care. And if it were
                                                                    standards-based claim that is not an HCLC and one that
not so, the broad meaning of "safety" would afford de-
                                                                    is an HCLC may not always be clear. But certain
fendant health care providers a special procedural ad-
                                                                    non-exclusive considerations lend themselves to analyz-
vantage in the guise of requiring [**17] plaintiffs to file
                                                                    ing whether such a claim is substantively related to the
expert reports in their suits regardless of whether tl1eir
                                                                    defendant's providing of medical or healt11 care and is
cause of action implicated the provision of medical or
                                                                    therefore an HCLC:
health care. We do not believe the Legislature intended
the statute to have such arbitrary results. See TEX. Gov'T
                                                                                                                         Page 6
                                         462 S.W.3d 496, *; 2015 Tex. LEXIS 361, **;
                                            58 Tex. Sup. J. 766; 58 Tex. Sup. J. 802

           1. Did the alleged negligence of the                    V. Conclusion
        defendant occur in the course of the de-
                                                                        Under this record Ross's claim is based on safety
        fendant's performing tasks witl1 the pur-
                                                                   standards that have no substantive relationship to the
        pose of protecting patients from harm;
                                                                   hospital's providing of health care, so it is not an HCLC.
             2. Did the injuries occur in a place                  Because her claim is not an HCLC, she was not required
        where patients might be during the time                    to serve an expert report to avoid dismissal of her suit.
        they were receiving care, so that the obli-                We reverse the judgment of the court of appeals and
        gation of the provider to protect persons                  [*506] remand the case to the trial court for further
        who require special, medical care was                      proceedings.
        implicated;
                                                                       Phil Johnson Justice
             3. At the time of the injury was the
                                                                       OPINION DELIVERED: May 1, 2015
        claimant in the process of seeking or re-
        ceiving health care;
                                                                   CONCUR BY: Debra H. Lehrmann
             4. At the time of the injury was the
        claimant providing or assisting in provid-                 CONCUR
        ing health care;
                                                                      WSTICE LEHRMANN, joined                    by   JUSTICE
             5. Is the alleged negligence based on                 DEVINE, concurring.
        safety standards arising from professional
                                                                       I join the Court's opinion and agree that the claims
        duties owed by the health care provider;
                                                                   asserted in this case have no connection to the provision
              6. If an instrumentality was involved                of health care. I write separately, however, to emphasize
        in the defendant's alleged negligence, was                 my concern that a statute intended to address the insur-
        it a type used in providing health care; or                ance crisis stemming from the volume of frivolous med-
                                                                   ical-malpractice lawsuits has become a nebulous barrier
             7. Did the alleged negligence occur
                                                                   to what were once ordinary negligence suits brought by
        [**20] in the course of the defendant's
                                                                   plaintiffs alleging no breach of any professional duty of
        taking action or failing to take action nec-
                                                                   care.
        essary to comply with safety-related re-
        quirements set for health care providers                          In Texas West Oaks Hospital, LP v. Williams, the
        by governmental or accrediting agencies?                   Court held that a plaintiffs claim against [**22] a phy-
                                                                   sician or health care provider may constitute a health
                                                                   care liability claim subject to the Texas Medical Liability
                                                                   Act even where no patient--physician or pa-
     Measuring Ross's claim by the foregoing considera-
                                                                   tient--health-care-provider relationship exists between
tions, it is clear that the answer to each is 11 no. 11 The rec-
                                                                   the parties. 371 S.W.3d 171, 177-78 (Tex. 2012). In my
ord does not show that the cleaning and buffing of the
                                                                   dissent in that case, I disagreed with the Court's holding
floor near the exit doors was for the purpose of protect-          11
                                                                      that the mere peripheral involvement of a patient trans-
ing patients. Nor does the record reflect that the area
                                                                   forms an ordinary negligence claim into a health care
where Ross fell was one where patients might be during
                                                                   claim." !d. at 194-95 (Lehrmann, J., dissenting). I la-
their treatment so that the hospital's obligation to protect
                                                                   mented what I viewed as the Court's departure from the
patients was implicated by the condition of the floor at
                                                                   importance we had previously placed on the relationship
that location. Ross was not seeking or receiving health
                                                                   between health care providers and their patients in con-
care, nor was she a health care provider or assisting in
                                                                   cluding that a patient's claims were covered by the Act.
providing health care at the time she fell. There is no
                                                                   Id. at 196-97 (citing Diversicare Gen. Partner, Inc. v.
evidence the negligence alleged by Ross was based on
                                                                   Rubio, 185 S.W.3d 842 (Tex. 2005)). The consequences
safety standards arising from professional duties owed by
                                                                   of that departure are evident in cases like this, in which
the hospital as a health care provider. There is also no
                                                                   defendants who happen to be health care providers seek
evidence that the equipment or materials used to clean
                                                                   the protections of the Medical Liability Act with respect
and buff the floor were particularly suited to providing
                                                                   to claims that have nothing to do with medical liability.
for the safety of patients, nor does the record demon-
strate that the cleaning and buffing of the floor near                   The Court holds, and I agree, that a cause of action
[**21] the exit doors was to comply with a safe-                   against a health care provider for a departure from safety
ty-related requirement set for health care providers by a          standards is a health care liability claim only if it has a
governmental or accrediting authority.                             11
                                                                      substantive relationship 11 with the provision of medical
                                                                   or health care.'       S.W.3d at       . I write separately to
                                                                                                                 Page 7
                                     462 S.W.3d 496, *; 2015 Tex. LEXIS 361, **;
                                        58 Tex. Sup. J. 766; 58 Tex. Sup. J. 802

emphasize [**23] the significance of the third and fifth      constitute health care liability claims. !d. at 854. These
factors, which consider whether the claimant was in the       statements are consistent with our recognition that health
process of seeking or receiving health care at the time of    care liability claims involve a "specialized standard of
the injmy and whether the alleged negligence was based        care" that is established by expert testimony. Garland
on safety standards arising from professional duties owed     Cmty. Hasp. v. Rose, 156 S.W.3d 541, 546 (Tex. 2004);
by the health care provider.                                  see also Jackson v. Axelrad, 221 S.W.3d 650, 655 (Tex.
                                                              2007) (explaining that a physician's duty of care owed to
       2 "Substantive" is defined as 11 Considerable in       a patient is that of "a reasonable and prudent member of
       amount or numbers; substantial. 11 WEBSTER 1S          the medical profession ... under the same or similar cir-
       THIRD NEW INT'LDICTIONARY 2280 (2002).                 cumstances" (quoting Hood v. Phillips, 554 S.W.2d 160,
                                                              165 (Tex. 1977))).
     As we recognized in Diversicare, the duty of care
that health care providers owe to their patients is funda-         In my view, focusing a safety-standards claim on the
mentally different from the duty of care owed to, say,        duty health care providers owe to their patients ensures
employees or visitors. 185 S.W.3d at 850-51 ("The obli-       that Diversicare's hypothetical visitor-assault and rick-
gation of a health care facility to its patients is not the   ety-staircase claims do not fall under the Medical Liabil-
same as the general duty a premises owner owes to in~         ity Act's umbrella. It also ensures that a covered cause of
vitees."). To that end, when we held in Diversicare that a    action will "implicate[] the provision of medical or
nursing home resident1s claim that she was sexually as-       health care" in accordance with the Court's holding in
saulted by another resident was a health care liability       this case.      S.W.3d at      . With these considerations
claim, we rejected the argument that the claim should be      in mind, I respectfully join the Court's opinion and
treated the same as that of a visitor who had been as-        judgment.
saulted at the facility precisely because of the distinct
                                                                  Debra H. Lehrmann
nature of those duties. Id. We also distinguished the cir-
cumstances at issue in that case from hypothetical claims         Justice
involving an "unlocked [**24] window that gave an
                                                                  OPINION DELIVERED: May I, 2015
intruder access to the facility" and a 11 rickety staircase
[*507] that gave way," which we implied would not
APPENDIX- ''2''
                                                                                                              Page I

            LexisNexis@
                                                I of 6 DOCUMENTS

                RAUL ERNESTO LOAISIGA, M.D., AND RAUL ERNESTO LOAISIGA, M.D.,
               P.A., PETITIONERS, v. GUADALUPE CERDA, INDIVIDUALLY AND AS NEXT
                FRIEND OF MARISSA CERDA, A MINOR, AND CINDY VELEZ, RESPOND-
                                             ENTS

                                                    N0.10-0928

                                         SUPREME COURT OF TEXAS

                            379 S.W.3d 248; 2012 Tex. LEXIS 736; 55 Tex. Sup. J. 1373

                                           Febq1ary 29, 2012, Argued
                                        August 31,2012, Opinion Delivered

SUBSEQUENT HISTORY:               Released for Publica-    TICE HECHT filed a concurring and dissenting opinion,
tion October 12, 2012.                                     in which JUSTICE MEDINA joined. JUSTICE WIL-
                                                           LETT filed a concurring and dissenting opinion. JUS-
PRIOR HISTORY: [**!]                                       TICE LEHRMANN filed a concurring and dissenting
  ON PETITION FOR REVIEW FROM THE COURT                    opinion.
OF APPEALS FOR THE THIRTEENTH DISTRICT OF
TEXAS.                                                     OPINION BY: Phil Johnson
Loaisiga v. Cerda, 2010 Tex. App. LEXIS 6326 (Tex.
App. Cmpus Christi, Aug. 5, 20/0)                          OPINION
                                                                [*252] The Texas Medical [**2] Liability Act
                                                           (TMLA) requires plaintiffs asserting health care liability
COUNSEL: For Sunshine Pediatrics LLP, Other inter-
                                                           claims (HCLCs) to timely serve each defendant with an
ested party: Michael Raphael Cowen, The Cowen Law
                                                           expert report meeting certain requirements. In this case
Group, PC, Brownsville TX.
                                                           we consider whether claims that a doctor assaulted pa-
                                                           tients by exceeding the proper scope of physical exami-
For Loaisiga, M.D., Raul Emesto and Raul Emesto
                                                           nations are subject to the TMLA's expert report require-
Loaisiga, M.D., P.A., Petitioners: , Escobar Law Firm,
                                                           ments.
PLLC, McAllen TX; Carlos EscobarGilberto Hinojosa,
Gilberto Hinojosa & Associates PC, Brownsville TX.               Two female patients sued a medical doctor, the pro-
                                                           fessional association bearing his name, and a clinic, al-
For Cerda, Guadalupe, Individually and as next friend of   leging the doctor assaulted the patients by groping their
Marissa Cerda, Minor, and Cindy Velez., Respondent:        breasts while examining them for sinus and flu symp-
Benigno (Trey) Martinez III, Martinez Barrera & Mar-       toms. Although they maintained that the claims were not
tinez LLP, Brownsville TX; Brendan K. McBride, The         HCLCs, the patients served the doctor and professional
McBride Law Firm, San Antonio TX; Stephanie Elaine         association with reports from a physician who, based
Burnett, The Law Office of Benigno (Trey) Martinez,        only on the assumption that allegations in the plaintiffs'
P.L.L.C., Brownsville, TX.                                 pleadings were true, opined that the defendant doctor's
                                                           alleged actions did not fall within any appropriate stand-
JUDGES: JUSTICE JOHNSON delivered the opinion              ard of care. The defendants argued that the claims were
of the Court in which CHIEF JUSTICE JEFFERSON,             HCLCs and moved for dismissal of the suit on the basis
JUSTICE WAINWRIGHT, JUSTICE GREEN, and                     that the reports were deficient. The trial court denied the
JUSTICE GUZMAN joined, and in Parts I through V.A.         motions. The court of appeals held that the claims were
and VI.A. of which JUSTICE WILLET! joined. JUS-            not HCLCs, expert reports were not required, and af-
                                                                                                                       Page 2
                                        379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                   55 Tex. Sup. J. 1373

fitmed the trial court's [**3) order without considering          curriculum vitae from Michael R. Kilgore, M.D., a fam-
the reports' adequacy.                                            ily practitioner. See id. § 74.351(a), (b). Dr. Kilgore
                                                                  stated in the report that he had reviewed the plaintiffs'
     We hold that the TMLA creates a rebuttable pre-
                                                                  petition. He recited allegations from the pet:tion .and
sumption that a patient1s claims against a physician or
                                                                  stated that if they were true, then Dr. LoalS!ga s actwns
health care provider based on facts implicating the de-
                                                                  were not within any appropriate standard of care, com-
fendanes conduct during the patient1s care, treatment, or
                                                                  prised an assault, and harmed the plaintiffs. In .a .supple-
confinement are HCLCs. The record before us does not
                                                                  mental report, Dr. Kilgore stated that the opmwns he
rebut the presumption as it relates to the TMLA's expert
                                                                  expressed as to Dr. Loaisiga also applied to the P.A.
report requirements, nor are the expert reports served by
the plaintiffs adequate under the TMLA. We reverse the                Dr. Loaisiga and the P .A. filed objections to the re-
judgment of the court of appeals and remand the case to           ports and motions to dismiss. They argued that the re-
the trial court for further proceedings.                          ports were deficient because they failed to (I) implicate
                                                                  conduct of either Dr. Loaisiga or the P.A., (2) set out the
I. Background                                                     applicable standard of care, (3) identify a breach of the
                                                                  standard of care, or (4) identify how the actions of Dr.
     Guadalupe Cerda, individually and as next friend of
                                                                  Loaisiga or the P.A. proximately caused the alleged IUJU-
her daughter Marissa Cerda, and Cindy Velez (collec-
                                                                  ries. The motions also asserted that Dr. Kilgore's report
tively, the plaintiffs) sued Raul Emesto Loaisiga,, M.D.,
                                                                  was "based [**6] upon pure speculation and assump-
[*253) Raul Emesto Loaisiga, M.D., P.A. (heremafter,
                                                                  tion11 and Dr. Kilgore, as a family practitioner, was not
the P.A,), and Sunshine Pediatrics, LLP. The plaintiffs'
                                                                  qualified to render an expert opinion regarding Dr.
claims are based on two separate incidents. Guadalupe
                                                                  Loaisiga's conduct as a pediatrician. The P.A. separately
alleges that she took Marissa, then age seventeen, to
                                                                  argued that neither the original nor the supplemental re-
Sunshine Pediatrics for treatment of a sinus problem,
                                                                  port addressed any theories of liability as to it and, in any
According to the pleadings, Dr. Loaisiga examined
                                                                  event, the supplemental report was deficient because it
Marissa and "under the guise of listening to [Marissa's)
                                                                  gave no explanation of why the opinions in the original
heart through the stethoscope . . . cupped [Marissa's)
                                                                  report applied to the P.A. The plaintiffs' response to each
breast with the [**4] palm of his hand." Velez, who
                                                                  motion maintained that Dr. Kilgore's reports were ade-
was employed as a nurse at Sunshine Pediatrics, alleges
                                                                  quate; Dr. Loaisiga was acting both individually and as
that Dr. Loaisiga offered to examine her when she ar-
                                                                  the P.A., so there was no difference between the actiOns
rived at work with flu-like symptoms. She further alleges
                                                                  of the two; and Dr. Kilgore's reports were directed to
that during the examination Dr. Loaisiga had her take off
                                                                  both. In the alternative, the plaintiffs requested thirty-day
her upper garment, then "he undid her bra from the front
                                                                  extensions to cure any defects in the reports. See id. §
, , , [and] palmed her breast with one hand during his
                                                                  74.351(c) (stating that if an expert report is not timely
entire examination. 11
                                                                  served "because the elements of the report are [*254)
     The plaintiffs sued for assault, medical negligence,         found deficient, the court may grant one 30-day exten-
negligence, gross negligence, and intentional infliction of       sion to the claimant in order to cure the deficiency").
emotional distress. They allege that Dr. Loaisiga knew or
                                                                       The trial court held a hearing on the motions to dis-
reasonably should have believed that Marissa and Velez
                                                                  miss and denied them without stating why. Dr. Loaisiga
would regard his touching of their breasts as offenstve or
                                                                  and the P.A. appealed, See id. § 51.014(a)(9) (permitting
provocative and Sunshine Pediatrics breached its duty
                                                                  [**7) immediate appeal of a trial court order denying all
and the appropriate standard of care by allowing Dr.
                                                                  or part of a motion to dismiss for failure to serve an ex-
Loaisiga to fondle them. The plaintiffs assert that alt-
                                                                  pert report in an HCLC). The court of appeals affirmed.
hough the case is actually for assault, in an 11 abundance
                                                                  S.W.3d       , The court reasoned that the plaintiffs were
of caution and in the alternative," they claim Dr. Loaisi-
                                                                  not required to file expert reports because their claims
ga,s actions 11 fell below the standard of care 11 for a doctor
                                                                  against Dr. Loaisiga are assault claims, not HCLCs. See
treating female patients. The pleadings of medical negli-
                                                                  id. at    , It did not reach the question of whether Dr.
gence specifically reference "Chapter 74 of the
                                                                  Kilgore's reports were deficient. The court also conclud-
CPRC"--the TMLA. See TEX. C!V. PRAC. & REM. CODE
                                                                  ed that the TMLA does not apply to the plaintiffs' claims
§§ 74.001-.507. The plaintiffs pray for judgment [**5)
                                                                  against the P .A, because the plaintiffs refer to the P .A.
against the three defendants, but they do not specifically
                                                                  only in the introductory part oftheir pleadings and do not
allege any type of claim, either direct or vicarious,
                                                                  assert liability claims against it. See id. at
against the P.A.
                                                                      We granted the petition for review of Dr. Loaisiga
      Within 120 days after filing their petition, the plain-
                                                                  and the P.A. 55 Tex. Sup. C!. J. 145 (Dec, 16, 2011).
tiffs served Dr. Loaisiga and the P .A. with a report and
                                                                  Before turning to the parties' arguments on the merits, we
                                                                                                                     Page 3
                                       379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                  55 Tex. Sup. J. 1373

address our jurisdiction to consider this interlocutory            The TMLA defines an HCLC as:
appeal.
                                                                         a cause of action against a health care
II. Jurisdiction                                                      provider or physician for treatment, lack
                                                                      of treatment, or other claimed departure
     Texas appellate courts generally have jurisdiction
                                                                      from accepted standards of medical care,
only over final judgments. Baily Total Fitness Corp. v.
                                                                      or health care, or safety or professional or
Jackson, 53 S.W.3d 352, 355 (Tex. 2001). But an excep-
                                                                      administrative services directly related to
tion exists for certain interlocutory orders. See TEX Civ.
                                                                      health care, which proximately results in
PRAC. &REM. CODE§ 51.014(a); Jackson, 53 S.W.3d at
                                                                      injury to or death of a claimant, whether
355. Section 51.014(a) [**8] provides in relevant part:
                                                                      the claimant's claim or cause of action
                                                                      sounds in tort or contract.
             A person may appeal from an interloc-
          utory order of a district court, county
          court at law, or county court that:
                                                              TEX CIV. PRAC. &REM. CODE§ 74.001(a)(13). Accord-
                                                              ing to its definition, an HCLC has three elements: (I) the
             (9) denies all or part of the relief
                                                              defendant is a health care provider or physician; [**10]
          sought by a motion under Section
                                                              (2) the claimant's cause of action is for treatment, lack of
          74.351(b), except that an appeal may not
                                                              treatment, or other claimed departure from accepted
          be taken from an order granting an exten-
                                                              standards of medical care, health care, or safety or pro-
          sion under Section 74.351.
                                                              fessional or administrative services directly related to
                                                              health care; and (3) the defendant's alleged departure
                                                              from accepted standards proximately caused the claim-
TEX CIV. PRAC. &REM. CODE§ 51.014(a)(9).
                                                              ant's injury or death. Marks v. St. Luke's Episcopal
     A court of appeals' judgment ordinarily is conclusive    Hasp., 319 S.W.3d 658, 662 (Tex. 2010) (plurality opin-
when an interlocutory appeal is taken pursuant to section     ion).
51.014(a)(9). See TEX GOV'T CODE § 22.225(b)(3).
                                                                   This case focuses on the second element which con-
However, we may consider an interlocutory appeal when
                                                              cerns the nature of a claimant's "cause of action" and the
the court of appeals 1 decision creates an inconsistency in
                                                              definitions of medical care, health care, safety and pro-
the law that should be clarified to remove unnecessary
                                                              fessional or administrative services directly related to
uncertainty and unfairness to litigants. Id. §§
                                                              health care. See TEX CIV. PRAC. & REM. CODE §
22.001(a)(2), (e); 22.225(c), (e). This case involves an
                                                              74.001 (a)(J3). The TMLA does not define the term
issue on which the courts of appeals have issued incon-
                                                              "cause of action," but the generally accepted meaning of
sistent decisions. Compare         S.W.3d at       (holding
                                                              that phrase refers to the "'fact or facts entitling one to
that a doctor's alleged fondling of the plaintiffs' breasts
                                                              institute and maintain an action, which must be alleged
during medical examinations could not feasibly be ex-
                                                              and proved in order to obtain relief."' In re Jorden, 249
plained as a necessary part of medical treatment and
                                                              S.W.3d 416, 421 (Tex. 2008) (quotingA.H. Bela Cmp. v.
therefore does not give rise to an HCLC), with
                                                              Blanton, 133 Tex. 391, 129 S.W.2d 619, 621 (1939)).
Vanderwerff v. Beathard, 239 S.W.3d 406, 409 (Tex.
                                                              "Health care" is broadly defined as "any act ... per-
App.--Da//as 2007, no pet.) (concluding [**9] that a
                                                              formed ... by any health care provider for [or] to ... a
chiropractor's alleged rubbing of a plaintiffs genitals
                                                              [**II] patient during the patient's medical care, treat-
during a chiropractic examination gave rise to an HCLC
                                   1
                                                              ment, or confinement." TEX. CIV. PRAC. & REM. CODE§
because whether the chiropractor s actions were within
                                                              74.001(a)(10). And "medical care" is defined as "any act
the scope of a chiropractic examination could not be
                                                              defined as practicing medicine under Section 151.002,
answered without reference to the standard of care re-
                                                              Occupations Code, performed or furnished, or which
quired of a chiropractic provider). We have jurisdiction
                                                              should have been performed, by one hcensed to practiCe
to resolve this issue. TEX. GOV'TCODE § 22.001(a)(2).
                                                              medicine in this state for, to, or on behalf of a patient
                                                              during the patient's care, treatment, or confinement." !d.
III. Health Care Liability Claims
                                                              § 74.001(a)(19). The Occupations Code, in turn, defines
                                                              "practicing medicine" as "the diagnosis, treatment, or
A. General
                                                              offer to treat a mental or physical disease or disorder or a
     Determining whether claims are HCLCs requires            physical deforn1ity or injury by any system or method, or
courts to constme the TMLA. We review issues of statu-        the attempt to effect cures of those conditions by a per-
tory interpretation [*255] de novo. Mo/inet v. Kim-           son who ... publicly professes to be a physician." TEX
brell, 356 S.W.3d 407, 411 (Tex. 2011).                       Occ. CODE§ 151.002(a)(13).
                                                                                                                      Page 4
                                      379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                 55 Tex. Sup. J. 1373

     Analysis of the second element--the cause of ac-                      (3) intentionally or knowingly causes
tion--focuses on the facts underlying the claim, not the               physical contact with another when the
form of, or artfully-phrased language in, the plaintiffs               person knows or should reasonably be-
pleadings describing the facts or legal theories asserted.             lieve that the other will regard the contact
See, e.g., Yamada v. Friend, 335 S.W.3d 192, 196-97                    as offensive or provocative.
(Tex. 2010); Diversicare Gen. Partner, Inc. v. Rubio, 185
S. W.Jd 842, 847, 854 (Tex. 2005). We have previously
determined that [**12] a claim based on one set of facts       TEX PENAL CODE§ 22.01(a). [**14] As relevant to the
cannot be spliced or divided into both an HCLC and an-         case before us, an assault occurs if a person 11 intentional-
other type of claim. See Yamada, 335 S.W.3d at 197;           ly or knowingly causes physical contact with another
Diversicare, 185 S.W.3d at 854. It follows that claims         when the person knows or should reasonably believe that
premised on facts that could support claims against a          the other will regard the contact as offensive or provoca-
physician or health care provider for departures from          tive." !d.§ 22.01(a)(3).
accepted standards of medical care, health care, or safety
                                                                    Distinguishing between claims to which the TMLA
or professional or administrative services directly related
                                                               applies and those to which it does not apply can be diffi-
to health care are HCLCs, regardless of whether the
                                                               cult when the plaintiff alleges an assault took place dur-
plaintiff alleges the defendant is liable for breach of any
                                                               ing a physical examination to which the patient consent-
of those standards. See TEX CIV. PRAC. & REM. CODE §
                                                               ed. The scope of medical examinations generally are
74.001(a)(13).
                                                               infmmed, and largely guided, by a combination of the
      [*256] The broad language of the TMLA evi-               patient's complaints and the examiner's training and pro-
dences legislative intent for the statute to have expansive    fessional judgment. During an examination for the pur-
application. See, e.g., TEX CJV. PRAC. & REM. CODE §           pose of diagnosing or treating a patient's condition, a
74.001(a)(JO) (defining "health care" to include "any act      medical or health care provider almost always will touch
... by any health care provider for, to, or on behalf of a     the patient intentionally. Frequently, examinations in-
patient during the patient1s medical care, treatment, or       volve examiners touching the patient's body in places
confinement." (emphasis added)); see also Moline/, 356         and in ways that would be assaults were it not for the
S. W.3d at 411 (noting that when interpreting statutes we      actual or implied consent of the patient in the context of
strive to ascertain and give effect to the Legislature1S       the medical or health care relationship. And the examiner
intent). The breadth of the statute's text essentially cre-    may need to examine parts of the patient's body that
ates a presumption that a claim is an HCLC if it [**13]        might not be anticipated by a person without medical or
is against a physician or health care provider and is based    [* * 15] health care training. Such a situation is demon-
on facts implicating the defendant's conduct during the        strated by Vanderwe1:f{, a case in which no expert report
course of a patient1s ·care, treatment, or confinement. See    was filed. There, Kristina Beathard sought treatment
Marks, 319 S. W.Jd at 662. But the presumption is nec-         from Eric Vanderwerff, a chiropractor, complaining of
essarily rebuttable. In some instances the only possible       pain in various parts of her body. 239 S.W.3d at 407.
relationship between the conduct underlying a claim and        Beathard later sued Vande1werff, alleging that "during
the rendition of medical services or healthcare will be the    the course of a routine examination of her knee" he
healthcare setting (i.e., the physical location of the con-    rubbed her genitals. Id. at 409. The trial court denied
duct in a health care facility), the defendant's status as a   Vanderwerffs motion to dismiss for Beathard's failure to
doctor or health care provider, or both.                       serve an expert report, but the court of appeals reversed.
                                                               !d. In doing so, it noted that Beathard had marked an
B. Assaults and the TMLA                                       anatomical drawing to show her areas of pain, and those
                                                               markings indicated she was having pain not only in her
     The elements of a civil assault mirror those of a
                                                               neck, wrists, ankle, and left knee, but also running from
criminal assault. See Wajj/e House, Inc. v. Williams, 313
                                                               her knee to her upper thigh. [*257] Id. The court of
S. W.3d 796, 801 n.4 (Tex. 2010). Under the Penal Code,
                                                               appeals set out the issue and its conclusion as follows:
an assault occurs if a person:
                                                                        The threshold questions raised by
          (I) intentionally, knowingly, or reck-
                                                                      Beathard's pleadings are whether she
       lessly causes bodily injmy to another, in-
                                                                      consented to treatment and whether
       cluding the person's spouse;
                                                                      Vanderwerffs examination was within the
          (2) intentionally or knowingly threat-
                                                                      scope of a chiropractic examination. Was
       ens another with imminent bodily injury,
                                                                      the examination a "routine" examination
       including the person's spouse; or
                                                                      as Beathard contends? These questions
                                                                      cannot be answered without reference to
                                                                                                                    Page 5
                                       379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                  55 Tex. Sup. J. 1373

        the standard of care required [**16] of a               of a metal weight in the patient's hand during a neuro-
        chiropractic provider.                                  logical examination).

                                                                IV. Expert Reports
Id. In essence, the court of appeals recognized that an
                                                                     The TMLA's expert report requirements do not re-
expert report was necessary because Vanderwerffs con-
                                                                quire a trial court to make a merits determination re-
duct in the overall context of the chiropractic examina-
                                                                garding whether the claim is an HCLC. See Murphy, 167
tion could have been part of the care he was rendering
                                                                S.W.3d at 838 (explaining that the [*258] requirement
pursuant to Beathard's consent to be examined and treat-
                                                                is a threshold over which a plaintiff must proceed); Am.
ed for pain which, in part, she reported extended from
                                                                Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46
her knee to the upper thigh.
                                                                S. W.3d 873, 878 (Tex. 2001) ("[T]he expert report must
      In balancing the respective rights of and burdens on      represent only a good-faith effort to provide a fair sum-
claimants and medical and healthcare defendants, the            mary of the expert's opinions. A report need not marshal
Legislature has determined that requiring claimants to          all the plaintiffs proof, but it must include the expert's
bear the expense of obtaining and serving expert reports        opinion on each of the elements identified in the stat-
early in HCLCs is preferable to having parties incur sub-       ute."). Nor does a determination that the TMLA's expert
stantial expense and devote considerable time to devel-         report requirements apply to a claim affect other matters
oping claims through discovery and trial preparation            such as whether a physician or health care provider may
before a trial court determines which ones are meritless.       be subject to professional sanctions or criminal prosecu-
See Scoresby, 346 S.W.3d at 552, 556; Palacios, 46             tion for the conduct [**19] on which a plaintiff bases a
S. W.3d at 877. However, we fail to see how the Legisla-        claim. See Vanderweif.t: 239 S.W.3d at 407 n.1 (noting
ture could have intended the requirement of an expert           that in addition to a civil case alleging sexual assault
report to apply under circumstances where the conduct of        against a chiropractor for rubbing the patient's genitals
which a plaintiff complains is wholly and conclusively          during an examination, a criminal complaint was filed
inconsistent with, and thus separable from, the rendition       against the defendant). The requirements are meant to
of 11 medical care, or health care, or safety or professional   identify frivolous claims and reduce the expense and
[** 17] or administrative services directly related to          time to dispose of any that are filed. See Scoresby v. San-
health care" even though the conduct occurred in a health       tillan, 346 S.W.3d 546, 554 (Tex. 2011) ("The purpose of
care context. See TEX C!V. PRAC. & REM. CODE §                  the expert report requirement is to deter frivolous claims,
74.001(a)(I3); see also TEX GOV'TCODE § 311.021 ("In            not to dispose of claims regardless of their merits." (cita-
enacting a statute, it is presumed that ... a just and rea-     tion omitted)); see a/so TEX C!V. PRAC. & REM. CODE§
sonable result is intended .... ").                             74.351(k), (t) (providing that an expert report is not ad-
                                                                missible in and shall not be used during depositions, trial,
     We conclude that a claim against a medical or health
                                                                or other proceedings, nor shall it be referred to for any
care provider for assault is not an HCLC if the record
                                                                purpose absent the plaintiffs using it in a way other than
conclusively shows that (I) there is no complaint about
                                                                serving it pursuant to the 120-day service requirement of
any act of the provider related to medical or health care
                                                                section 74.351(a)); id. § 74.351(s) (limiting discovery
services other than the alleged offensive contact, (2) the
                                                                until the expert report and curriculum vitae of the expert
alleged offensive contact was not pursuant to actual or
                                                                have been served).
implied consent by the plaintiff, and (3) the only possible
relationship between the alleged offensive contact and               In Palacios we held that the TMLA's language re-
the rendition of medical services or healthcare was the         quires a trial court to determine a report's adequacy from
setting in which the act took place. See Mwphy v. Rus-          its four comers. 46 S.W.3d at 878. [**20] The statute
sell, 167 S.W.3d 835, 838 (Tex. 2005) (per curiam)             does not similarly limit what a trial court may consider
(holding that a plaintiffs battery claim was an HCLC            when the question is whether a claim is subject to the
because "[t]here may [have] be[en] reasons for providing        TMLA's expert report requirements. Thus, when making
treatment without specific consent that do not breach any       that determination courts should consider the entire court
applicable standard of care[, and] [t]he existence or non-      record, including the pleadings, motions and responses,
existence of such reasons is necessarily the subject of         and relevant evidence properly admitted. This could in-
[**18] expert testimony"); Buck v. Blum, 130 S.W.3d             clude, but is not limited to, reports such as those the
285, 289-90 (Tex. App.--Houston [14th Dist.] 2004, no           plaintiffs served here, medical records regarding exami-
pet.) (concluding that a neurologist's conduct was not in       nation or treatment of the plaintiff, if any, and the de-
the course and scope of his employment when a patient           fendant's pleadings and explanation for how the contact
complained that the neurologist placed his penis instead        at issue was part of medical care, or health care, or safety
                                                                                                                      Page 6
                                      379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                 55 Tex. Sup. J. 1373

or professional or administrative services directly related            to listen to the heartbeat of the patient.
to health care.                                                        However, in all applicable medical stand-
                                                                       ards of care, it is unnecessary that a pa-
     In light of the foregoing, we tum to the parties' con-
                                                                       tient remove their brazier, nor is it neces-
tentions. We address the defendants separately, begin-
                                                                       sary to cup, palm or touch the breast of a
ning with Dr. Loaisiga.
                                                                       female patient either with the hand hold-
                                                                       ing the stethoscope or the other hand not
V. Dr. Loaisiga
                                                                       holding the instrument to listen to a heart
                                                                       beat.
A. Was an Expert Report Required
     Dr. Loaisiga argues that the plaintiffs were required
to file an expert report because the alleged assaults oc-
                                                                    Another distinction is that the record in Vanderweljf
curred during the course of his administering medical
                                                               contained an anatomical drawing on which the plaintiff
services and all his actions were inseparable from the
                                                               indicated to the chiropractor that she [**23] had pain
rendition of those medical services. The plaintiffs urge
                                                               running from her knee to her upper thigh. Id. at 409.
that, as the court of appeals held, their [**21] assault
                                                               Based on that document, the court of appeals recognized
claims are not subject to the TMLA's expert report re-
                                                               that the chiropractor1s touching of, or near, the patienfs
quirements because Dr. Loaisiga's acts do not implicate
                                                               genitals could have been part of the examination. See id.
medical or health care services, regardless of whether
                                                               Here, the record does not contain any documents other
medical treatment was occurring at the time of the as-
                                                               than the plaintiffs' pleadings to shed light on the plain-
saults. Rather, they say the alleged acts of assault are so
                                                               tiffs' symptoms or their complaints to Dr. Loaisiga. As
inconsistent with the medical services Dr. Loaisiga was
                                                               discussed in more detail below, apart from allegations in
rendering, that the TMLA does not apply. In analyzing
                                                               the plaintiffs' pleadings, Dr. Kilgore's reports make no
these arguments, we consider the entire record before the
                                                               reference to the plaintiffs' medical records or the com-
trial court and the overall context of the plaintiffs' suit,
                                                               plaints they made to Dr. Loaisiga in the clinical setting.
including the nature of the factual allegations in their
pleadings, [*259] Dr. Loaisiga's contentions, and the              The substance of the plaintiffs' complaint is that Dr.
motions to dismiss and responses.                              Loaisiga1S conduct exceeded the scope of the examina-
                                                               tions to which they consented, and Dr. Kilgore's report
     We look first to the pleadings. The plaintiffs' plead-
                                                               shows that it is unnecessary for a physician to touch a
ings contain allegations that except for Dr. Loaisiga's
                                                               female patient1s breasts during routine examinations of
touching of their breasts, the examinations were routine.
                                                               the type Dr. Loaisiga was performing. But even taken
The pleadings do not assert a lack of proper care by Dr.
                                                               together, these aspects of the record do not conclusively
Loaisiga other than his touching of their breasts. Further,
                                                               rebut the presumptive application of the TMLA's expert
the plaintiffs' brief on the merits posits that their plead-
                                                               report requirements. The lack of information to give
ings made "no factual allegations that they were injured
                                                               context to Dr. Loaisiga1s actions during the examina-
by any deficiencies in the medical care provided by Dr.
                                                               tions--such as medical [* *24] records, if any, reference
Loaisiga."
                                                               to the medical records by Dr. Kilgore in his reports, or
     The plaintiffs' claims are qualitatively similar to the   other information regarding the plaintiffs' symptoms and
claims in Vanderwerff See 239 S.W.3d at 407. [**22]           complaints to Dr. Loaisiga--prevents the plaintiffs from
Like the plaintiff in Vanderweiff, the plaintiffs here al-     showing conclusively that the only relationship between
lege an examining doctor inappropriately touched parts         the alleged touching of their breasts and Dr. Loaisiga's
of their bodies during the course of otherwise routine         rendition of medical services was the physical location of
examinations. See id. But because the determination of         the examinations at the offices of Sunshine Pediatrics
whether the plaintiffs were required to serve an expert        and his status as a doctor or health care provider.
report is to be made based on the whole record, we must
                                                                    We conclude that the record does not contain suffi-
also consider other relevant documents in the record and
                                                               cient information to conclusively show that Dr. Loaisi-
Dr. Loaisiga's contentions. In that regard, this case is
                                                               ga's conduct [*260] could not have been part of the
distinguishable from Vanderwerff
                                                               examination he was perfom1ing. But because we are
     One distinguishing factor is that the plaintiff in        clarifying the standard for whether claims are subject to
Vanderweljf did not serve an expet1 repot1. Here the           the TMLA's expert report requirements and the plaintiffs
plaintiffs served a report that stated, in part:               maintain that theirs are not, we conclude it is appropriate
                                                               to remand the case to the trial court for further proceed-
         During a routine "sick 11 visit with a                ings regarding that issue. See Low v. Henry, 221 S. W.3d
       physician, a stethoscope may be utilized
                                                                                                                      Page 7
                                       379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                  55 Tex. Sup. J. 1373

609, 621 (Tex. 2007) (remanding "to allow the parties to         on his position that Dr. Kilgore's reports cannot be good
present evidence responsive to our guidelines 11 ) .             faith attempts to provide expert reports because they
                                                                 merely assume the truth of [**27] what is in the plain-
B. Adequacy of the Reports                                       tiffs' pleadings. Dr. Loaisiga first argues that Dr. Kil-
                                                                 gore's assuming the truth of the plaintiffs' pleadings re-
     The court of appeals did not consider whether Dr.
                                                                 sults in the reports being wholly speculative because the
Kilgore's reports are adequate to meet the requirements
                                                                 pleadings are merely unverified allegations. He also as-
of [**25] section 74.351 because it concluded that no
                                                                 serts that the reports (1) improperly require the trial court
expert reports were necessary.       S.W.3d at      . If, on
                                                                 to assume facts outside their four comers and (2) do not
remand, the trial court determines expert reports are nec-
                                                                 in good faith identity and state the breach and causation
essary under the TMLA, the adequacy of Dr. Kilgore's
                                                                 elements required to be contained in expert reports be-
reports must be determined. Dr. Loaisiga preserved the
                                                                 cause they are conditioned on certain facts being true. In
adequacy issue in the courts below and briefed and ar-
                                                                 response, the plaintiffs maintain that Dr. [*261] Kil-
gued it here. Therefore, without expressing any opinion
                                                                 gore was entitled to rely on their pleadings as true. They
as to whether the TMLA's expert report requirements
                                                                 posit that whether their allegations are credible is a mat-
will ultimately apply to this case, in the interest of judi-
                                                                 ter for the jury to decide, not a matter for the trial judge
cial efficiency we address whether Dr. Kilgore's reports
                                                                 in passing on whether the reports are a good faith effort
comply with the TMLA's requirements. See TEX R. APP.
                                                                 to comply with the TMLA requirements. To a certain
P. 53.4; Reid Road Mun. Uti/. Dis!. No. 2 v. Speedy Stop
                                                                 extent we agree with both parties.
Food Stores, Ltd., 337 S.W.3d 846, 855 (Tex. 2011).
                                                                      The fact that pleadings are not verified does not re-
     When a document purporting to be an expert report
                                                                 lieve attorneys and parties from their obligation to avoid
is timely served in an HCLC and is properly challenged,
                                                                 including groundless or bad faith allegations in them. To
the trial court
                                                                 the contrary, including such allegations in pleadings is
                                                                 sanctionable. See TEX R. CIV. P. 13. Thus, we do not see
            shall grant a motion challenging the
                                                                 why an expert, [**28] in formulating an opinion,
        adequacy of an expert report only if it ap-
                                                                 should be precluded from considering and assuming the
        pears to the court, after hearing, that the
                                                                 validity of matters set out in pleadings in the suit, absent
        report does not represent an objective
                                                                 a showing that the pleadings are groundless or in bad
        good faith effort to comply with the defi-
                                                                 faith or rebutted by evidence in the record.
        nition of an expert report in Subsection
        (r)(6).                                                       On the other hand, the purpose of an expert report is
                                                                 to give the trial court sufficient information within the
                                                                 four corners of the report to determine if the plaintiffs
TEX C!V. PRAC. &REM. CODE§ 74.351(1). To qualify as              claim has merit. Scoresby, 346 S.W.3d at 554, 556. If an
an objective good faith effort the report must (1) inform        expert could formulate an adequate expert report by
the defendant [**26] of the specific conduct the plain-          merely reviewing the plaintiffs pleadings and assuming
tiff questions, and (2) provide a basis for the trial court to   them to be tme, then artful pleading could neutralize the
conclude that the plaintiffs claims have merit. Scoresby,        Legislature's requirement that expert reports demonstrate
346 S.W.3d at 556 (citing Palacios, 46 S.W.3d at 879). A       the plaintiffs claims have merit. See id. That is because
report meets the minimum qualifications for an expert            the facts and circumstances alleged in the plaintiffs
report under the statute 11 if it contains the opinion of an     pleadings might omit or misstate, inadvertently or other-
individual with expertise that the claim has merit, and if       wise, matters critical to a valid expert opinion. An expert
the defendant's conduct is implicated." Id. at 557. If a         report based only on the plaintiffs pleadings could mask
report meets these qualifications but is deficient, and an       the context of the medical services or health care ren-
extension to cure is requested, the trial court may grant        dered. Significant matters involved in the rendition of the
one thirty-day extension to cure the deficiencies. See           care, such as the patient's complaints or the health care
TEX C!V. PRAC. &REM. CODE§ 74.351(c). But if a report            provider's findings, could wan·ant investigation [**29]
does not meet the standard set in Scoresby, it is not an         and examination beyond that which might otherwise
expert report under the statute, and the trial court must        seem to have been appropriate, yet be unknown to the
dismiss the plaintiffs claims if the defendant has proper-       expert. If such matters were not in the plaintiffs plead-
ly moved for dismissal. TEX CIV. PRAC. & REM. CODE§              ings the expert would not have considered them, the ex-
74.351(b).                                                       pert report would not reference them, and because they
                                                                 are outside the four comers of the report, the trial court
    Dr. Loaisiga advances three arguments why the case
                                                                 could not consider them in deciding whether the plain-
should be dismissed if the TMLA's expert report re-
quirements apply. The arguments all substantively rely
                                                                                                                    Page 8
                                      379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                 55 Tex. Sup. J. 1373

tiffs claims have merit, That is not what we believe the       that we interpret statutory text according to its plain
Legislature intended. See id. at 552-54.                       meaning and context unless such a construction leads to
                                                               absurd or nonsensical results). The beginning of the sen-
     We conclude that in formulating an adequate expert
                                                               tence the court of appeals quoted refers to "a health care
report under section 74.351, an expert may consider and
                                                               liability claim." TEX CIV. PRAC, & REM. CODE §
rely on the plaintiffs pleadings, but the expert must con-
                                                               74.351(a), Reading the sentence as a whole shows that "a
sider more than the pleadings. How much more will de-
                                                               liability claim'' is merely an abbreviated reference to "a
pend on the particular circumstances of the claim, But
                                                               health care liability claim," which is elsewhere defined in
we fail to see how in most instances, and particularly in
                                                               the TMLA as "a cause of action." Id. § 74.001(a)(l3);
claims involving the scope of an examination, an expert
                                                               [**32] see also Mokkala v. Mead, 178 S.W.3d 66, 71
report could be adequate unless the expert at least con-
                                                               (Tex. App.--Houston [14th Dist.] 2005, pet, denied) ("A
sidered and commented on the patient's medical records
                                                               'health care liability claim' is a 'cause of action,' not a
to the extent the records and their contents--or lack of
                                                               lawsuit"). And as we have explained, a 11 Cause of action"
appropriate contents--are relevant to the expert's opinion.'
                                                               means the "fact or facts entitling one to institute and
     In this case Dr. Kilgore's reports and curriculum vi-     maintain an action, which must be alleged and proved in
tae demonstrate that he is a trained and practicing physi-     order to obtain relief." In re Jorden, 249 S.W.3d at 421
cian. [**30) He has sufficient expertise in the medical        (citation omitted). Therefore, the expert report require-
field to be qualified to provide an adequate expert report.    ments are triggered when a plaintiff names a person or
See Scoresby, 346 S.W.3d at 557. The reports also             entity as a defendant and seeks to obtain relief from that
demonstrate that he is of the opinion the plaintiffs' claims   defendant based on facts that. possibly implicate the
have merit. See id. But his failure to consider any matters    TMLA,
other than the plaintiffs' pleadings in formulating his
                                                                    This construction of the statute furthers the purpose
opinion make his existing reports inadequate to comply
                                                               of the expert report requirements. See Scoresby, 346
with section 74.351's expert report requirements. On the
                                                               S.W.3d at 554; see also Moline/, 356 S.W.3d at 4JI
other hand, we disagree with Dr. Loaisiga's position that
                                                               (stating that our objective in construing a statute is to
the deficiencies in Dr. Kilgore's reports require dismissal
                                                               ascertain and give effect to the Legislature's intent). If a
of the plaintiffs' claims against him. The reports meet the
                                                               plaintiff could name and seek judgment against a medi-
standard set out in Scoresby, and the [*262] plaintiffs
                                                               cal or health care provider based on facts that fall within
requested a thirty-day extension to cure defects in them
                                                               the TMLA's coverage without triggering the 120-day
in the event they were deficient. Accordingly, if on re-
                                                               deadline for serving an expert report, it would open the
mand the trial court determines that the TMLA's expert
                                                               door to artful pleading and undermine the Legislature's
report requirements apply to this case, the court should
                                                               goal of accelerating the disposition            [**33) of
consider the plaintiffs' request for an extension of time to
                                                               non-meritorious HCLCs. See Scoresby, 346 S. W.3d at
cure deficiencies in the reports as to Dr. Loaisiga. See id.
                                                               554; Diversicare, 185 S.W.3d at 854.
VI. The P.A.                                                         In this case the plaintiffs made the P .A. a party to
                                                               the case and sought judgment against it based on no facts
A. Was an Expert Report Required                               other than those underlying their claims against Dr.
                                                               Loaisiga. The P .A. is named after Dr. Loaisiga, and he
    The plaintiffs' petition names the P .A. as a defendant
                                                               has not disputed the plaintiffs' allegation that he was and
and prays for judgment against it, but the pleading does
                                                               is its sole officer and director. The plaiutiffs' response to
not mention the P.A. otherwise. [**31) The court of
                                                               the P.A.'s motion to dismiss alleged that Dr. Loaisiga
appeals concluded that the 1MLA did not apply to the
                                                               acted both individually and as the P.A. when he assaulted
P.A., given the lack of"allegations of medical negligence
                                                               the plaintiffs and there "is no differentiation between the
or otherwise" against the P.A.        S.W.3d at       . We
                                                               two. 11
disagree with that conclusion.
                                                                      [*263) As we discuss above, the determiuation of
      The court of appeals focused on the latter part of the
                                                               whether a plaintiffs expert report is adequate is not a
first sentence of section 74.351(a}, emphasizing there-
                                                               merits determination, but rather a preliminary determina-
quirement of an expert report 11 for each physician or
                                                               tion designed to expeditiously weed out claims that have
health care provider against whom a liability claim is
                                                               no merit. In this case the pleadings and record were suf-
asserted."      S.W.3d at      (quoting TEX Civ. PRAC. &
                                                               ficient to make the plaintiffs' claims as to the P.A. clear:
REM. CoDE § 74.351(a)). However, that portion of the
                                                               they claimed it was vicariously liable for Dr. Loaisiga's
statute's text must be read in conjunction with the words
                                                               conduct. The P.A. could have excepted to and sought
that surround it. See Omaha Healthcare Ctr., LLC v.
                                                               clarification of the pleadings if it desired to have them
Johnson, 344 S.W.3d 392, 395 (Tex. 20JI) (explaining
                                                               clarified, but it did not do so.
                                                                                                                      Page 9
                                       379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                  55 Tex. Sup. J. 1373

    We conclude that if the plaintiffs' claims assert                 Principal among the Legislature's stated purposes in
HCLCs, then [**34] the TMLA's expert report re-                  enacting the Medical Liability Act was decreasing the
quirements apply to the claims against the P.A. just as          cost of health care liability claims without unduly re-
they do to the claims against Dr. Loaisiga individually.         stricting a claimant's rights.' But disagreements [*264]
                                                                 over the Act's expert report requirement/ which is mere-
B. Adequacy of the Reports                                       ly intended to weed out frivolous claims early on,' have
                                                                 resulted [**36] in protracted pretrial proceedings and
     The court of appeals did not consider whether Dr.
                                                                 multiple interlocutory appeals, threatening to defeat the
Kilgore's reports are adequate to meet the requirements
                                                                 Act's purpose by increasing costs and delay that do
of section 74.351 as to the P.A.       S.W.3d at   . We
                                                                 nothing to advance claim resolution. In an effort to
address the issue for the same reasons expressed above
                                                                 staunch this waste of time and money, we have tried to
as to Dr. Loaisiga. See TEX. R. APP. P. 53.4; Reid Road
                                                                 minimize the grounds for such disagreements. We have
Mun. Uti/. Dist. No.2, 337 S.W.3d at 855.
                                                                 held that the standard for adequacy of a report is lenient,'
     Dr. Kilgore stated in his September 3, 2009 report          and that leave to cure any deficiencies in a report must be
that "[a]ll opinions expressed and contained in my pre-          freely given.' As a result, objections and appeals should
vious report are adopted in this supplemental report and         be fewer.
are also applicable to [the P.A.]." His previous report
demonstrated that he is a trained and practicing physician               1   Act of June 2, 2003, 78th Leg., R.S., ch. 204,
who holds the opinion that Dr. Loaisiga's conduct is im-                §§ 10.01, lO.ll(b) (2), (3), 2003 Tex. Gen. Laws
plicated and the plaintiffs' claims against Dr. Loaisiga                847, 864, 884-885 (adopting the Medical Liabil-
have merit. See supra Part V.B. But, as we explain                      ity Act as Chapter 74 of the Texas Civil Practice
above, Dr. Kilgore's previous report is not adequate to                 & Remedies Code, and providing that "it is the
comply with section 74.351 because he considered only                   purpose of [the Act] to improve and modifY the
the plaintiffs' pleadings in formulating his opinions, By               system by which health care liability claims are
adopting the previous report, the supplemental report                   determined in order to ... decrease the cost of
meets the minimal standard set out in Scoresby, just as                 those claims and . . . do so in a manner that will
the [**35] original report did, but it is deficient as to               not unduly restrict a claimant's rights . .. .u); see
the P .A., just as the original report was deficient as to Dr.          also Scoresby v. Santillan, 346 S.W.3d 546, 552
Loaisiga. So, if on remand the plaintiffs' claims are de-               (Tex. 2011) ("Fundamentally, the goal of [the
termined to be HCLCs subject to the TMLA's expert                       Act] has been to make health care in Texas more
report requirements, the trial court should consider the                available and less expensive by reducing the cost
plaintiffs' request for an extension of time to cure the                of health care liability [**37] claims.").
reports as to the P.A. See TEX. C!V. PRAC. & REM. CODE§                 2 The Act requires that within 120 days of fil-
74.351(c).                                                              ing suit, a claimant must serve a defendant with
                                                                        an expert report setting out the applicable stand-
VII. Conclusion                                                         ard of care, how the defendant breached it, and
                                                                        how that breach caused the claimant's damages.
     We reverse the judgment of the court of appeals. We                TEX. C!V. PRAC. &REM. CODE§ 74.351(a), M(6).
remand the case to the trial court for further proceedings              3 Scoresby, 346 S.W.3d at 552 (stating that the
in accordance with this opinion. See id.; Scoresby, 346                 Act seeks "to deter frivolous lawsuits by requir-
S. W.3d at 557.
                                                                        ing a claimant early in litigation to produce the
    Phil Johnson                                                        opinion of a suitable expert that his claim has
                                                                        merit11 ).
    Justice                                                             4 Id. at 549 ("[A] document qualifies as an ex-
     OPINION DELIVERED: August31, 2012                                  pert report if it contains a statement of opinion by
                                                                        an individual with expertise indicating that the
CONCUR BY: Nathan L. Hecht (In Part); Don R. Wil-                       claim asserted by the plaintiff against the de-
lett (In Part); Debra H. Lehrmann                                       fendant has merit. An individual's lack of relevant
                                                                        qualifications and an opinion's inadequacies are
DISSENT BY: Nathan L. Hecht (In Part); Don R. Wil-                      deficiencies the plaintiff should be given an op-
lett (In Part); Debra H. Lehrmann                                       portunity to cure if it is possible to do so. This le-
                                                                        nient standard avoids the expense and delay of
DISSENT                                                                 multiple interlocutory appeals and assures a
                                                                        claimant a fair opportunity to demonstrate that his
     JUSTICE HECHT, joined by JUSTICE MEDINA, concur-                   claim is not frivolous.11
                                                                                                    ),
ring in part and dissenting in part.
                                                                                                                 Page 10
                                       379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                  55 Tex. Sup. J. 1373

       5 Id. ("[The Act] authorizes the trial court to          the alleged touching will suffice. Thus, it is unnecessary
       give a plaintiff who meets the 120-day deadline          for the Court to allow the claimants on remand to attempt
       an additional thirty days in which to cure [**38]        to show, again, that an expert rep01i is not required. The
       a 'deficiency' in the elements of the report. The        Court's suggestion that they might succeed contradicts
       trial court should err on the side of granting the       the standard the Court announces. I would not allow fur-
       additional time and must grant it if the deficien-       ther proceedings on the issue and risk another appeal. In
       cies are curable." (footnotes omitted)).                 all other respects, I join the Court's opinion.
     With the same goal in mind, the Court today tackles            Nathan L. Hecht
the issue of when an expert report is required. The Court
                                                                    Justice
concludes that "[t]he breadth of the statute's text essen-
tially creates a presumption that a claim is an HCLC if it          Opinion delivered: August 31, 2012
is against a physician or health care provider and is based
                                                                     JUSTICE WILLETT, concurring in part and dissenting
on facts implicating the defendant's conduct during the
                                                                in part.
course of a patient's care, treatment, or confinement. tt 6 I
agree that the Act creates such a presumption and that it            I join today's well-reasoned decision save one quib-
is, as the Court says, "necessarily rebuttable 11 •7            ble: Because I find Parts V.B and Vl.B of the Court's
                                                                opinion advisory--and thus inadvisable--! respectfully
        6   Ante at .                                           dissent from those sections.
        7   Ante at .
                                                                      Today the Court clarifies the standard for defining a
    For the claimant who contends his claim is not an           healthcare liability claim (HCLC) and remands so the
HCLC, obtaining an expert report should not present a           trial court can apply our new guidance. So far so good. If
major obstacle, as this case illustrates. The expert report     the trial court concludes these claims are not HCLCs,
here says, in essence, that sexual assault is not a part of     then no expert report is necessary. The Court, however,
health care. One need not tum to the Mayo Clinic for            proceeds to (p)review the [**41] reports' sufficiency
such an opinion. An expert report, as we have interpreted       just in case the trial court goes the other way.
it, is a low threshold a person claiming against a health
                                                                     This analysis is premature. The trial court hasn't
care provider must cross merely to show that his claim is
                                                                even applied our new test to determine whether these are
not frivolous. Occasionally [**39] there will be cases--
                                                                HCLCs in the first place. I wouldn't short-circuit its re-
this may be one -- in which an expeti report is required
                                                                view by pre-deciding an issue that might never need de-
even though evidence later shows that the claim is not an
                                                                ciding at all and that might benefit immensely from low-
HCLC. While the requirement is thus not perfect, it is
                                                                er-court analysis.
nevertheless a reasonable effort by the Legislature to
address what it found to be a crisis in HCLCs. But the               As a judiciary, our constitutional role dictates that
Act's limitations on damages and other restrictions are         we decide concrete cases and not dispense contingent
far more severe. A conclusion made early in the case that       advice. "[T]he judicial power does not embrace the giv-
an expert report must be produced does not preclude a           ing of advisory opinions,' 11 and prudent development of
later determination, after the [*265] case is more fully        the law requires that courts refrain from speculating on
developed, that the Act's provisions do not apply after         situations that may never arise.
all.
                                                                       I Firemen's Ins. Co. of Newark, N.J. v. Burch,
     The claimants in this case proceeded exactly as they
                                                                       442 S.W.2d 331, 333 (Tex. 1968).
should have. Insisting that their claims are not HCLCs
but claims for assault, they nevertheless produced an                The Coures motivation, of course, is commendable:
expert report. I agree with the Court that the expert could     to advance judicial efficiency and squeeze out inordinate
not rely entirely on the claimants' petition. A requirement     delay. But unless and until the lower courts conclude that
that an expert do no more than opine that a pleaded             plaintiffs' claims are indeed HCLCs, I would not suggest
claim, if true, has merit would do little to forestall frivo-   a premature predecision that presupposes--if not predes-
lous claims. In most instances, medical records will be         tines--a certain lower-court path.
enough to support an expert's opinion. In this case, it
seems unlikely that a chart notation, "groped patient un-           Don R. Willett
necessarily", will be found, and the expert may need to             Justice
base [**40] his opinion on an interview with the
claimants. In any event, the deficiency should be simple            OPINION DELIVERED: August31, 2012
to cure. The expert's review of records showing that the            JUSTICE LEHRMANN, concurring and dissenting.
claimants' medical or physical conditions did not warrant
                                                                                                                Page 11
                                      379 S.W.3d 248, *; 2012 Tex. LEXIS 736, **;
                                                 55 Tex. Sup. J. 1373

     Whether a claim against a health care provider                 In describing the expert report requirement imposed
[**42] is a health care liability claim is a knotty issue      by the Act's predecessor, we have noted on more than
this Court has repeatedly struggled with. See, e.g., Tex.      one occasion that claimants are not required to marshal
W. Oaks Hosp., LP v. Williams, 371 S.W.3d 171, 2012            their proof to [**44] comply with the statute. Bowie
Tex. LEXIS 561, 2012 WL 2476807 {Tex. 2012); St. Da-           Mem'l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002);
vid's Health care P'ship v. Esparza, 348 S.W.3d 904 {Tex.     Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46
2011); Omaha Healthcare Ctr., LLC v. Johnson, 344 S.W.3d 873, 878 (Tex. 2001). The policy underlying the
S. W.3d 392 (Tex. 2011); Diversicare Gen. Partner, Inc.        expert report requirement in the current Act remains un-
v. Rubio, 185 S.W.3d 842 (Tex. 2005). Claims alleging         changed; not to shield health care providers from legiti-
that a [*266] physician's actions in examining a pa-           mate claims, but to weed out frivolous claims at an early
tient amounted to an assault can be particularly con-          stage, before the parties and the courts have expended
founding, for the reasons the Court discusses: the physi-      extensive resources. Scoresby v. Santillan, 346 S. W.3d
cal examination of a patient necessarily involves touch-       546, 554 (Tex. 2011). It makes sense not to place a heavy
ing, which may be uncomfortable, unexpected, and mis-          burden on claimants early in the process, in part, because
understood. I concur in the Court's judgment remanding         the Act greatly restricts the discovery that is available
this case to allow the plaintiffs an opportunity to estab-     before an expert report is filed. TEX. CIV. PRAC. & REM.
lish that their assault claims are not health care liability   CODE§ 74.351(s). In my view, the Court's imposition of
claims. I write separately, however, because I believe the     a requirement that claimants conclusively establish that
Court places too onerous a burden on claimants by re-          their allegations do not amount to health care liability
quiring them to conclusively establish that their claims       claims is inconsistent with those considerations.
are not health care liability claims. I would require a
                                                                    In light of the Act's purposes and its broad applica-
claimant to satisfy a standard comparable to a "clear and
                                                               tion, I agree that claimants must to do more than estab-
convincing" standard of proof. Under that standard, a
                                                               lish that their claims are plausibly, or even likely, not
trial court should require a [**43] claimant asserting
                                                               health care liability claims. But I would not go so far as
claims against a health care provider arising in the con-
                                                               the Court. Instead, I would hold that plaintiffs [**45]
text of the delivery of medical services to file an expert
                                                               whose claims arise in the medical context are not re-
report unless the record justifies a finn conviction or
                                                               quired to provide expert reports if the record justifies a
belief that the claims presented are not health care liabil-
                                                               firm belief or conviction that the claims are not health
ity claims.
                                                               care liability claims. This is essentially the same as the
    Unquestionably, the Legislature intended to alleviate      burden of proof required to terminate parental rights. See
what it deemed a "health care liability crisis" when it        Santosky v. Kramer, 455 U.S. 745, 769, 102 S. Ct. 1388,
enacted the Texas Medical Liability Act, TEX. C!V. PRAC.       71 L. Ed. 2d 599 (1982); In re G.M, 596 S.W.2d 846,
& REM. CODE§§ 74.001-.507. Accordingly, I agree that           847 (Tex. 1980). Surely a burden sufficient to protect
claims arising in the context of the delivery of health        parents' constitutional rights in raising their children
care services are presumptively health care liability          should be sufficiently stringent to protect any interest
claims. But, as the Court recognizes, nothing in the Act       medical providers might enjoy in having a cause of ac-
signals an intent to shield physicians from liability for      tion alleging assault [*267] proceed as a health care
sexual assaults or similar intentional misconduct. I fear      liability claim. Accordingly, I respectfully concur in the
that the requirement the Court imposes, that a claimant        Court's judgment but disagree with the standard the
conclusively establish that a claim is not a health care       Court imposes.
liability claim in order to rebut the Act's presumptive
                                                                   Debra H. Lehrmann
application, may force assault victims to submit expert
reports or see their cases dismissed.                              Justice
                                                                   OPINION DELIVERED: August 31,2012
APPENDIX- ''3''
                                                                                                              Page 1

           LexisNexis®
                                               1 of 4 DOCUMENTS

                ROY KENJI YAMADA, M.D., PETITIONER, v. LAURA FRIEND, INDIVIDU-
               ALLY AND AS PERSONAL REPRESENTATIVE OF THE ESTATE OF SARAH
               ELIZABETH FRIEND, DECEASED, AND LUTHER FRIEND, INDIVIDUALLY,
                                        RESPONDENTS

                                                   NO. 08-0262

                                        SUPREME COURT OF TEXAS

                           335 S.W.3d 192; 2010 Tex. LEXJS 1012; 54 Tex. Sup. J. 382

                                          March 10, 2009, Argued
                                     December 17, 2010, Opinion Delivered

SUBSEQUENT HISTORY:              Released for Publica-
tion January 28, 2011.                                    OPINION
                                                               [*193] In this appeal we address whether claims
PRIORHISTORY: [**l]
                                                          against a health care provider based on one set of under-
  ON PETITION FOR REVIEW FROM THE COURT
                                                          lying facts can be brought as both health care liability
OF APPEALS FOR THE SECOND DISTRICT OF
                                                          claims subject to the Texas Medical Liability Act
TEXAS.
                                                          (TMLA) and ordinary negligence claims not subject to
Yamada v. Friend, 335 S. W.Jd 201, 2008 Tex. App.
                                                          the TMLA. We hold that they cannot.
LEXIS 1680 (Tex. App. Fort Worth, Feb. 28, 2008)
                                                               Sarah Friend collapsed at a water park and later
                                                          died. As a result of her death her parents sued several
COUNSEL: For ROY KENJI YAMADA, M.D., PETI-                parties, including Roy Yamada, M.D. Sarah's parents
TIONER: Mr. J. Kevin Carey, Carey Law Firm, Fort          alleged that Dr. Yamada negligently advised the water
Worth, TX; Ms. Bonnie Susan Bleil, Law Office of Bleil    park about safety procedures and placement of defibril-
& King, Fort Worth, TX.                                   lators. They did not file an expert report as is required by
                                                          the TMLA for health care liability claims.
For LAURA FRIEND, RESPONDNET: Mr. Darrell L.
                                                               The court of appeals held that the Friends' allega-
Keith, Ms.· Cominey Shannon Keith, Ms. Arin Kay
                                                          tions that Dr. Yamada's actions violated medical stand-
Schall, Keith Law Firm, P.C., Fort Wmih, TX; Mr. Jef-
                                                          ards of care were health care liability claims and the
frey H. Kobs, Kobs, Haney & Hundley, LLP, Fort
                                                          Friends were required to comply with provisions of the
Worth, TX.
                                                          TMLA as to those claims. The Friends do not dispute
                                                          that holding. The court also held, however, that the
For City of North Richland Hills, OTHER: Mr. George
                                                          Friends' allegations that the same actions by Dr. Yamada
A. Staples Jr., Taylor Olson Adkins Sralla & Elam, Fort
                                                          violated ordinary standards [**2] of care and were not
Worth, TX.
                                                          subject to the TMLA.
For Jeff Ellis, OTHER: Mr. Russell Ramsey, Ramsey &           We hold that because all the claims against Dr.
Murray, Houston, TX.                                      Yamada were based on the same underlying facts, they
                                                          must be dismissed because the Friends did not timely file
JUDGES: WSTICE JOHNSON delivered the opinion              an expert report. When the underlying facts are encom-
of the Court.                                             passed by provisions of [*194] the TMLA in regard to
                                                          a defendant, then all claims against that defendant based
OPINION BY: Phil Johnson                                  on those facts must be brought as health care liability
                                                                                                                  Page 2
                                     335 S.W.3d 192, *; 2010 Tex. LEXIS 1012, **;
                                                 54 Tex. Sup. J. 382

claims. Application of the TMLA cannot be avoided by           court denied Dr. Yamada's motion and he appealed. See
artfully pleading around it or splitting claims into both      id. § 51.014(a)(9) (authorizing interlocutory appeal from
health care liability claims and other types of claims such    an order denying a motion to dismiss for lack of an ex-
as ordinary negligence claims,                                 pert report).

I. Background                                                  B. Court of Appeals
                                                                    The court of appeals noted that the only alleged acts
A. Trial Court
                                                               or omissions on which the Friends based their claims
     The city of North Richland Hills owns and operates        against Dr. Yamada were his failure to properly provide
North Richland Hills Family Water Park. In July 2004,          advice and recotmnendations to the City about its safety
twelve-year-old Sarah Friend was waiting in line for one       practices, including the placement and maintenance of
of the water park rides when she collapsed. Personnel          AEDs.         S.W.3d              . It determined that the
from the water park and North Richland Hills Fire De-          pleadings stated claims for negligence based on breach
partment administered emergency aid and she was then           of an emergency medicine physicians' standard of care,
transported to a hospital where she died from a heart          but also stated claims for ordinary negligence. Id. at
condition.                                                     The appeals court reasoned that [**5] medical testimo-
                                                               ny is not required to establish [*195] the proper
     Sarah's mother and father, Laura ' and Luther
                                                               placement of AED devices, thus such claims were not
Friend, sued the City and several individual defendants.
                                                               health care liability claims because the alleged negli-
They alleged that Sarah's death was proximately caused
                                                               gence was not based on advice directly related to acts
by the defendants' [**3] failure to timely and properly
                                                               performed or furnished by a health care provider to Sarah
evaluate and care for her after she collapsed. The
                                                               during her medical care, treatment, or confinement. The
Friends' allegations focused on the failure of water park
                                                               court held that the trial court properly refused to dismiss
personnel to use an automated external defibrillator
                                                               the claims based on allegations of ordinary negligence.
(AED) in attending to Sarah.
                                                               Id. at    . However, the court also held that the pleadings
                                                               alleging Dr. Yamada gave negligent advice about where
           Laura sued individually and as representative
                                                               to locate AEDs were health care liability claims to the
       of Sarah's estate.
                                                               extent they alleged Dr. Yamada had a duty to act as an
     The Friends eventually joined Dr. Yamada as a de-         emergency physician under the circumstances and he
fendant. They alleged that he (1) was a licensed medical       breached that duty. The court held that the Friends' fail-
doctor who specialized in emergency medicine; (2) "had         ure to file an expert report required dismissal of the
a duty to exercise ordinary ,care and act as an emergency      claims based upon allegations of breach of an emergency
medicine physician of reasonable and ordinary prudence         room physician's standard of care. Id. at       . Thus, the
under the same or similar circumstances 11 ; (3) "was re-      court of appeals held that the same acts and omissions by
sponsible for and provided medical consultative advice         Dr. Yamada formed the basis of both health care and
and recommendations to and for the various safety prac-        non-health care claims based on pleadings alleging that
tices and procedures 11 at the water park prior to and as of   the acts and omissions breached different standards of
the date Sarah collapsed; (4) "had a duty under Texas          care.
law to exercise ordinary care and act as an emergency
medicine physician of reasonable and ordinary prudenceu        C. [**6] Positions of the Parties
in providing services to the water park; and (5) breached
                                                                   The Friends did not file a petition for review. But
"that duty" by (a) failing to timely, properly, and ade-
                                                               Dr. Yamada did and we granted it. 52 Tex. Sup. Ct. J.
quately provide services to the water park and (b) com-
                                                               331, 333 (Feb. 13, 2009).
mitting "other acts or omissions of negligence or
wrongdoing." There was never a doctor-patient [**4]                 Dr. Yamada asserts that the court of appeals erred in
relationship between Dr. Yamada and Sarah.                     two ways. First, he argues the court construed the defini-
                                                               tion of health care liability claim based on a breach of
    The Friends did not file an expert report pursuant to
                                                               accepted standards of safety too narrowly. Second, he
Texas Civil Practice and Remedies Code section 74.351
                                                               asserts the court impermissibly allowed "claim splitting"
after they sued Dr. Yamada, so he filed a motion to dis-
                                                               by holding that the same underlying facts gave rise to an
miss. See TEX C!V. PRAC. & REM. CODE§ 74.351 (a), (b).
                                                               ordinary negligence claim, which the court held ·could
The Friends' response specified that their claims were
                                                               continue, and a health care liability claim, which the
based on Dr. Yamada1s provision of medical consultative
                                                               court dismissed. The difference between the claims, Dr.
advice and recommendations in regard to various safety
                                                               Yamada urges, is nothing more than artful pleading.
practices and procedures at the water park. The trial
                                                                                                                     Page 3
                                      335 S.W.3d 192, *; 2010 Tex. LEXIS 1012, **;
                                                  54 Tex. Sup. J. 382

     In their brief, the Friends specify that Dr. Yamada's              whether the claimant's claim or cause of
connection to Sarah's death was his consultative services               action sounds in tort or contract.
in regard to placement of life-saving devices such as the
AEDs. They do not dispute the court of appeals' charac-
terization of their claims as alleging only that Dr. Yama-      ld. § 74.00J(a)(13).
da failed to properly provide advice and recommenda-
                                                                     Whether a claim is a health care liability claim de-
tions to the City about its safety practices. And they
                                                                pends on the underlying nature of the claim being made.
agree that the court of appeals "correctly ... reversed the
                                                                Garland Cmty. Hosp. v. Rose, 156 S.W.3d 541, 543 (Tex.
trial court's order denying Petitioner Dr. [**7] Yama-
                                                                2004) (addressing former TEX. REV. Civ. STAT. art. 45901,
da's motion to dismiss [their] claims that are based on a
                                                                repealed by Act of June 2, 2003, 78th [**9] Leg., ch.
standard of medical care and dismissed those claims with
                                                                204, § 10.09, 2003 Tex. Gen. Laws 847, 884). Artful
prejudice." However, they argue that their ordinary neg-
                                                                pleading does not alter that nature. Diversicare Gen.
ligence claim should not be dismissed because it is not in
                                                                Partne1~ Inc. v. Rubio, 185 S.W.3d 842, 854 (Tex. 2005);
essence a health care liability claim. The Friends first
                                                                Garland Cmty. Hosp., 156 S.W.3d at 543.
assert that their ordinary negligence claim is not for
breach of standards of medical care or health care as
                                                                III. Discussion
those terms are defined in the TMLA. Next, they argue
that to be a health care liability claim for breach of an            In Diversicare, Maria Rubio was the victim of a
accepted standard of safety under the TMLA, the claim           sexual assault at a nursing home. 185 S.W.3d at 845.
must be for an act or omission directly related to health       Rubio filed suit against the nursing home based in part
care, which their ordinary negligence claim is not. See         on claims that the home failed to hire and train appropri-
TEX. CiV. PRAC. &REM. CODE§ 74.00l(a)(l3).                      ate personnel to monitor Rubio, failed to provide twen-
                                                                ty-four-hour nursing services from a sufficient uumber of
     We agree with Dr. Yamada in part. 2 The court of
                                                                qualified nursing personnel to meet her nursing needs,
appeals' holding that the Friends asserted health care
                                                                hired incompetent staff who were unqualified to care for
liability claims against Dr. Yamada is unchallenged and
                                                                her, and failed to establish and implement appropriate
all their claims were based on the same facts. The
                                                                safety policies to protect its residents. I d. The concurring
Friends' claims against [*196] Dr. Yamada cannot be
                                                                and dissenting justices in Diversicare concluded that
split into health care and non-health care claims by
                                                                Rubio asserted a premises liability claim against the
pleading that his actions violated different standards of
                                                                nursing home independent of her health care liability
care; all their claims must be dismissed.
                                                                claim. ld. at 857-58 (Jefferson, C.J., concuning in part,
                                                                and dissenting in part) (pointing to Rubio's claims that
        2 Our decision makes it unnecessary to consid-
                                                                the home failed to protect her by failing to implement
        er whether the court of appeals [**8] properly
                                                                safety precautions and establish appropriate corporate
        construed the TMLA's language regarding
                                                                safety, training, and staffing [**10] policies); id. at
        breaches of accepted standards of safety. It is also
                                                                861-66 (O'Neill, J., dissenting) (construing Rubio's claim
        unnecessary to consider the effect, if any, of the
                                                                that the facility failed to use ordinary care to protect her
        lack of a doctor-patient relationship between Dr.
                                                                from a known danger to be a premises liability claim).
        Yamada and Sarah.
                                                                The Court rejected the view that Rubio could allege a
                                                                claim for premises liability independent of her healthcare
II. Claims Under the TMLA
                                                                liability claim because it "would open the door to splic-
    The TMLA requires the trial court to dismiss a suit         ing health care liability claims into a multitude of other
asserting health care liability claims against a physician      causes of action with standards of care, damages, and
or health care provider if the plaintiff does not timely file   procedures contrary to the Legislature's explicit require-
an expert report as to that defendant. ld. § 74.351. The        ments. It is well settled that such artful pleading and re-
TMLA defines "health care liability claim" as                   casting of claims is not permitted." ld. at 854; see also
                                                                Murphy v. Russell, 167 S.W.3d 835, 838 (Tex. 2005)
           [A] cause of action against a health                 ("[A] claimant cannot escape the Legislature's statutory
        care provider or physician for treatment,               scheme by artful pleading."); Garland Cmty. Hosp., 156
        lack of treatment, or other claimed depar-              S. W.3d at 543 ("Plaintiffs cannot use artful pleadiug to
        ture from accepted standards of medical                 avoid the MUlA's requirements when the essence of the
        care, or health care, or safety or profes-              suit is a health care liability claim.").
        sional or administrative services directly
                                                                    Because the Friends do not challenge the court of
        related to health care, which proximately
                                                                appeals' holding that their claims against Dr. Yamada are
        results in injmy to or death of a claimant,
                                                                in part health care liability claims and based on facts
                                                                                                                    Page 4
                                     335 S.W.3d 192, *; 2010 Tex. LEXIS 1012, **;
                                                 54 Tex. Sup. J. 382

covered by the TMLA, the question before us is whether         tient tries to sit down in it. Nevertheless, the Friends note
claims based on the [**11] [*197] same facts can               their agreement with the court of appeals' holding that
alternatively be maintained as ordinary negligence             the Azua's claim, although pled as an ordinary negli-
claims. We hold that they cannot.                              gence claim, was a health care liability claim. !d.
     Despite agreeing that the court of appeals correctly           Clearly, particular actions or omissions underlying
dismissed their health care liability claims based on the      health care liability claims can be highlighted and al-
acts and omissions of Dr. Yamada, the Friends allege           leged to be breaches of ordinary standards of care. But if
that his conduct can also be measured by ordinary stand-       the same underlying facts are allowed to give rise to both
ards of care as opposed to standards that require specific     types of claims, then the TMLA and its procedures and
expertise in health care. But it would be hard to find a       limitations will effectively be negated. Plaintiffs will be
health care liability claim in which some action by the        able to entirely avoid application of the TMLA by care-
health care provider or physician arguably would not be        fully choosing the acts and omissions on which to base
within the common knowledge of jurors, and thus would          their claims and the language by which they assert the
support a claim for ordinary negligence. This case is a        claims.
prime example of such a claim. The Friends assert that
                                                                   Our prior decisions are to the effect that if the gra-
the same actions and omissions by Dr. Yamada are gov-
                                                               vamen or essence of a cause of action is a health care
erned by both standards requiring expert testimony to
                                                               liability claim, then allowing the claim to be split or
establish--one of the factors that can be considered in
                                                               spliced into a multitude of other causes of action with
dete1mining whether a claim is a health care liability
                                                               differing standards of care, damages, and procedures
claim--and standards that do not require expert testimo-
                                                               would contravene the Legislature's explicit requirements.
ny.
                                                               Diversicare, 185 S.W.3d at 854. Those decisions dictate
     The Friends reference other examples in their brief.      the outcome here. The Friends' allegations that Dr.
In Institute for Women's Health, P.L.L.C. v. !mad, 2006        Yamada's actions breached ordinary [**14] standards
Tex. App. Lexis 1182 (Tex. App.--San Antonio Feb. 15,          of care did [*198] not change either the substantive
2006, no pet.), an embryologist dropped a tray of em-          basis or the nature of the claims.
bryos [**12] and destroyed all of them except one. The
Friends note their agreement with the holding that the         IV. Conclusion
claims against the emb1yologist were health care liability
                                                                    Based on the unchallenged holding of the court of
claims because the specific acts and omissions of the
                                                               appeals that the Friends' claims based on Dr. Yamada's
embryologist were an inseparable part of the health and
                                                               actions encompassed health care liability claims, all their
medical transaction. But even though the carrying of the
                                                               claims should have been dismissed because they did not
tray was an inseparable part of the health and medical
                                                               file an expert report. We affirm the court of appeals'
services, the care required in carrying a tray of embryos
                                                               judgment to the extent it reversed the trial court's order
without dropping it could have been asserted as ordinary
                                                               and dismissed some of the Friends' claims. We reverse
negligence because the care required to carry a
                                                               the court of appeals' judgment to the extent it affumed
tray--whether one carrying embryos or something else
                                                               the trial court's order denying Dr. Yamada's motion to
such as a child's lunch--is not generally outside the
                                                               dismiss. Because Dr. Yamada requested his attorney's
common knowledge of jurors.
                                                               fees and costs iu the trial court under Texas Civil Prac-
     The Friends also reference Valley Baptist Medical         tice and Remedies Code section 74.35l(b)(l), we remand
Center v. Azua, 198 S.W.3d 810 (Tex. App.--Corpus              to that court with instructions to dismiss all the Friends'
Christi 2006, no pet.). There a hospital employee was          claims against Dr. Yamada and consider his request for
assisting a patient into a wheelchair. The employee al-        attorney's fees and costs.
legedly failed to block the wheels of the wheelchair and
                                                                   Phil Johnson
the patient was injured when the wheelchair moved as
the patient was attempting to sit in it. Id. at 814. It cer-       Justice
tainly could be argued, as Azua did, that expert testimo-
                                                                   OPINION DELIVERED: December 17,2010
ny is not necessary to establish the need to secure a
wheelchair so it will not move when an ill [**13] pa-
APPENDIX- ''4''
       A\JTit£NTICA·mfl
      US. GOVERNMENT
       INFO~MATION

               GPO

                                §482.1                                                                   42 CFR Ch. IV (1 0-1-11 Edition)
                                  AUTHORITY: Sees. 1102, 1871 and 1881 of the                Medicaid must meet the requirements
                                Social Security Act (42 U.S.O. 1302, 1395hh,                 for participation in Medicare (except in
                                and l395rr), unless otherwise noted,
                                                                                             the case of medical supervision of
                                  SouRCE:: 51 FR 22042, June 17, 1986, unless                nurse-midwife services. See §§ 440.10 and
                                otherwise noted.                                             440.165 of this chapter.).
                                                                                               (b) Scope. Except as provided in sub-
                                   Subpart A-General Provisions                              part A of part 488 of this chapter, the
                                § 482.1  Basis and scope.                                    provisions of this part serve as the
                                                                                             basis of survey activities for the pur-
                                  (a) Statutory basis. (1) Section 1861(e)                   pose of determining whether a hospital
                                of the Act provides that--                                   qualifies for a provider agreement
                                  (i) Hospitals participating in Medi-
                                                                                             under Medicare and Medicaid.
                                care must meet certain specified re-
                                quirements; and                                              (51 FR 22042, June 17, 1986, as amended at 60
                                  (ii) The Secretary may impose addi-                        FR 50442, Sept. 29, 19951
                                tional requirements if they are found
                                necessary in the interest of the health                      § 482,2   Provision of emergency serv-
                                and safety of the individuals who are                             ices by nonparticipating hospitals.
                                furnished services in hospitals.                               (a) The services of an institution that
                                  (2) Section 1861(f) of the Act provides                    does not have an agreement to partici-
                                that an institution participating in                         pate in the Medicare program may,
                                Medicare as a psychiatric hospital                           nevertheless, be reimbursed under the
                                must meet certain specified require-                         program if-
                                ments imposed on hospitals under sec-                          (1) The services are emergency serv-
                                tion l86l(e), must be primarily engaged                      ices; and
                                in providing, by or under the super-
                                                                                               (2) The institution meets the require-
                                vision of a physician, psychiatric serv-
                                ices for the diagnosis and treatment of                      ments of section 186l(e) (1) through (5)
                                mentally ill persons, must maintain                          and (7) of the Act. Rules applicable to
                                clinical records and other records that                      emergency services furnished by non-
                                the Secretary finds necessary, and                           participating hospitals are set forth in
                                must meet staffing requirements that                         subpart G of part 424 of this chapter.
                                the Secretary finds necessary to carry                         (b) Section 440.170(e) of this chapter
                                out an active program of treatment for                       defines emergency hospital services for
                                individuals who are furnished services                       purposes of Medicaid reimbursement.
                                in the hospital. A distinct part of an                       [51 FR 22042, June 17, 1986, as amended at 53
                                institution can participate as a psy-                        FR 6648, Mar. 2, 1986]
                                chiatric hospital if the institution
                                meets the specified 1861(e) require-
                                ments and is primarily engaged in pro-                             Subpcirt 8-Administralion
                                viding psychiatric services, and if the
                                                                                             § 482.11   Condition of participation:
                                distinct part meets the records and                               Compliance with Federal, State and
                                staffing requirements that the Sec-                               local laws,
                                retary finds necessary,
                                  (3) Sections 186l(k) and 1902(a)(30) of                      (a) The hospital must be in compli-
                                the Act provide that hospitals partici-                      ance with applicable Federal laws re-
                                pating in Medicare and Medicaid must                         lated to the health and safety of pa-
                                have a utilization review plan that                          tients.
                                meets specified requirements.                                  (b) The hospital must be---
                                  (4) Section 1883 of the Act sets forth                       (1) Licensed; or
                                the requirements for hospitals that                            (2) Approved as meeting standards for
                                provide long term care under an agree-                       licensing established by the agency of
                                ment with the Secretary,                                     the State or locality responsible for li-
                                  (5) Section 1905(a) of the Act provides                    censing hospitals.
                                that "medical assistance" (Medicaid)
                                payments may be applied to various                             (c) The hospital must assure that
                                hospital services. Regulations inter-                        personnel are licensed or meet other
                                preting those provisions specify that                        applicable standards that are required
                                hospitals receiving payment under                            by State or local laws.

                                                                                         6

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APPENDIX - ''5''
      AUTHENTICA.CW9
     US. GOVERNMENT
      INFORMATION
              r:.Po

                                Centers tor Medicare & Medicaid Services, HHS                                                     §482.21
                                his or her other rights under this sec-                     (b) Standard: Program data. (l) The
                                tion.                                                     program must incorporate quality indi-
                                  (2) Inform each patient (or support                     cator data including patient care data,
                                person, where appropriate) of the right,                  and other relevant data, for example,
                                subject to his or her consent, to receive                 information submitted to, or received
                                the visitors whom he or she designates,                   from, the hospital's Quality Improve-
                                including, but not limited to, a spouse,                  ment Organization.
                                a domestic partner (including a same-                       (2) The hospital must use the data
                                sex domestic partner), another family                     collected to------
                                member, or a friend, and his or her                         (i) Monitor the effectiveness and
                                right to withdraw or deny such consent                    safety of services and quality of care;
                                at any time.                                              and
                                  (3) Not restrict, limit, or otherwise                      (ii) Identify opportunities for im-
                                deny visitation privileges on the basis                    provement and changes that will lead
                                of race, color, national origin, religion,                 to improvement.
                                sex, gender identity, sexual orienta-                        (3) The frequency and detail of data
                                tion, or disability.                                       collection must be specified by the hos-
                                  (4) Ensure that all visitors enjoy full                  pital's governing body.
                                and equal visitation privileges con-
                                                                                            (c) Standard: Program activities.             (1)
                                sistent with patient preferences.
                                                                                          The hospital must set priorities for its
                                (71 FR 71426, Dec. 8, 2006, as amended at 75              performance improvement activities
                                FR 70844, Nov. 19, 2010]                                  that--
                                                                                            (i) Focus on high-risk, hig·h-volume,
                                      Subpart c-Basic Hospital                            or problem-prone areas;
                                              Functions                                     (ii) Consider the incidence, preva-
                                                                                          lence, and severity of problems in those
                                § 482.21  Condition of participation:                     areas; and
                                     Quality assessment and perform·
                                     ance improvement program.                              (iii) Affect health outcomes, patient
                                                                                          safety, and quality of care,
                                  The hospital must develop, imple-                         (2) Performance improvement activi-
                                ment, and maintain an effective, ongo-                    ties must track medical errors and ad-
                                ing, hospital-wide, data-driven quality
                                                                                          verse patient events, analyze their
                                assessment and performance improve-                       causes, and implement preventive ac-
                                ment program. The hospital's gov-
                                erning body must ensure that the pro-                     tions and mechanisms that include
                                                                                          feedback and learning throughout the
                                gram reflects the complexity of the
                                hospital's organization and services;                     hospital.
                                involves all hospital departments and                       (3) The hospital must take actions
                                services (including those services fur-                   aimed at performance improvement
                                nished under contract or arrangement);                    and, after implementing those actions,
                                and focuses on indicators related to im-                  the hospital must measure its success,
                                proved health outcomes and the pre-                       and track performance to ensure that
                                vention and reduction of medical er-                      improvements are sustained.
                                rors. The hospital must maintain and                         (d) Standard: Performance improvement
                                demonstrate evidence of its QAPI pro-                      projects. As part of its quality assess-
                                gram for review by OMS.                                    ment and performance improvement
                                  (a) Standard: Program scope. (1) The                     program, the hospital must conduct
                                program must include, but not be lim-                      performance improvement projects.
                                ited to, an ongoing program that shows                       (1) The number and scope of distinct
                                measurable improvement in indicators                       improvement projects conducted annu-
                                for which there is evidence that it will                   ally must be proportional to the scope
                                improve health outcomes and identify                       and complexity of the hospital's serv-
                                and reduce medical errors.                                 ices and operations.
                                  (2) The hospital must measure, ana-                        (2) A hospital may, as one of its
                                lyze, and track quality indicators, in-                    projects, develop and implement an in-
                                cluding adverse patient events, and                        formation technology system explic-
                                other aspects of performance that as-                      itly designed to improve patient safety
                                sess processes of care, hospital service                   and quality of care. This project, in its
                                and operations.                                            initial stage of development, does not

                                                                                      13

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                                §482.22                                                             42 CFR Ch.IV (10-1-11 Edition)
                                need to demonstrate measurable im-                            (1) The medical staff must periodi-
                                provement in indicators related to                         cally conduct appraisals of its mem-
                                health outcomes.                                           bers.
                                  (3) The hospital must document what                         (2) The medical staff must examine
                                quality       improvement         projects      are        credentials of candidates for medical
                                being conducted, the reasons for con-                      staff membership and make rec-
                                ducting these projects, and the measur-                    ommendations to the governing body
                                able       progress     achieved       on     these        on the appointment of the candidates.
                                projects.                                                     (3) When telemedicine services are
                                  (4) A hospital is not required to par-                   furnished to the hospital's patients
                                ticipate in a QIO cooperative project,                     through an agreement with a distant-
                                but its own projects are required to be                    site hospital, the governing body of the
                                of comparable effort.                                      hospital whose patients are receiving
                                   (e)   Standard: Executive responsibilities.             the telemedicine services may choose,
                                The hospital's governing body (or orga-                    in lieu of the requirements in para-
                                nized group or individual who assumes                      g'l'aphs (a)(l) and (a)(2) of this section,
                                full legal authority and responsibility                    to have its medical staff rely upon the
                                for operations of the hospital), medical                   credentialing and privileging decisions
                                staff, and administrative officials are                    made by the distant-site hospital when
                                responsible and accountable for ensur-                     making recommendations on privi1eges
                                ing the following:                                         for the individual distant-site physi-
                                  (1) That an ongoing program for qual-                    cians and practitioners providing such
                                ity improvement and patient safety,                        services, if the hospital's governing
                                including the reduction of medical er-                     body ensures, through its written
                                rors, is defined, implemented, and                         agreement with the distant-site hos-
                                maintained.                                                pital, that all of the following provi-
                                  (2) That the hospital-wide quality as-                   sions are met:
                                sessment and performance improve-                             (i) The distant-site hospital providing
                                ment efforts address priorities for im-                    the telemedicine services is a Medi-
                                proved quality of care and patient safe-                   care-participating hospital.
                                ty; and that all improvement actions                          (ii) The individual distant-site physi-
                                are evaluated.                                             cian or practitioner is privileged at the
                                  (3) That clear expectations for safety                   distant-site hospital providing the tale-
                                are established.                                           medicine services, which provides a
                                  (4) That adequate resources are allo-                    current list of the distant-site physi-
                                cated for measuring, assessing, improv-                    cian's or practitioner's privileges at
                                ing, and sustaining the hospital's per-                    the distant-site hospital.
                                formance and reducing risk to patients.                       (iii) The individual distant-site phy-
                                  (5) That the determination of the                        sician or practitioner holds a license
                                number      of distinct improvement                        issued or recognized by the State in
                                projects is conducted annually.                            which the hospital whose patients are
                                                                                           receiving the telemedicine services is
                                f6B FR 3454, Jan. 24, 2003]                                located.
                                                                                              (iv) With respect to a distant-site
                                § 482.22  Condition of participation:                      physician or practitioner, who holds
                                    Medical staff,                                         current privileges at the hospital
                                  The hospital must have an organized                      whose patients are receiving the tele-
                                medical staff that operates under by-                      medicine services, the hospital has evi-
                                laws approved by the governing body                        dence of an internal review of the dis-
                                and is responsible for the quality of                      tant-site physician's or practitioner's
                                medical care provided to patients by                       performance of these privileges and
                                the hospital.                                              sends the distant-site hospital such
                                  (a) Standard: Composition of the med-                    performance information for use in the
                                ical staff, The medical staff must be                      periodic appraisal of the distant-site
                                composed of doctors of medicine or os-                     physician or practitioner. At a min-
                                teopathy and, in accordance with State                     imum, this information must include
                                law, may also be composed of other                         all adverse events that result from the
                                practitioners appointed by the gov-                        telemedicine services provided by the
                                erning body.                                               distant-site physician or practitioner

                                                                                      14

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APPENDIX- ''6'' ·
       AUTH£NTICATED9
      US GoVEIINMENT
       INfORMI\TION
                GPO

                                 §482.41                                                               42 CFR Ch. IV (1 0-1-11 Edition)

                                 professional services provided, to de-                        (ii) Chapter 19.3.6.3.2, exception num-
                                 termine medical necessity and to pro-                      ber 2 of the adopted edition of the LSC
                                 mote the most efficient use of avail-                      does not apply to hospitals.
                                 able health facilities and services.                          (2) After consideration of State sur-
                                                                                            vey agency findings, OMS may waive
                                 §482.41      Condition        of    participation:         specific provisions of the Life Safety
                                     Physical environment,                                  Code which, if rigidly applied, would
                                   The hospital must be constructed, ar-                    result in unreasonable hardship upon
                                 ranged, and maintained to ensure the                       the facility, but only if the waiver does
                                 safety of the patient, and to provide fa-                  not adversely affect the health and
                                 cilities for diagnosis and treatment and                   safety of the patients.
                                 for special hospital services appro-                          (3) The provisions of the Life Safety
                                 priate to the needs of the community.                      Code do not apply in a State where
                                   (a) Standard: Buildings. The condition                   CMS finds that a fire and safety code
                                 of the physical plant and the overall                      imposed by State law adequately pro-
                                 hospital environment must be devel-                        tects patients in hospitals.
                                 oped and maintained in such a manner                          (4) Beginning March 13, 2006, a hos-
                                 that the safety and well-being of pa-                      pital must be in compliance with Chap-
                                 tients are assured.                                        ter 19.2.9, Emergency Lighting.
                                   (1) There must be emergency power                           (5) Beginninjr March 13, 2006, Chapter
                                 and lighting in at least the operating,                    19.3.6.3.2, exception number 2 does not
                                 recovery, intensive care, and emer-                        apply to hospitals.
                                 gency rooms, and stairwells. In all                           (6) The hospital must have proce-
                                 other areas not serviced by the emer-                      dures for the proper routine storage
                                 gency supply source, battery lamps and                     and prompt disposal of trash.
                                 flashlights must be available.
                                   (2) There must be facilities for emer-                      (7) The hospital must have written
                                 gency gas and water supply.                                fire control plans that contain provi-
                                                                                            sions for prompt reporting of fires; ex-
                                   (b) Standard: Life safety [rom [ire. (1)
                                                                                            tinguishing fires; protection of pa-
                                 Except as otherwise provided in this
                                                                                            tients, personnel and guests; evacu-
                                 section-
                                   (1) The hospital must meet the appli-
                                                                                            ation; and cooperation with fire fight-
                                 cable provisions of the 2000 edition of                    ing authorities.
                                 the Life Safety Code of the National                          (8) The hospital must maintain writ-
                                 Fire Protection Association. The Di-                       ten evidence of regular inspection and
                                 rector of the Office of the Federal Reg-                   approval by State or local fire control
                                 ister has approved the NFPA 101 ® 2000                     agencies.
                                 edition of the Life Safety Code, issued                       (9) Notwithstanding any provisions of
                                 January 14, 2000, for incorporation by                     the 2000 edition of the Life Safety Code
                                 reference in accordance with 5 U.S.C.                      to the contrary, a hospital may install
                                 552(a) and 1 CFR part 51. A copy of the                    alcohol-based hand rub dispensers in
                                 Code is available for inspection at the                    1ts facility if-
                                 OMS Information Resource Center, 7500                         (i) Use of alcohol-based hand rub dis-
                                 Security Boulevard, Baltimore, MD or                       pensers does not conflict with any
                                 at the National Archives and Records                       State or local codes that prohibit or
                                 Administration (NARA). For informa-                        otherwise restrict the placement of al-
                                 tion on the availability of this mate-                     cohol-based hand rub dispensers in
                                 rial at NARA, call 202-741-6030, or go                     health care facilities;
                                 to:               htlp:!lwww.aTchives.gov/                    (ii) The dispensers are installed in a
                                 [ederal_Tegisterl                                          manner that minimizes leaks and spills
                                 code_of__federal_regulations/                              that could lead to falls;
                                 ibr_locations.html. Copies may be ob-                         (iii) The dispensers are installed in a
                                 tained from the National Fire Protec-                      manner that adequately protects
                                 tion Association, 1 Batterymarch Park,                     against inappropriate access;
                                 Quincy, MA 02269. If any changes in                           (iv) The dispensers are installed in
                                 this edition of the Code are incor-                        accordance with chapter 18.3.2.7 or
                                 porated by reference, CMS will publish                     chapter 19.3.2.7 of the 2000 edition of
                                 notice in the FEDERAL REGISTER to an-                      the Life Safety Code, as amended by
                                 nounce the changes.                                        NFPA Temporary Interim Amendment

                                                                                       24

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                                Centers for Medicare & Medicaid Services, HHS                                                      §482.43
                                00-1(101), issued by the Standards Coun-                   fying, reporting, investigating, and
                                cil of the National Fire Protection As-                    controlling infections and commu-
                                sociation on April 15, 2004. The Direc-                    nicable diseases of patients and per-
                                tor of the Office of the Federal Register                  sonnel.
                                has approved NFPA Temporary In-                              (2) The infection control officer or of-
                                terim Amendment 00-1(101) for incorpo-                     ficers must maintain a log of incidents
                                ration by reference in accordance with                     related to infections and commu-
                                5 U .S.C. 552(a) and 1 CFR part 51. A                      nicable diseases.
                                copy of the amendment is available for                       (b) Standard: Responsibilities of chief
                                inspection at the OMS Information Re-                      executive officer, medical staff, and dime-
                                source Center, 7500 Security Boulevard,                    tor of nursing services. The chief execu-
                                Baltimore, MD and at the Office of the                     tive officer, the medical staff, and the
                                Federal Register, 800 North Capitol                        director of nursing services must-
                                Street NW., Suite 700, Washington, DC.                       (1) Ensure that the hospital-wide
                                Copies may be obtained from the Na-                        quality assurance program and train-
                                tional Fire Protection Association, 1                      ing programs address problems identi-
                                Batterymaroh Park, Quincy, MA 02269;                       fied by the infection control officer or
                                and                                                        officers; and
                                  (v) The dispensers are maintained in                       (2) Be responsible for the implemen-
                                accordance with dispenser manufac-                         tation of successful corrective action
                                turer guidelines.                                          plans in affected problem areas.
                                  (c) Standard: Facilities. The hospital
                                must maintain adequate facilities for                      § 482.43 Condition of           participation:
                                its services.                                                  Dischal'ge planning.
                                  (1) Diagnostic and therapeutic facili-
                                ties must be located for the safety of                       The hospital must have in effect a
                                patients.                                                  discharge planning process that applies
                                  (2) Facilities, supplies, and equip--                    to all patients. The hospital's policies
                                ment must be maintained to ensure an                       and procedures must be specified in
                                acceptable level of safety and quality.                    writing.
                                  (3) The extent and complexity of fa-                       (a) Standard: Identification of patients
                                cilities must be determined by the                         in need of discharge planning. The hos-
                                services offered.                                          pital must identify at an early stage of
                                  (4) There must be proper ventilation,                    hospitalization all patients who are
                                light, and temperature controls in                         likely to suffer adverse health con-
                                pharmaceutical, food preparation, and                      sequences upon discharge if there is no
                                other appropriate areas.                                   adequate discharge planning,
                                                                                             (b) Standard: Discharge planning eval-
                                (51 FR 22042, June 17, 1966, as amended at 53              uation. (1) The hospital must provide a
                                FR 11509, Apr, 7, 1988; 68 FR 1386, Jan. 10,
                                2003; 69 FR 49267, Aug, 11, 2004; 70 FR 15238,
                                                                                           discharge planning evaluation to the
                                Mar. 25, 2005; 71 FR 55340, Sept, 22, 2006]                patients identified in paragraph (a) of
                                                                                           this section, and to other patients upon
                                § 482.42   Condition of participation: In·                 the patient's request, the request of a
                                     fection control.                                      person acting on the patient's behalf,
                                   The hospital must provide a sanitary                    or the request of the physician.
                                environment to avoid sources and                             (2) A registered nurse, social worker,
                                transmission of infections and commu-                      or other appropriately qualified per-
                                nicable diseases. There must be an ac-                     sonnel must develop, or supervise the
                                tive program for the prevention, con-                      development of, the evaluation.
                                trol, and investigation of infections                        (3) The discharge planning evaluation
                                and communicable diseases.                                 must include an evaluation of the like-
                                   (a) Standard: Organization and poli-                    lihood of a patient needing post-- hos-
                                cies. A person or persons must be des-                     pital services and of the availability of
                                ignated as infection control officer or                    the services.
                                officers to develop and implement poli-                      {4) The discharge planning evaluation
                                cies governing control of infections and                   must include an evaluation of the like-
                                communicable diseases.                                     lihood of a patient's capacity for self-
                                   (1) The infection control officer or of-                care or of the possibility of the patient
                                ficers must develop a system for identi-                   being cared for in the environment

                                                                                      25

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APPEND IX - ''7''
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                          Texas Administrative Code
             TITLE 25                   HEALTH SERVICES
             PART I                     DEPARTMENT OF STATE HEALTH SERVICES
             CHAPTER 133                HOSPITAL LICENSING
             SUBCHAPTER A               GENERAL PROVISIONS
             RULE §133.1                Purpose
 -----·-·-------
 (a) The purpose of this chapter is to implement the Health and Safety Code, Chapter 241, which
 requires general and special hospitals to be licensed by the Department of State Health Services.

 (b) This chapter provides procedures for obtaining a hospital license; minimum standards for hospital
 functions and services; patient rights standards; discrimination or retaliation standards; patient
 transfer and other policy and protocol requirements; reporting, posting and training requirements
 relating to abuse and neglect; standards for voluntary agreements; waiver provisions; inspection and
 investigation procedures; enforcement standards; fire prevention and protection requirements;
 general safety standards; physical plant and construction requirements for existing and new hospitals,
 and mobile transportable and relocatable units; and standards for the preparation, submittal, review
 and approval of construction documents.

 (c) Compliance with this chapter does not constitute release from the requirements of other
 applicable federal, state, or local laws, codes, mles, regulations and ordinances. This chapter must be
 followed where it exceeds other codes and ordinances.

 Source Note: The provisions of this §133.1 adopted to be effective June 21,2007, 32 TexReg 3587

                                  List of Titles   -]   L[___Ba_c_k_to_Li_st_ _   _j

                   TEXAS REGISTER          TEXAS ADMINISTRATIVE CODE              OPEN MEETINGS

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                          Texas Administrative Code
             TITLE25                   HEALTH SERVICES
             PART I                    DEPARTMENT OF STATE HEALTH SERVICES
             CHAPTER 133               HOSPITAL LICENSING
             SUBCHAPTER C              OPERATIONAL REQUIREMENTS
             RULE §133.41              Hospital Functions and Services

 (a) Anesthesia services. If the hospital furnishes anesthesia services, these services shall be provided
 in a well-organized manner under the direction of a qualified physician in accordance with the
 Medical Practice Act and the Nursing Practice Act. The hospital is responsible for and shall
 document all anesthesia services administered in the hospital.

  (1) Organization and staffing. The organization of anesthesia services shall be appropriate to the
 scope of the services offered. Only personnel who have been approved by the facility to provide
 anesthesia services shall administer anesthesia. All approvals or delegations of anesthesia services as
 authorized by law shall be documented and include the training, experience, and qualifications of the
 person who provided the service.

  (2) Delivery of services. Anesthesia services shall be consistent with needs and resources. Policies
 on anesthesia procedure shall include the delineation of pre-anesthesia and post-anesthesia
 responsibilities. The policies shall ensure that the following are provided for each patient.

   (A) A pre-anesthesia evaluation by an individual qualified to administer anesthesia under
 paragraph (1) of this subsection shall be performed within 48 hours prior to surgery.

   (B) An intraoperative anesthesia record shall be provided. The record shall include any
 complications or problems occurring during the anesthesia including time, description of symptoms,
 review of affected systems, and treatments rendered. The record shall correlate with the controlled
 substance administration record.

    (C) A post-anesthesia follow-up report shall be written by the person administering the anesthesia
 before transferring the patient from the post-anesthesia care unit and shall include evaluation for
 recovery from anesthesia, level of activity, respiration, blood pressme, level of consciousness, and
 patient's oxygen saturation level.

     (i) With respect to inpatients, a post-anesthesia evaluation for proper anesthesia recovery shall be
 performed after transfer from the post-anesthesia care unit and within 48 hours after surgery by the
 person administering the anesthesia, registered nurse (RN), Ol' physician in accordance with policies
 and procedures approved by the medical staff and using criteria written in the medical staff bylaws
 for postoperative monitoring of anesthesia.

     (ii) With respect to outpatients, immediately prior to discharge, a post-anesthesia evaluation for
 proper anesthesia recovery shall be performed by the person administering the anesthesia, RN, or
 physician in accordance with policies and procedures approved by the medical staff and using
 criteria written in the medical staff bylaws for postoperative monitoring of anesthesia.
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  (b) Chemical dependency services.

  (1) Chemical dependency unit. A hospital may not admit patients to a chemical dependency
 services unit unless the unit is approved by the Department of State Health Services (department) as
 meeting the requirements of§ 133.163(q) of this title (relating to Spatial Requirements for New
 Construction).

  (2) Admission criteria. A hospital providing chemical dependency services shall have written
 admission criteria that are applied uniformly to all patients who are admitted to the chemical
 dependency unit.

    (A) The hospital's admission criteria shall include procedures to prevent the admission of minors
 for a condition which is not generally recognized as responsive to treatment in an inpatient setting for
 chemical dependency services.

     (i) The following conditions are not generally recognized as responsive to treatment in a
 treatment facility for chemical dependency unless the minor to be admitted is qualified because of
 other disabilities, such as:

      (I) cognitive disabilities due to intellectual disability;

      (II) learning disabilities; or

      (III) psychiatric disorders.

     (ii) A minor may be qualified for admission based on other disabilities which would be
 responsive to chemical dependency services.

     (iii) A minor patient shall be separated from adult patients.

    (B) The hospital shall have a preadmission examination procedure under which each patient's
 condition and medical history are reviewed by a member of the medical staff to determine whether
 the patient is likely to benefit significantly from an intensive inpatient program or assessment.

   (C) A voluntarily admitted patient shall sign an admission consent form prior to admission to a
 chemical dependency unit which includes verification that the patient has been informed of the
 services to be provided and the estimated charges.

  (3) Compliance. A hospital providing chemical dependency services in an identifiable unit within
 the hospital shall comply with Chapter 448, Subchapter B of this title (relating to Standard of Care
 Applicable to All Providers).

 (c) Comprehensive medical rehabilitation services.

  (I) Rehabilitation units. A hospital may not admit patients to a comprehensive medical
 rehabilitation services unit unless the unit is approved by the department as meeting the requirements
 of §133.163(z) of this title.

  (2) Equipment and space. The hospital shall have the necessary equipment and sufficient space to
 implement the treatment plan described in paragraph (7)(C) of this subsection and allow for adequate
 care. Necessary equipment is all equipment necessary to comply with all parts of the written
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 treatment plan. The equipment shall be on-site or available through an atTangement with another
 provider. Sufficient space is the physical area of a hospital which in the aggregate, constitutes the
 total amount of the space necessary to comply with the written treatment plan.

  (3) Emergency requirements. Emergency personnel, equipment, supplies and medications for
 hospitals providing comprehensive medical rehabilitation services shall be as follows.

    (A) A hospital that provides comprehensive medical rehabilitation services shall have emergency
 equipment, supplies, medications, and designated personnel assigned for providing emergency care
 to patients and visitors.

    (B) The emergency equipment, supplies, and medications shall be properly maintained and
 immediately accessible to all areas of the hospital. The emergency equipment shall be periodically
 tested according to the policy adopted, implemented and enforced by the hospital.

   (C) At a minimum, the emergency equipment and supplies shall include those specified in
 subsection (e)(4) of this section.

    (D) The personnel providing emergency care in accordance with this subsection shall be staffed
 for 24-hour coverage and accessible to all patients receiving comprehensive medical rehabilitation
 services. At least one person who is qualified by training to perform advanced cardiac life support
 and administer emergency drugs shall be on duty each shift.

   (E) All direct patient care licensed personnel shall maintain current certification in
 cardiopulmonary resuscitation (CPR).

  (4) Medications. A rehabilitation hospital's governing body shall adopt, implement and enforce
 policies and procedures that require all medications to be administered by licensed nurses,
 physicians, or other licensed professionals authorized by law to administer medications.

  (5) Organization and Staffing.

    (A) A hospital providing comprehensive medical rehabilitation services shall be organized and
 staffed to ensure the health and safety of the patients.

     (i) All provided services shall be consistent with accepted professional standards and practice.

     (ii) The organization of the services shall be appropriate to the scope of the services offered.

     (iii) The hospital shall adopt, implement and enforce written patient care policies that govern the
 services it furnishes.

   (B) The provision of comprehensive medical rehabilitation services in a hospital shall be under the
 medical supervision of a physician who is on duty and available, or who is on-call 24 hours each day.

    (C) A hospital providing comprehensive medical rehabilitation services shall have a medical
 director or clinical director who supervises and administers the provision of comprehensive medical
 rehabilitation services.

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     (i) The medical director or clinical director shall be a physician who is board certified or eligible
 for board certification in physical medicine and rehabilitation, orthopedics, neurology, neurosurgery,
 internal medicine, or rheumatology as appropriate for the rehabilitation program.

     (ii) The medical director or clinical director shall be qualified by training or at least two years
 training and experience to serve as medical director or clinical director. A person is qualified under
 this subsection if the person has training and experience in the treatment of rehabilitation patients in
 a rehabilitation setting.

  (6) Admission criteria. A hospital providing comprehensive medical rehabilitation services shall
 have written admission criteria that are applied uniformly to all patients who are admitted to the
 comprehensive medical rehabilitation unit.

    (A) The hospital's admission criteria shall include procedures to prevent the admission of a minor
 for a condition which is not generally recognized as responsive to treatment in an inpatient setting for
 comprehensive medical rehabilitation services.

    (i) The following conditions are not generally recognized as responsive to treatment in an
 inpatient setting for comprehensive medical rehabilitation services unless the minor to be admitted is
 qualified because of other disabilities, such as:

      (I) cognitive disabilities due to intellectual disability;

      (II) learning disabilities; or

      (III) psychiatric disorders.

     (ii) A minor may be qualified for admission based on other disabilities which would be
 responsive to comprehensive medical rehabilitation services.

    (B) The hospital shall have a preadmission examination procedure under which each patient's
 condition and medical history are reviewed by a member of the medical staffto determine whether
 the patient is likely to benefit significantly from an intensive inpatient program or assessment.

  (7) Care and services.

    (A) A hospital providing comprehensive medical rehabilitation services shall use a coordinated
 interdisciplinary team which is directed by a physician and which works in collaboration to develop
 and implement the patient's treatment plan.

     (i) The interdisciplinary team for comprehensive medical rehabilitation services shall have
 available to it, at the hospital at which the services are provided or by contract, members of the
 following professions as necessary to meet the treatment needs of the patient:

      (I) physical therapy;

      (II) occupational therapy;

      (III) speech-language pathology;

      (IV) therapeutic recreation;
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       (V) social services and case management;

       (VI) dietetics;

       (VII) psychology;

       (VIII) respiratory therapy;

       (IX) rehabilitative nursing;

       (X) ce1iified orthotics;

       (XI) certified prosthetics;

       (XII) phmmaceutical care; and

     (XIII) in the case of a minor patient, persons who have specialized education and training in
 emotional, mental health, or chemical dependency problems, as well as the treatment of minors.

     (ii) The coordinated interdisciplinary temn approach used in the rehabilitation of each patient
 shall be documented by periodic entries made in the patient's medical record to denote:

       (I) the patient's status in relationship to goal attainment; and

      (II) that team conferences are held at least every two weeks to determine the appropriateness of
 treatment.

   (B) An initial assessment and preliminary treatment plaJI shall be performed or established by the
 physician within 24 hours of admission.

    (C) The physiciaJI in coordination with the interdisciplinary team shall establish a written
 treatment plan for the patient within seven working days of the date of admission.

     (i) Comprehensive medical rehabilitation services shall be provided in accordaJice with the
 written treatment plan.

     (ii) The treatment provided under the written treatment plan shall be provided by staff who are
 qualified to provide services under state law. The hospital shall establish written qualifications for
 services provided by each discipline for which there is no applicable state statute for professional
 licensure or certification.

     (iii) Services provided under the written treatment plan shall be given in accordance with the
 orders of physiciaJis, dentists, podiatrists or practitioners who are authorized by the governing body,
 hospital administration, and medical staff to order the services, and the orders shall be incorporated
 in the patient's record.

     (iv) The written treatment plan shall delineate anticipated goals and specifY the type, amount,
 frequency, and anticipated duration of service to be provided.

 Cont'd ...

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                                 List of Titles   ~   [_      Back to List
                                                                     ·---
                                                                                J
                   TEXAS REGISTER         TEXAS ADMINISTRATIVE CODE             OPEN MEETINGS

                                                                                                  6

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 <>
                          Texas Administrative Code
             TITLE 25                  HEALTH SERVICES
             PART I                    DEPARTMENT OF STATE HEALTH SERVICES
             CHAPTER 133               HOSPITAL LICENSING
             SUBCHAPTER C              OPERATIONAL REQUIREMENTS
             RULE §133.41              Hospital Functions and Services

     (v) Within 10 working days after the date of admission, the written treatment plan shall be
 provided. It shall be in the person's primary language, if practicable. What is or would have been
 practicable shall be determined by the facts and circumstances of each case. The written treatment
 plan shall be provided to:

      (I) the patient;

      (II) a person designated by the patient; and

      (III) upon request, a family member, guardian, or individual who has demonstrated on a routine
 basis responsibility and participation in the patient's care or treatment, but only with the patient's
 consent unless such consent is not required by law.

    (vi) The written treatment plan shall be reviewed by the interdisciplinary team at least every two
 weeks.

     (vii) The written treatment plan shall be revised by the interdisciplinary team if a comprehensive
 reassessment of the patient's status or the results of a patient case review conference indicates the
 need for revision.

     (viii) The revision shall be incorporated into the patient's record within seven working days after
 the revision.

     (ix) The revised treatment plan shall be reduced to writing in the person's primary language, if
 practicable, and provided to:

      (I) the patient;

      (II) a person designated by the patient; and

      (III) upon request, a family member, guardian, or individual who has demonstrated on a routine
 basis responsibility and participation in the patient's care or treatment, but only with the patient's
 consent unless such consent is not required by law.

  (8) Discharge and continuing care plan. The patient's interdisciplinary team shall prepare a written
 continuing care plan that addresses the patient's needs for care after discharge.

   (A) The continuing care plan for the patient shall include recommendations for treatment and care
 and information about the availability of resources for treatment or care.
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   (B) If the patient's interdisciplinary team deems it impracticable to provide a written continuing
 care plan prior to discharge, the patient's interdisciplinary team shall provide the written continuing
 care plan to the patient within two working days after the date of discharge.

   (C) Prior to discharge or within two working days after the date of discharge, the written
 continuing care plan shall be provided in the person's primary language, if practicable, to:

     (i) the patient;

     (ii) a person designated by the patient; and

     (iii) upon request, to a family member, guardian, or individual who has demonstrated on a routine
 basis responsibility and participation in the patient's care or treatment, but only with the patient's
 consent unless such consent is not required by law.

 (d) Dietary services. The hospital shall have organized dietary services that are directed and staffed
 by adequate qualified personnel. However, a hospital that has a contract with an outside food
 management company or an a!1'angement with another hospital may meet this requirement if the
 company or other hospital has a dietitian who serves the hospital on a full-time, part-time, or
 consultant basis, and if the company or other hospital maintains at least the minimum requirements
 specified in this section, and provides for the frequent and systematic liaison with the hospital
 medical staff for recommendations of dietetic policies affecting patient treatment. The hospital shall
 ensure that there are sufficient personnel to respond to the dietary needs of the patient population
 being served.

  (1) Organization.

    (A) The hospital shall have a full-time employee who is qualified by experience or training to
 serve as director of the food and dietetic service, and be responsible for the daily management of the
 dietary services.

    (B) There shall be a qualified dietitian who works full-time, part-time, or on a consultant basis. If
 by consultation, such services shall occur at least once per month for not less than eight hours. The
 dietitian shall:

    (i) be currently licensed under the laws of this state to use the titles oflicensed dietitian or
 provisional licensed dietitian, or be a registered dietitian;

     (ii) maintain standards for professional practice;

     (iii) supervise the nutritional aspects of patient care;

    (iv) make an assessment of the nutritional status and adequacy of nutritional regimen, as
 appropriate;

     (v) provide diet counseling and teaching, as appropriate;

    (vi) document nutritional status and pertinent information in patient medical records, as
 appropriate;

     (vii) approve menus; and
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     (viii) approve menu substitutions.

   (C) There shall be administrative and teclmical personnel competent in their respective duties. The
 administrative and technical personnel shall:

     (i) participate in established departmental or hospital training pertinent to assigned duties;

    (ii) conform to food handling teclmiques in accordance with paragraph (2)(E)(viii) of this
 subsection;

     (iii) adhere to clearly defined work schedules and assignment sheets; and

     (iv) comply with position descriptions which are job specific.

   (2) Director. The director shall:

    (A) comply with a position description which is job specific;

    (B) clearly delineate responsibility and authority;

    (C) participate in conferences with administration and department heads;

   (D) establish, implement, and enforce policies and procedures for the overall operational
 components of the department to include, but not be limited to:

     (i) quality assessment and performance improvement program;

     (ii) frequency of meals served;

     (iii) nonroutine occurrences; and

     (iv) identification of patient trays; and

    (E) maintain authority and responsibility for the following, but not be limited to:

     (i) orientation and training;

     (ii) performance evaluations;

     (iii) work assignments;

     (iv) supervision of work and food handling techniques;

      (v) procur~ment of food, paper, chemical, and other supplies, to include implementation of first-
 in first-out rotation system for all food items;

     (vi) ensuring there is a four-day food supply on hand at all times;

     (vii) menu planning; and

     (viii) ensuring compliance with §§229.161 -229.171 of this title (relating to Texas Food
 Establishments).
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   (3) Diets. Menus shall meet the needs of the patients.

   (A) Therapeutic diets shall be prescribed by the physician(s) responsible for the care of the
 patients. The dietary department of the hospital shall:

     (i) establish procedures for the processing of therapeutic diets to include, but not be limited to:

      (I) accurate patient identification;

      (II) transcription from nursing to dietary services;

      (III) diet planning by a dietitian;

      (IV) regular review and updating of diet when necessary; and

      (V) written and verbal instruction to patient and family. It shall be in the patient's primary
 language, if practicable, prior to discharge. What is or would have been practicable shall be
 determined by the facts and circumstances of each case;

     (ii) ensure that therapeutic diets are planned in writing by a qualified dietitian;

     (iii) ensure that menu substitutions are approved by a qualified dietitian;

    (iv) document pertinent information about the patient's response to a therapeutic diet in the
 medical record; and

     (v) evaluate therapeutic diets for nutritional adequacy.

    (B) Nutritional needs shall be met in accordance with recognized dietmy practices and in
 accordance with orders of the physician(s) or appropriately credentialed practitioner(s) responsible
 for the care of the patients. The following requirements shall be met.

     (i) Menus shall provide a sufficient variety of foods served in adequate mnounts at each meal
 according to the guidance provided in the Recommended Dietmy Allowances (RDA), as published
 by the Food and Nutrition Board, Commission on Life Sciences, National Research Council, Tenth
 edition, 1989, which may be obtained by writing the National Academies Press, 500 Fifth Street, NW
 Lockbox 285, Washington, D.C. 20055, telephone (888) 624-8373.

    (ii) A maximum of 15 hours shall not be exceeded between the last meal of the day (i.e. supper)
 and the breakfast meal, unless a substantial snack is provided. The hospital shall adopt, implement,
 and enforce a policy on the definition of "substantial" to meet each patient's varied nutritional needs.

   (C) A current therapeutic diet manual approved by the dietitian and medical staff shall be readily
 available to all medical; nursing, and food service personnel. The therapeutic manual shall:

     (i) be revised as needed, not to exceed 5 years;

     (ii) be appropriate for the diets routinely ordered in the hospital;

     (iii) have standards in compliance with the RDA;

     (iv) contain specific diets which are not in compliance with RDA; and
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     (v) be used as a guide for ordering and serving diets.

 (e) Emergency services. All licensed hospital locations, including multiple-location sites, shall have
 an emergency suite that complies with §133.161(a)(l)(A) of this title (relating to Requirements for
 Buildings in Which Existing Licensed Hospitals are Located) or § 133.163(f) of this title, and the
 following.

   (I) Organization. The organization of the emergency services shall be appropriate to the scope of
 the services offered.

   (A) The services shall be organized under the direction of a qualified member of the medical staff
 who is the medical director or clinical director.

    (B) The services shall be integrated with other departments of the hospital.

    (C) The policies and procedures governing medical care provided in the emergency suite shall be
 established by and shall be a continuing responsibility of the medical staff.

    (D) Medical records indicating patient identification, complaint, physician, nurse, time admitted to
 the emergency suite, treatment, time discharged, and disposition shall be maintained for all
 emergency patients.

    (E) Each freestanding emergency medical care facility shall advertise as an emergency room. The
 facility shall display notice that it functions as an emergency room.

    (i) The notice shall explain that patients who receive medical services will be billed according to
 comparable rates for hospital emergency room services in the same region.

     (ii) The notice shall be prominently and conspicuously posted for display in a public area of the
 facility that is readily available to each patient, managing conservator, or guardian. The postings
 shall be easily readable and consumer-friendly. The notice shall be in English and in a second
 language appropriate to the demographic makeup of the community served.

  (2) Personnel.

    (A) There shall be adequate medical and nursing personnel qualified in emergency care to meet
 the written emergency procedures and needs anticipated by the hospital.

   (B) Except for comprehensive medical rehabilitation hospitals and pediatric and adolescent
 hospitals that generally provide care that is not administered for or in expectation of compensation:

     (i) there shall be on duty and available at all times at least one person qualified as determined by
 the medical staff to initiate immediate appropriate lifesaving measures; and

     (ii) in general hospitals where the emergency treatment area is not contiguous with other areas of
 the hospital that maintain 24 hour staffing by qualified staff (including but not limited to separation
 by one or more floors in multiple-occupancy buildings), qualified personnel must be physically
 present in the emergency treatment area at all times.

   (C) Except for comprehensive medical rehabilitation hospitals and pediatric and adolescent
 hospitals that generally provide care that is not administered for or in expectation of compensation,
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 the hospital shall provide that one or more physicians shall be available at all times for emergencies,
 as follows.

     (i) General hospitals, except for hospitals designated as critical access hospitals (CAHs) by the
 Centers for Medicare & Medicaid Services (CMS), located in counties with a population of I 00,000
 or more shall have a physician qualified to provide emergency medical care on duty in the
 emergency treatment area at all times.

 Cont'd ...

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                   TEXAS REGISTER        TEXAS ADMINISTRATIVE CODE            OPEN MEETINGS

                                                                                                     12

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                            Texas Administrative Code
              TITLE 25                    HEALTH SERVICES
              PARTl                       DEPARTMENT OF STATE HEALTH SERVICES
              CHAPTER 133                 HOSPITAL LICENSING
              SUBCHAPTER C                OPERATIONAL REQUIREMENTS
              RULE §133.41                Hospital Functions and Services

     (ii) Special hospitals, hospitals designated as CAHs by the CMS, and general hospitals located in
 counties with a population of less than 100,000 shall have a physician on-call and able to respond in
 person, or by radio or telephone within 30 minutes.

   (D) Schedules, names, and telephone numbers of all physicians and others on emergency call duty,
 including alternates, shall be maintained. Schedules shall be retained for no less than one year.

   (3) Supplies and equipment. Adequate age appropriate supplies and equipment shall be available
 and in readiness for use. Equipment and supplies shall be available for the administration of
 intravenous medications as well as facilities for the control of bleeding and emergency splinting of
 fractures. Provision shall be made for the storage of blood and blood products as needed. The
 emergency equipment shall be periodically tested according to the policy adopted, implemented and
 enforced by the hospital.

  (4) Required emergency equipment. At a minimum, the age appropriate emergency equipment and
 supplies shall include the following:

    (A) emergency call system;

    (B) oxygen;

   (C) mechanical ventilatory assistance equipment, including airways, manual breathing bag, and
 mask;

    (D) cardiac defibrillator;

    (E) cardiac monitoring equipment;

    (F) laryngoscopes and endotracheal tubes;

    (G) suction equipment;

    (H) emergency dmgs and supplies specified by the medical staff;

    (I) stabilization devices for cervical injuries;

    (J) blood pressure monitoring equipment; and

    (K) pulse oximeter or similar medical device to measure blood oxygenation.
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   (5) Participation in local emergency medical service (EMS) system.

   (A) General hospitals shall participate in the local EMS system, based on the hospital's capabilities
 and capacity, and the locale's existing EMS plan and protocols.

   (B) The provisions of subparagraph (A) of this paragraph do not apply to a comprehensive medical
 rehabilitation hospital or a pediatric and adolescent hospital that generally provides care that is not
 administered for or in expectation of compensation.

  (6) Emergency services for survivors of sexual assault. This section does not affect the duty of a
 health care facility to comply with the requirements of the federal Emergency Medical Treatment
 and Active Labor Act of 1986 (42 U.S.C. § 1395dd) that are applicable to the facility.

   (A) The hospital shall develop, implement and enforce policies and procedures to ensure that,
 except as otherwise provided by subparagraph (C) of this paragraph, after a sexual assault survivor
 presents to the hospital following a sexual assault, the hospital shall provide the care specified under
 subparagraph (D) of this paragraph.

    (B) A facility that is not a health care facility designated in a community-wide plan as the primary
 health care facility in the community for treating sexual assault survivors shall inform the survivor
 that:

     (i) the facility is not the designated facility and provide to the survivor the name and location of
 the designated facility; and

     (ii) the survivor is entitled, at the survivor's option:

     (I) to receive the care described by subparagraph (D) of this paragraph at that facility, subject to
 subparagraph (D)(i) of this paragraph; or

       (II) to be stabilized and to be transferred to and receive the care described by subparagraph (D)
 of this paragraph at a health care facility designated in a community-wide plan as the primary health
 care facility in the community for treating sexual assault survivors.

    (C) If a sexual assault survivor chooses to be transferred under subparagraph (B)(ii)(II) of this
 paragraph, after obtaining the survivor's written, signed consent to the transfer, the facility shall
 stabilize and transfer the survivor to a health care facility in the community designated in a
 community-wide plan as the health care facility for treating sexual assault survivors, where the
 survivor will receive the care specified under subparagraph (D) of this paragraph.

    (D) A hospital providing care to a sexual assault survivor shall provide the survivor with the
 following:

     (i) subject to subparagraph (G) of this paragraph, a forensic medical examination in accordance
 with Government Code, Chapter 420, Subchapter B, when the examination has been requested by a
 law enforcement agency under Code of Criminal Procedure, Article 56.06, or is conducted under
 Code of Criminal Procedure, Article 56.065. If a sexual assault survivor is age 18 or older and has
 not reported the assault to a law enforcement agency, a hospital shall provide this forensic medical
 examination, when the sexual assault survivor has arrived at the facility not later than 96 hours after
 the time the assault occurred and has consented to the examination;
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     (ii) a private area, if available, to wait or speak with the appropriate medical, legal, or sexual
 assault crisis center staff or volunteer until a physician, nurse, or physician assistant is able to treat
 the survivor;

    (iii) access to a sexual assault program advocate, if available, as provided by Code of Criminal
 Procedure, Article 56.045;

     (iv) the infmmation form required by Health and Safety Code, §323.005;

     (v) a private treatment room, if available;

    (vi) if indicated by the histmy of contact, access to appropriate prophylaxis for exposure to
 sexually transmitted infections; and

     (vii) the name and telephone number of the nearest sexual assault crisis center.

   (E) The hospital must obtain documented consent before providing the forensic medical
 examination and treatment.

   (F) Upon request, the hospital shall submit to the department its plan for the provision of service to
 sexual assault survivors. The plan must describe how the hospital will ensure that the services
 required under subparagraph (D) of this paragraph will be provided.

     (i) The hospital shall submit the plan by the 60th day after the department makes the request.

    (ii) The department will approve or reject the plan not later than the !20th day following the
 submission of the plan.

     (iii) If the department is not able to approve the plan, the department will return the plan to the
 hospital and will identify the specific provisions of statutes or rules with which the hospital's plan
 failed to comply.

     (iv) The hospital shall correct and resubmit the plan to the department for approval not later than
 the 90th day after the plan is returned to the hospital.

   (G) A person may not perform a forensic examination on a sexual assault survivor unless the
 person has the basic training described by Health and Safety Code, §323.0045, or the equivalent
 education and training.

   (H) Basic Sexual Assault Forensic Evidence Collection Training.

     (i) A person who performs a forensic examination on a sexual assault survivor must have at least
 basic forensic evidence collection training or the equivalent education.

     (ii) A person who completes a continuing medical or nursing education course in forensic
 evidence collection that is approved or recognized by the appropriate licensing board is considered to
 have basic sexual assault forensic evidence training for purposes of this chapter.

     (iii) Each health care facility that has an emergency depmiment and that is not a health care
 facility designated in a community-wide plan as the primary health care facility in the community for

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 treating sexual assault survivors shall develop a plan to train personnel on sexual assault forensic
 evidence collection.

    (I) Sexual Assault Survivors Who Are Minors. This chapter does not affect participating entities of
 children's advocacy centers under Family Code, Chapter 264, Subchapter E, or the working protocols
 set forth by their multidisciplinary teams to ensure access to specialized medical assessments for
 sexual assault survivors who are minors. To the extent of a conflict with Family Code, Chapter 264,
 Subchapter E, that subchapter controls.

 (f) Governing body.

  (I) Legal responsibility. There shall be a governing body responsible for the organization,
 management, control, and operation of the hospital, including appointment of the medical staff. For
 hospitals owned and operated by an individual or by partners, the individual or partners shall be
 considered the governing body.

  (2) Organization. The governing body shall be formally organized in accordance with a written
 constitution and bylaws which clearly set forth the organizational structure and responsibilities.

  (3) Meeting records. Records of governing body meetings shall be maintained.

  (4) Responsibilities relating to the medical staff.

    (A) The governing body shall ensure that the medical staff has current bylaws, rules, and
 regulations which are implemented and enforced.

    (B) The governing body shall approve medical staff bylaws and other medical staff rules and
 regulations.

    (C) In hospitals that provide obstetrical services, the governing body shall ensure that the hospital
 collaborates with physicians providing services at the hospital to develop quality initiatives, through
 the adoption, implementation, and enforcement of appropriate hospital policies and procedures, to
 reduce the number of elective or nonmedically indicated induced deliveries or cesarean sections
 performed at the hospital on a woman before the 39th week of gestation.

    (D) In hospitals that provide obstetrical services, the governing body shall ensure that the hospital
 implements a newborn audiological screening program, consistent with the requirements of Health
 and Safety Code, Chapter 47 (Hearing Loss in Newborns), and performs, either directly or through a
 referral to another program, audiological screenings for the identification of hearing loss on each
 newborn or infant born at the facility before the newborn or infant is discharged. These audiological
 screenings are required to be performed on all newborns or infants before discharge from the facility
 unless:

     (i) a parent or legal guardian of the newborn or infant declines the screening;

    (ii) the newbom or infant requires emergency transfer to a tertiary care facility prior to the
 completion of the screening;

     (iii) the screening previously has been completed; or

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      (iv) the newborn was discharged from the facility not more than I 0 hours after birth and a referral
 for the newborn was made to another program.·

    (E) In hospitals that provide obstetrical services, the governing body shall adopt, implement, and
 enforce policies and procedures related to the testing of any newborn for critical congenital heart
 disease (CCHD) that may present themselves at birth. The facility shall implement testing programs
 for all infants born at the facility for CCHD. In the event that a newborn is presented at the
 emergency room following delivery at a birthing center or a home birth that may or may not have
 been assisted by a midwife, the facility shall ascertain if any testing for CCHD had occurred and, if
 not, shall provide the testing necessary to make such determination. The rules conceming the CCHD
 procedures and requirements are described in §§37.75- 37.79 of this title.

    (F) The governing body shall determine, in accordance with state law and with the advice ofthe
 medical staff, which categories of practitioners are eligible candidates for appointment to the medical
 staff.

    (i) In considering applications for medical staff membership and privileges or the renewal,
 modification, or revocation of medical staff membership and privileges, the governing body must
 ensure that each physician, podiatrist, and dentist is afforded procedural due process.

      (I) If a hospital's credentials committee has failed to take action on a completed application as
 required by subclause (VIII) of this clause, or a physician, podiatrist, or dentist is subject to a
 professional review action that may adversely affect his medical staff membership or privileges, and
 the physician, podiatrist, or dentist believes that mediation of the dispute is desirable, the physician,
 podiatrist, or dentist may require the hospital to participate in mediation as provided in Civil Practice
 and Remedies Code (CPRC), Chapter 154. The mediation shall be conducted by a person meeting
 the qualifications required by CPRC §154.052 and within a reasonable period of time.

      (II) Subclause (I) of this clause does not authorize a cause of action by a physician, podiatrist, or
 dentist against the hospital other than an action to require a hospital to pmticipate in mediation.

      (III) An applicant for medical staff membership or privileges may not be denied membership or
 privileges on any ground that is otherwise prohibited by law.

      (IV) A hospital's bylaw requirements for staff privileges may require a physician, podiatrist, or
 dentist to document the person's cmTent clinical competency and professional training and
 experience in the medical procedures for which privileges are requested.

 Cont'd ...

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                   TEXAS REGISTER           TEXAS ADMINISTRATIVE CODE                       OPEN MEETINGS

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                           Texas Administrative Code
             TITLE 25                   HEALTH SERVICES
             PART!                      DEPARTMENT OF STATE HEALTH SERVICES
             CHAPTER 133                HOSPITAL LICENSING
             SUBCHAPTER C               OPERATIONAL REQUIREMENTS
             RULE §133.41               Hospital Functions and Services

      (V) In granting or refusing medical staff membership or privileges, a hospital may not
 differentiate on the basis of the academic medical degree held by a physician.

      (VI) Graduate medical education may be used as a standard or qualification for medical staff
 membership or privileges for a physician, provided that equal recognition is given to training
 programs accredited by the Accreditation Council for Graduate Medical Education and by the
 American Osteopathic Association.

      (VII) Board certification may be used as a standard or qualification for medical staff
 membership or privileges for a physician, provided that equal recognition is given to certification
 programs approved by the American Board of Medical Specialties and the Bill'eau of Osteopathic
 Specialists.

       (VIII) A hospital's credentials committee shall act expeditiously and without unnecessary delay
 when a licensed physician, podiatrist, or dentist submits a completed application for medical staff
 membership or privileges. The hospital's credentials committee shall take action on the completed
 application not later than the 90th day after the date on which the application is received. The
 governing body of the hospital shall take final action on the application for medical staff membership
 or privileges not later than the 60th day after the date on which the recommendation of the
 credentials committee is received. The hospital must notify the applicant in writing of the hospital's
 final action, including a reason for denial or restriction of privileges, not later than the 20th day after
 the date on which final action is taken.

     (ii) The governing body is authorized to adopt, implement and enforce policies concerning the
 granting of clinical privileges to advanced practice nurses and physician assistants, including policies
 relating to the application process, reasonable qualifications for privileges, and the process for
 renewal, modification, or revocation of privileges.

       (I) If the governing body of a hospital has adopted, implemented and enforced a policy of
 granting clinical privileges to advanced practice nurses or physician assistants, an individual
 advanced practice nurse or physician assistant who qualifies for privileges under that policy shall be
 entitled to certain procedural rights to provide fairness of process, as determined by the governing
 body of the hospital, when an application for privileges is submitted to the hospital. At a minimum,
 any policy adopted shall specify a reasonable period for the processing and consideration of the
 application and shall provide for written notification to the applicant of any final action on the
 application by the hospital, including any reason for denial or restriction of the privileges requested.

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       (II) If an advanced practice nurse or physician assistant has been granted clinical privileges by a
 hospital, the hospital may not modifY or revoke those privileges without providing certain procedural
 rights to provide fairness of process, as determined by the governing body of the hospital, to the
 advanced practice nurse or physician assistant. At a minimum, the hospital shall provide the
 advanced practice nurse or physician assistant written reasons for the modification or revocation of
 privileges and a mechanism for appeal to the appropriate committee or body within the hospital, as
 determined by the governing body of the hospital.

       (III) If a hospital extends clinical privileges to an advanced practice nurse or physician assistant
 conditioned on the advanced practice nurse or physician assistant having a sponsoring or
 collaborating relationship with a physician and that relationship ceases to exist, the advanced practice
 nurse or physician assistant and the physician shall provide written notification to the hospital that
 the relationship no longer exists. Once the hospital receives such notice from an advanced practice
 nurse or physician assistant and the physician, the hospital shall be deemed to have met its
 obligations under this section by notifYing the advanced practice nurse or physician assistant in
 writing that the advanced practice nurse's or physician assistant's clinical privileges no longer exist at
 that hospital.

      (IV) Nothing in this clause shall be construed as modifYing Subtitle B, Title 3, Occupations
 Code, Chapter 204 or 301, or any other law relating to the scope of practice of physicians, advanced
 practice nurses, or physician assistants.

      (V) This clause does not apply to an employer-employee relationship between an advanced
 practice nurse or physician assistant and a hospital.

   (G) The goveming body shall ensure that the hospital complies with the requirements concerning
 physician communication and contracts as set out in Health and Safety Code, §241.10 15 (Physician
 Communication and Contracts).

    (H) The governing body shall ensure the hospital complies with the requirements for reporting to
 the Texas Medical Board the results and circumstances of any professional review action in
 accordance with the Medical Practice Act, Occupations Code, §160.002 and §160.003.

   (I) The governing body shall be responsible for and ensure that any policies and procedures
 adopted by the governing body to implement the requirements of this chapter shall be implemented
 and enforced.

  (5) Hospital administration. The governing body shall appoint a chief executive officer or
 administrator who is responsible for managing the hospital.

  ( 6) Patient care. In accordance with hospital policy adopted, implemented and enforced, the
 governing body shall ensure that:

    (A) every patient is under the care of:

     (i) a physician. This provision is not to be construed to limit the authority of a physician to
 delegate tasks to other qualified health care personnel to the extent recognized under state law or the
 state's regulatory mechanism;

     (ii) a dentist who is legally authorized to practice dentistry by the state and who is acting within
 the scope of his or her license; or
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     (iii) a podiatrist, but only with respect to functions which he or she is legally authorized by the
 state to perform.

   (B) patients are admitted to the hospital only by members of the medical staff who have been
 granted admitting privileges;

    (C) a physician is on duty or on-call at all times;

    (D) specific colored condition alert wrist bands that have been standardized for all hospitals
 licensed under Health and Safety Code, Chapter 241, are used as follows:

     (i) red wrist bands for allergies;

     (ii) yellow wrist bands for fall risks; and

     (iii) purple wrist bands for do not resuscitate status;

    (E) the governing body shall consider the addition of the following optional condition alert wrist
 bands. This consideration must be documented in the minutes of the meeting of the governing body
 in which the discussion was held:

     (i) green wrist bands for latex allergy; and

     (ii) pink wrist bands for restricted extremity; and

    (F) the governing body shall adopt, implement, and enforce a policy and procedure regarding the
 removal of personal wrist bands and bracelets as well as a patient's right to refuse to wear condition
 alert wrist bands.

  (7) Services. The governing body shall be responsible for all services furnished in the hospital,
 whether furnished directly or under contract. The governing body shall ensure that services are
 provided in a safe and effective manner that permits the hospital to comply with applicable rules and
 standards. At hospitals that have a mental health service tmit, the governing body shall adopt,
 implement, and enforce procedures for the completion of criminal background checks on all
 prospective employees that would be considered for assignment to that unit, except for persons
 currently licensed by this state as health professionals.

  (8) Nurse Staffing. The governing body shall adopt, implement and enforce a written nurse staffing
 policy to ens me that an adequate number and skill mix of nurses are available to meet the level of
 patient care needed. The governing body policy shall require that hospital administration adopt,
 implement and enforce a nurse staffing plan and policies that:

   (A) require significant consideration be given to the nurse staffing plan recommended by the
 hospital's nurse staffing committee and the committee's evaluation of any existing plan;

   (B) are based on the needs of each patient care unit and shift and on evidence relating to patient
 care needs;

   (C) ensure that all nursing assignments consider client safety, and are commensurate with the
 nurse's educational preparation, experience, knowledge, and physical and emotional ability;

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    (D) require use of the official nurse services staffing plan as a component in setting the nurse
 staffing budget;

   (E) encourage nurses to provide input to the nurse staffing committee relating to nurse staffing
 concerns;

    (F) protect from retaliation nurses who provide input to the nurse staffing committee; and

    (G) comply with subsection (o) of this section.

  (9) Photo identification badge. The governing body shall adopt a policy requiring employees,
 physicians, contracted employees, and individuals in training who provide direct patient care at the
 hospital to wear a photo identification badge during all patient encounters, unless precluded by
 adopted isolation or sterilization protocols. The badge must be of sufficient size and worn in a
 manner to be visible and must clearly state:

    (A) at minimum the individual's first or last name;

    (B) the department of the hospital with which the individual is associated;

    (C) the type of license held by the individual, if applicable under Title 3, Occupations Code; and

    (D) the provider's status as a student, intern, trainee, or resident, if applicable.

 (g) Infection control. The hospital shall provide a sanitary environment to avoid sources and
 transmission of infections and communicable diseases. There shall be an active program for the
 prevention, control, and surveillance of infections and communicable diseases.

  (1) Organization and policies. A person shall be designated as infection control professional. The
 hospital shall ensure that policies governing prevention, control and surveillance of infections and
 communicable diseases are developed, implemented and enforced.

   (A) There shall be a system for identifYing, reporting, investigating, and controlling health care
 associated infections and communicable diseases between patients and personnel.

    (B) The infection control professional shall maintain a log of all reportable diseases and health
 care associated infections designated as epidemiologically significant according to the hospital's
 infection control policies.

    (C) A written policy shall be adopted, implemented and enforced for reporting all reportable
 diseases to the local health authority and the Infectious Disease Surveillance and Epidemiology
 Branch, Department of State Health Services, Mail Code 2822, P.O. Box 149347, Austin, Texas
 78714-9347, in accordance with Chapter 97 of this title (relating to Communicable Diseases), and
 Health and Safety Code, §§98.103, 98.104, and 98.1045 (relating to Reportable Infections,
 Alternative for Reportable Surgical Site Infections, and Reporting of Preventable Adverse Events).

    (D) The infection control program shall include active participation by the pharmacist.

  (2) Responsibilities ofthe chief executive officer (CEO), medical staff, and chief nursing officer
 (CNO). The CEO, the medical staff, and the CNO shall be responsible for the following.

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   (A) The hospital-wide quality assessment and performance improvement program and training
 programs shall address problems identified by the infection control professional.

    (B) Successful corrective action plans in affected problem areas shall be implemented.

  (3) Universal precautions. The hospital shall adopt, implement, and enforce a written policy to
 monitor compliance of the hospital and its personnel and medical staff with universal precautions in
 accordance with HSC Chapter 85, Acquired Immune Deficiency Syndrome and Human
 Immunodeficiency Virus Infection.

 (h) Laboratory services. The hospital shall maintain directly, or have available adequate laboratory
 services to meet the needs of its patients.

  (1) Hospital laboratory services. A hospital that provides laboratory services shall comply with the
 Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988), in accordance with the
 requirements specified in 42 Code ofPederal Regulations (CPR), §§493.1 - 493.1780. CLIA 1988
 applies to all hospitals with laboratories that examine human specimens for the diagnosis, prevention,
 or treatment of any disease or impairment of, or the assessment of the health of, human beings.

   (2) Contracted laboratory services. The hospital shall ensure that all laboratory services provided to
 its patients through a contractual agreement are performed in a facility certified in the appropriate
 specialties and subspecialties of service in accordance with the requirements specified in 42 CPR
 Part 493 to comply with CLIA 1988.

  (3) Adequacy of laboratory services. The hospital shall ensure the following.

 Cont'd ...

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                   TEXAS REGISTER           TEXAS ADMINISTRATIVE CODE            OPEN MEETINGS

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                           Texas Administrative Code
              TITLE 25                   HEALTH SERVICES
              PART 1                     DEPARTMENT OF STATE HEALTH SERVICES
              CHAPTER 133                HOSPITAL LICENSING
              SUBCHAPTER C               OPERATIONAL REQUIREMENTS
             RULE §133.41                Hospital Functions and Services

    (A) Emergency laboratory services shall be available 24 hours a day.

    (B) A written description of services provided shall be available to the medical staff.

    (C) The laboratory shall make provision for proper receipt and reporting of tissue specimens.

   (D) The medical staff and a pathologist shall determine which tissue specimens require a
 macroscopic (gross) examination and which require both macroscopic and microscopic examination.

    (E) When blood and blood components are stored, there shall be written procedures readily
 available containing directions on how to maintain them within permissible temperatures and
 including instructions to be followed in the event of a power failure or other disruption of
 refrigeration. A label or tray with the recipient's first and last names and identification number, donor
 unit number and interpretation of compatibility, if performed, shall be attached securely to the blood
 container.

    (F) The hospital shall establish a mechanism for ensuring that the patient's physician or other
 licensed health care professional is made aware of critical value lab results, as established by the
 medical staff, before or after the patient is discharged.

  (4) Chemical hygiene. A hospital that provides laboratory services shall adopt, implement, and
 enforce written policies and procedures to manage, minimize, or eliminate the risks to laboratory
 personnel of exposure to potentially hazardous chemicals in the laboratory which may occur during
 the normal course of job performance.

 (i) Linen and laund1y services. The hospital shall provide sufficient clean linen to ensm-e the comfort
 of the patient.

  (1) For purposes of this subsection, contaminated linen is linen which has been soiled with blood or
 other potentially infectious materials or may contain sharps. Other potentially infectious materials
 means:

    (A) the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial
 fluid, pleural fluid, pericardia! fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any
 body fluid that is visibly contaminated with blood, and all body fluids in situations where it is
 difficult or impossible to differentiate between body fluids;

    (B) any unfixed tissue or organ (other than intact skin) from a human (living or dead); and

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    (C) Human Immunodeficiency Virus (HIV)-containing cell or tissue cultures, organ cultures, and
 HIV or Hepatitis B Virus (HBV)-containing culture medium or other solutions; and blood, organs, or
 other tissues from experimental animals infected with HIV or HBV.

  (2) The hospital, whether it operates its own laundry or uses commercial service, shall ensure the
 following.

   (A) Employees of a hospital involved in transporting, processing, or otherwise handling clean or
 soiled linen shall be given initial and follow-up in-service training to ensure a safe product for
 patients and to safeguard employees in their work.

    (B) Clean linen shall be handled, transported, and stored by methods that will ensure its
 cleanliness.

   (C) All contaminated linen shall be placed and transported in bags or containers labeled or color-
 coded.

   (D) Employees who have contact with contaminated linen shall wear gloves and other appropriate
 personal protective equipment.

   (E) Contaminated linen shall be handled as little as possible and with a minimum of agitation.
 Contaminated linen shall not be sorted or rinsed in patient care areas.

    (F) All contaminated linen shall be bagged or put into carts at the location where it was used.

     (i) Bags containing contaminated linen shall be closed prior to transport to the laundry.

     (ii) Whenever contaminated linen is wet and presents a reasonable likelihood of soalc-tlu·ough of
 or leakage from the bag or container, the linen shall be deposited and transported in bags that prevent
 leakage of fluids to the exterior.

     (iii) All linen placed in chutes shall be bagged.

    (iv) If chutes are not used to convey linen to a central receiving or sorting room, then adequate
 space shall be allocated on the various nursing units for holding the bagged contaminated linen.

    (G) Linen shall be processed as follows:

     (i) If hot water is used, linen shall be washed with detergent in water with a temperature of at
 least 71 degrees Centigrade (160 degrees Fahrenheit) for 25 minutes. Hot water requirements
 specified in Table 5 of §133.169(e) of this title (relating to Tables) shall be met.

     (ii) If low-temperature (less than or equal to 70 degrees Centigrade) (!58 degrees Fahrenheit)
 laundry cycles are used, chemicals suitable for low-temperature washing at proper use concentration
 shall be used.

     (iii) Commercial dry cleaning of fabrics soiled with blood also renders these items free of the risk
 of pathogen transmission.

   (H) Flammable liquids shall not be used to process laundry, but may be used for equipment
 maintenance.
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 G) Medical record services. The hospital shall have a medical record service that has administrative
 responsibility for medical records. A medical record shall be maintained for every individual who
 presents to the hospital for evaluation or treatment.

  (I) The organization of the medical record service shall be appropriate to the scope and complexity
 of the services performed. The hospital shall employ or contract with adequate personnel to ensure
 prompt completion, filing, and retrieval of records.

  (2) The hospital shall have a system of coding and indexing medical records. The system shall
 allow for timely retrieval by diagnosis and procedure, in order to support medical care evaluation
 studies.

  (3) The hospital shall adopt, implement, and enforce a policy to ensure that the hospital complies
 with HSC, Chapter 241, Subchapter G (Disclosure of Health Care Information).

  (4) The medical record shall contain information to justifY admission and continued hospitalization,
 support the diagnosis, reflect significant changes in the patient's condition, and describe the patient's
 progress and response to medications and services. Medical records shall be accurately written,
 promptly completed, properly filed and retained, and accessible.

  (5) Medical record entries must be legible, complete, dated, timed, and authenticated in written or
 electronic form by the person responsible for providing or evaluating the service provided, consistent
 with hospital policies and procedures.

   (6) All orders (except verbal orders) must be dated, timed, and authenticated the next time the
 prescriber or another practitioner who is responsible for the care of the patient and has been
 credentialed by the medical staff and granted privileges which are consistent with the written orders
 provides care to the patient, assesses the patient, or documents information in the patient's medical
 record.

  (7) All verbal orders must be dated, timed, and authenticated within 96 hours by the prescriber or
 another practitioner who is responsible for the care of the patient and has been credentialed by the
 medical staff and granted privileges which are consistent with the written orders.

    (A) Use of signature stamps by physicians and other licensed practitioners credentialed by the
 medical staff may be allowed in hospitals when the signature stamp is authorized by the individual
 whose signature the stamp represents. The administrative offices of the hospital shall have on file a
 signed statement to the effect that he or she is the only one who has the stamp and uses it. The use of
 a signature stamp by any other person is prohibited.

   (B) A list of computer codes and written signatures shall be readily available and shall be
 maintained under adequate safeguards.

   (C) Signatures by facsimile shall be acceptable. If received on a thermal machine, the facsimile
 document shall be copied onto regular paper.

   (8) Medical records (reports and printouts) shall be retained by the hospital in their original or
 legally reproduced fmm for a period of at least ten years. A legally reproduced form is a medical
 record retained in hard copy, microform (microfilm or microfiche), or other electronic medium.
 Films, scans, and other image records shall be retained for a period of at least five years. For
 retention purposes, medical records that shall be preserved for ten years include:
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    (A) identification data;

    (B) the medical history of the patient;

   (C) evidence of a physical examination, including a health history, performed no more than 30
 days prior to admission or within 24 hours after admission. The medical histoty and physical
 examination shall be placed in the patient's medical record within 24 hours after admission;

    (D) an updated medical record entry documenting an examination for any changes in the patient's
 condition when the medical history and physical examination are completed within 30 days before
 admission. This updated examination shall be completed and documented in the patient's medical
 record within 24 hours after admission;

    (E) admitting diagnosis;

    (F) diagnostic and therapeutic orders;

   (G) properly executed informed consent forms for procedures and treatments specified by the
 medical staff, or by federal or state laws if applicable, to require written patient consent;

   (H) clinical observations, including the results of therapy and treatment, all orders, nursing notes,
 medication records, vital signs, and other infmmation necessary to monitor the patient's condition;

   (I) reports of procedures, tests, and their results, including laboratory, pathology, and radiology
 reports;

   (J) results of all consultative evaluations of the patient and appropriate findings by clinical and
 other staff involved in the care of the patient;

    (K) discharge summaty with outcome of hospitalization, disposition of care, and provisions for
 follow-up care; and

    (L) final diagnosis with completion of medical records within 30 calendar days following
 discharge.

   (9) If a patient was less than 18 years of age at the time he was last treated, the hospital may
 authorize the disposal of those medical records relating to the patient on or after the date of his 20th
 birthday or on or after the 1Oth anniversary of the date on which he was last treated, whichever date
 is later.

   (1 0) The hospital shall not destroy medical records that relate to any matter that is involved in
 litigation if the hospital knows the litigation has not been finally resolved.

  (11) The hospital shall provide written notice to a patient, or a patient's legally authorized
 representative, that the hospital may authorize the disposal of medical records relating to the patient
 on or after the periods specified in this section. The notice shall be provided to the patient or the
 patient's legally authorized representative not later than the date on which the patient who is or will
 be the subject of a medical record is treated, except in an emergency treatment situation. In an
 emergency treatment situation, the notice shall be provided to the patient or the patient's legally
 authorized representative as soon as is reasonably practicable following the emergency treatment
 situation.
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  (12) If a licensed hospital should close, the hospital shall notify the department at the time of
 closure the disposition of the medical records, including the location of where the medical records
 will be stored and the identity and telephone number of the custodian of the records.

 (k) Medical staff.

  (I) The medical staff shall be composed of physicians and may also be composed of podiatrists,
 dentists and other practitioners appointed by the governing body.

    (A) The medical staff shall periodically conduct appraisals of its members according to medical
 staff by laws.

   (B) The medical staff shall examine credentials of candidates for medical staff membership and
 make recommendations to the governing body on the appointment of the candidate.

  (2) The medical staff shall be well-organized and accountable to the governing body for the quality
 of the medical care provided to patients.

    (A) The medical staff shall be organized in a manner approved by the governing body.

   (B) If the medical staff has an executive committee, a majority of the members of the committee
 shall be doctors of medicine or osteopathy.

    (C) Records of medical staff meetings shall be maintained.

   (D) The responsibility for organization and conduct of the medical staff shall be assigned only to
 an individual physician.

   (E) Each medical staff member shall sign a statement signifying they will abide by medical staff
 and hospital policies.

   (3) The medical staff shall adopt, implement, and enforce bylaws, rules, and regulations to carry out
 its responsibilities. The bylaws shall:

    (A) be approved by the governing body;

   (B) include a statement of the duties and privileges of each category of medical staff (e.g., active,
 courtesy, consultant);

    (C) describe the organization of the medical staff;

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                      TEXAS REGISTER        TEXAS ADMINISTRATIVE CODE                          OPEN MEETINGS

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                            Texas Administrative Code
              TITLE25                    HEALTH SERVICES
              PART I                     DEPARTMENT OF STATE HEALTH SERVICES
              CHAPTER 133                HOSPITAL LICENSING
              SUBCHAPTER C               OPERATIONAL REQUIREMENTS
              RULE §133.41               Hospital Functions and Services

   (D) describe the qualifications to be met by a candidate in order for the medical staff to
 recommend that the candidate be appointed by the governing body;

    (E) include criteria for determining the privileges to be granted and a procedure for applying the
 criteria to individuals requesting privileges; and

   (F) include a requirement that a physical examination and medical history be done no more than
 30 days before or 24 hours after an admission for each patient by a physician or other qualified
 practitioner who has been granted these privileges by the medical staff. The medical history and
 physical examination shall be placed in the patient's medical record within 24 hours after admission.
 When the medical history and physical examination are completed within the 30 days before
 admission, an updated examination for any changes in the patient's condition must be completed and
 documented in the patient's medical record within 24 hours after admission.

 (I) Mental health services.

   (1) Mental health services unit. A hospital may not admit patients to a mental health services unit
 unless the unit is approved by the department as meeting the requirements of§ 133 .163(q) of this
 title.

  (2) Admission criteria. A hospital providing mental health services shall have written admission
 criteria that are applied uniformly to all patients who are admitted to the service.

    (A) The hospital's admission criteria shall include procedures to prevent the admission of minors
 for a condition which is not generally recognized as responsive to treatment in an inpatient setting for
 mental health services.

     (i) The following conditions are not generally recognized as responsive to treatment in a hospital
 unless the minor to be admitted is qualified because of other disabilities, such as:

      (I) cognitive disabilities due to intellectual disability; or

      (II) learning disabilities.

     (ii) A minor may be qualified for admission based on other disabilities which would be
 responsive to mental health services.

   (B) The medical record shall contain evidence that admission consent was given by the patient, the
 patient's legal guardian, or the managing conservator, if applicable.
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    (C) The hospital shall have a preadmission examination procedure under which each patient's
 condition and medical histmy are reviewed by a member of the medical staff to determine whether
 the patient is likely to benefit significantly from an intensive inpatient program or assessment.

   (D) A voluntarily admitted patient shall sign an admission consent form prior to admission to a
 mental health unit which includes verification that the patient has been informed of the services to be
 provided and the estimated charges.

  (3) Compliance. A hospital providing mental health services shall comply with the following rules
 administered by the department. The rules are:

   (A) Chapter 411, Subchapter J of this title (relating to Standards of Care and Treatment in
 Psychiatric Hospitals);

   (B) Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health
 Services);

    (C) Chapter 405, Subchapter E of this title (relating to Electroconvulsive Therapy (ECT));

  (D) Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive
 Medication--Mental Health Services); and

    (E) Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs).

 (m) Mobile, transportable, and relocatable units. The hospital shall adopt, implement and enforce
 procedures which address the potential emergency needs for those inpatients who are taken to mobile
 units on the hospital's premises for diagnostic procedures or treatment.

 (n) Nuclear medicine services. If the hospital provides nuclear medicine services, these services shall
 meet the needs of the patients in accordance with acceptable standards of practice and be licensed in
 accordance with §289.256 of this title (relating to Medical and Veterinary Use of Radioactive
 Material).

  (1) Policies and procedures. Policies and procedures shall be adopted, implemented, and enforced
 which will describe the services nuclear medicine provides in the hospital and how employee and
 patient safety will be maintained.

  (2) Organization and staffing. The organization of the nuclear medicine services shall be
 appropriate to the scope and complexity of the services offered.

   (A) There shall be a medical director or clinical director who is a physician qualified in nuclear
 medicine.

   (B) The qualifications, training, functions, and responsibilities of nuclear medicine personnel shall
 be specified by the medical director or clinical director and approved by the medical staff.

  (3) Delivety of services. Radioactive materials shall be prepared, labeled, used, transported, stored,
 and disposed of in accordance with acceptable standards of practice and in accordance with §289.256
 of this title.

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   (A) In-house preparation ofradiopharmaceuticals shall be by, or under, the direct supervision of
 an appropriately trained licensed pharmacist or physician.

   (B) There shall be proper storage and disposal of radioactive materials.

   (C) If clinical laboratory tests are performed by the nuclear medicine services staff, the nuclear
 medicine staff shall comply with CLIA 1988 in accordance with the requirements specified in 42
 CFR Part 493.

   (D) Nuclear medicine workers shall be provided personnel monitoring dosimeters to measure their
 radiation exposure. Exposure repotts and documentation shall be available for review.

  (4) Equipment and supplies. Equipment and supplies shall be appropriate for the types of nuclear
 medicine services offered and shall be maintained for safe and efficient performance. The equipment
 shall be inspected, tested, and calibrated at least annually by qualified personnel.

  (5) Records. The hospital shall maintain signed and dated reports of nuclear medicine
 interpretations, consultations, and procedures.

   (A) The physician approved by the medical staff to interpret diagnostic procedures shall sign and
 date the interpretations of these tests.

    (B) The hospital shall maintain records of the receipt and disposition ofradiopharmaceuticals until
 disposal is authorized by the department's Radiation Safety Licensing Branch in accordance with
 §289.256 of this title.

    (C) Nuclear medicine services shall be ordered only by an individual whose scope of state
 licensure and whose defined staff privileges allow such referrals.

 (o) Nursing services. The hospital shall have an organized nursing service that provides 24-hour
 nursing services as needed.

  (1) Organization. The hospital shall have a well-organized service with a plan of administrative
 authority and delineation of responsibilities for patient care.

   (A) Nursing services shall be under the administrative authority of a chief nursing officer (CNO)
 who shall be an RN and comply with one of the following:

     (i) possess a master's degree in nursing;

     (ii) possess a master's degree in health care administration or business administration;

     (iii) possess a master's degree in a health-related field obtained through a curriculum that
 included courses in administration and management; or

     (iv) be progressing under a written plan to obtain the nursing administration qualifications
 associated with a master's degree in nursing. The plan shall:

     (I) describe efforts to obtain the knowledge associated with graduate education and to increase
 administrative and management skills and experience;

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     (II) include courses related to leadership, administration, management, performance
 improvement and theoretical approaches to delivering nursing care; and

      (III) provide a time-line for accomplishing skills.

   (B) The CNO in hospitals with I 00 or fewer licensed beds and located in counties with a
 population of less than 50,000, or in hospitals that have been certified by the Centers for Medicare
 and Medicaid Services as critical access hospitals in accordance with the Code of Federal
 Regulations, Title 42, Volume 3, Part 485, Subpa1t F, §485.606(b), shall be exempted from the
 requirements in subparagraph (A)(i)- (iv) of this paragraph.

    (C) The CNO shall be responsible for the operation of the services, including determining the
 types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of
 the hospital.

   (D) The CNO shall report directly to the individual who has authority to represent the hospital and
 who is responsible for the operation of the hospital according to the policies and procedures ofthe
 hospital's governing board.

    (E) The CNO shall participate with leadership from the governing body, medical staff, and clinical
 areas, in planning, promoting and conducting performance improvement activities.

  (2) Staffing and delivery of care.

   (A) The nursing services shall adopt, implement and enforce a procedure to verify that hospital
 nursing personnel for whom licensure is required have valid and current licensure.

   (B) There shall be adequate numbers ofRNs, licensed vocational nurses (LVNs), and other
 personnel to provide nursing care to all patients as needed.

   (C) There shall be supervisory and staff personnel for each depmtment or nursing unit to provide,
 when needed, the immediate availability of an RN to provide care for any patient.

   (D) An RN shall be on duty in each building of a licensed hospital that contains at least one
 nursing unit where patients are present. The RN shall supervise and evaluate the nursing care for
 each patient and assign the nursing care to other nursing personnel in accordance with the patient's
 needs and the specialized qualifications and competence of the nursing staff available.

   (E) The nursing staff shall develop and keep cmTent a nursing plan of care for each patient which
 addresses the patient's needs.

    (F) The hospital shall establish a nurse staffing committee as a standing committee of the hospital.
 The committee shall be established in accordance with Health and Safety Code (HSC), §§161.031-
 161.033, to be responsible for soliciting and receiving input from mu·ses on the development,
 ongoing monitoring, and evaluation of the staffing plan. As provided by HSC, §161.032, the
 hospital's records and review relating to evaluation of these outcomes and indicators are confidential
 and not subject to disclosure under Government Code, Chapter 552 and not subject to disclosure,
 discove1y, subpoena or other means of!egal compulsion for their release. As used in this subsection,
 "committee" or "staffing committee" means a nurse staffing committee established under this
 subparagraph.

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       (i) The committee shall be composed of:

     (I) at least 60% registered nurses who are involved in direct patient care at least 50% of their
 work time and selected by their peers who provide direct care during at least 50% of their work time;

     (II) at least one representative from either infection control, quality assessment and performance
 improvement or risk management;

        (III) members who are representative of the types of nursing services provided at the hospital;
 and

        (IV) the chief nursing officer of the hospital who is a voting member.

     (ii) Participation on the committee by a hospital employee as a committee member shall be part
 of the employee's work time and the hospital shall compensate that member for that time
 accordingly. The hospital shall relieve the committee member of other work duties during committee
 meetings.

       (iii) The committee shall meet at least quarterly.

       (iv) The responsibilities of the committee shall be to:

      (I) develop and recommend to the hospital's governing body a nurse staffing plan that meets the
 requirements of subparagraph (G) of this paragraph;

        (II) review, assess and respond to staffing concerns expressed to the committee;

      (III) identify the nurse-sensitive outcome measures the committee will use to evaluate the
 effectiveness of the official nurse services staffing plan;

      (IV) evaluate, at least semiannually, the effectiveness of the official nurse services staffing plan
 and variations between the plan and the actual staffing; and

      (V) submit to the hospital's governing body, at least semiannually, a report on nurse staffing and
 patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse
 services staffing plan and aggregate variations between the staffing plan and actual staffing.

   (G) The hospital shall adopt, implement and enforce a written official nurse services staffing plan.
 As used in this subsection, "patient care unit" means a unit or area of a hospital in which registered
 nurses provide patient care.

       (i) The official nurse services staffing plan and policies shall:

 Con!' d ...

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                      TEXAS REGISTER            TEXAS ADMINISTRATIVE CODE                    OPEN MEETINGS
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 <>
                              Texas Administrative Code
                TITLE25                    HEALTH SERVICES
                PART 1                     DEPARTMENT OF STATE HEALTH SERVICES
                CHAPTER 133                HOSPITAL LICENSING
                SUBCHAPTER C               OPERATIONAL REQUIREMENTS
                RULE §133.41               Hospital Functions and Services

      (I) require significant consideration to be given to the nurse staffing plan recommended by the
 hospital's nurse staffing committee and the committee's evaluation of any existing plan;

      (II) be based on the needs of each patient care unit and shift and on evidence relating to patient
 care needs;

       (III) require use of the official nurse services staffing plan as a component in setting the nurse
 staffing budget;

     (IV) encourage nurses to provide input to the nurse staffing committee relating to nurse staffing
 concerns;

         (V) protect from retaliation nurses who provide input to the nurse staffing committee; and

         (VI) comply with subsection (o) of this section.

     (ii) The plan shall:

         (I) set minimum staffing levels for patient care units that are:

          (-a-) based on multiple nurse and patient considerations including:

        (-1-) patient characteristics and number of patients for whom care is being provided,
 including number of admissions, discharges and transfers on a unit;

           (-2-) intensity of patient care being provided and variability of patient care across a nursing
 unit;

           (-3-) scope of services provided;

        (-4-) context within which care is provided, including architecture and geography of the
 environment, and the availability of technology; and

        (-5-) nursing staff characteristics, including staff consistency and tenure, preparation and
 experience, and the number and competencies of clinical and non-clinical support staffthe nurse
 must collaborate with or supervise.

       (-b-) determined by the nursing assessment and in accordance with evidence-based safe
 nursing standards; and
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        (-c-) recalculated at least annually, or as necessary;

      (II) include a method for adjusting the staffing plan shift to shift for each patient care unit based
 on factors, such as, the intensity of patient care to provide staffing flexibility to meet patient needs;

       (III) include a contingency plan when patient care needs unexpectedly exceed direct patient care
 staff resources;

      (IV) include how on-call time will be used;

        (V) reflect current standards established by private accreditation organizations, governmental
 entities, national nursing professional associations, and other health professional organizations and
 should be developed based upon a review of the codes of ethics developed by the nursing profession
 tlll'ough national nursing organizations;

      (VI) include a mechanism for evaluating the effectiveness of the official nurse services staffing
 plan based on patient needs, nursing sensitive quality indicators, nurse satisfaction measures
 collected by the hospital and evidence based nurse staffing standards. At least one from each of the
 following three types of outcomes shall be coJTelated to the adequacy of staffing:

         (-a-) nurse-sensitive patient outcomes selected by the nurse staffing committee, such as, patient
 falls, adverse drug events, injuries to patients, skin breakdown, pneumonia, infection rates, upper
 gastrointestinal bleeding, shock, cardiac arrest, length of stay, or patient readmissions;

       (-b-) operational outcomes, such as, work-related injury or illness, vacancy and turnover rates,
 nursing care hours per patient day, on-call use, or overtime rates; and

       (-c-) substantiated patient complaints related to staffing levels;

     (VII) incorporate a process that facilitates the timely and effective identification of concerns
 about the adequacy of the staffing plan by the nurse staffing committee established pursuant to
 subparagraph (F) of this paragraph. This process shall include:

       (-a-) a prohibition on retaliation for reporting concerns;

       (-b-) a requirement that nurses report concerns timely through appropriate channels within the
 hospital;

       (-c-) orientation of nurses on how to report concerns and to whom;

       (-d-) encouraging nurses to provide input to the committee relating to nurse staffing concerns;

     (-e-) review, assessment, and response by the committee to staffing concerns expressed to the
 committee;

       (-f-) a process for providing feedback during the committee meeting on how concerns are
 addressed by the committee established under subparagraph (F) of this paragraph; and

       (-g-) use of the nurse safe harbor peer review process pursuant to Occupations Code,
 §303.005;

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      (VIII) include policies and procedures that require:

        (-a-) orientation of nurses and other personnel who provide nursing care to all patient care
 units to which they are assigned on either a temporary or permanent basis;

       (-b-) that the orientation of nurses and other personnel and the competency to perform nursing
 services is documented in accordance with hospital policy;

       (-c-) that nursing assignments be congruent with documented competency; and

      (IX) be used by the hospital as a component in setting the nurse staffing budget and guiding the
 hospital in assigning nurses hospital wide.

     (iii) The hospital shall make readily available to nurses on each patient care unit at the beginning
 of each shift the official nurse services staffing plan levels and current staffing levels for that unit and
 that shift.

     (iv) There shall be a semiannual evaluation by the staffing committee of the effectiveness ofthe
 official nurse services staffing plan and variations between the staffing plan and actual staffing. The
 evaluation shall consider the outcomes and nursing-sensitive indicators as set out in clause (ii)(VI) of
 this subparagraph, patient needs, nurse satisfaction measures collected by the hospital, and evidence
 based nurse staffing standards. This evaluation shall be documented in the minutes of the committee
 established under subparagraph (F) of this paragraph and presented to the hospital's governing body.
 Hospitals may determine whether this evaluation is done on a unit or facility level basis. To assist the
 committee with the semiannual evaluation, the hospital shall report to the committee the variations
 between the staffing plan and actual staffing. This report of variations shall be confidential and not
 subject to disclosure under Government Code, Chapter 552 and not subject to disclosure, discovery,
 subpoena or other means oflegal compulsion for their release.

     (v) The staffing plan shall be retained for a period of two years.

    (H) Nonemployee licensed nurses who are working in the hospital shall adhere to the policies and
 procedures of the hospital. The CNO shall provide for the adequate orientation, supervision, and
 evaluation of the clinical activities of nonemployee nursing personnel which occur within the
 responsibility of the nursing services.

    (I) The hospital shall annually report to the department on:

     (i) whether the hospital's governing body has adopted a nurse staffing policy;

    (ii) whether the hospital has established a nurse staffing committee that meets the membership
 requirements of subparagraph (F) of this paragraph;

     (iii) whether the nurse staffing committee has evaluated the hospital's official nurse services
 staffing plan and has reported the results of the evaluation to the hospital's goveming body; and

    (iv) the nurse-sensitive outcome measures the committee adopted for use in evaluating the
 hospital's official nurse services staffing plan.

  (3) Mandatory ove1time. The hospital shall adopt, implement and enforce policies on use of
 mandatory overtime.
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    (A) As used in this subsection:

     (i) "on-call time" means time spent by a nurse who is not working but who is compensated for
 availability; and

    (ii) "mandatory overtime" means a requirement that a nurse work hours or days that are in
 addition to the hours or days scheduled, regardless of the length of a scheduled shift or the number of
 scheduled shifts each week. Mandatory overtime does not include prescheduled on-call time or time
 immediately before or after a scheduled shift necessary to document or communicate patient status to
 ensure patient safety.

   (B) A hospital may not require a nurse to work mandatmy overtime, and a nurse may refuse to
 work mandatory overtime.

    (C) This section does not prohibit a nurse from volunteering to work overtime.

    (D) A hospital may not use on-call time as a substitute for mandatory overtime.

    (E) The prohibitions on mandatory overtime do not apply if:

     (i) a health care disaster, such as a natural or other type of disaster that increases the need for
 health care personnel, unexpectedly affects the county in which the nurse is employed or affects a
 contiguous county;

     (ii) a federal, state, or county declaration of emergency is in effect in the county in which the
 nurse is employed or is in effect in a contiguous county;

     (iii) there is an emergency or unforeseen event of a kind that:

      (I) does not regularly occur;

      (II) increases the need for health care personnel at the hospital to provide safe patient care; and

      (III) could not prudently be anticipated by the hospital; or

     (iv) the nurse is actively engaged in an ongoing medical or surgical procedure and the continued
 presence of the nurse through the completion of the procedure is necessary to ensure the health and
 safety of the patient. The nurse staffing committee shall ensure that scheduling a nurse for a
 procedure that could be anticipated to require the nurse to stay beyond the end of his or her
 scheduled shift does not constitute mandatmy overtime.

    (F) If a hospital determines that an exception exists under subparagraph (E) of this paragraph, the
 hospital shall, to the extent possible, make and document a good faith effort to meet the staffing need
 through voluntary overtime, including calling per diems and agency nurses, assigning floats, or
 requesting an additional day of work from off-duty employees.

   (G) A hospital may not suspend, terminate, or otherwise discipline or discriminate against a nurse
 who refuses to work mandatory overtime.

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  ( 4) Dmgs and biologicals. Dmgs and biologicals shall be prepared and administered in accordance
 with federal and state laws, the orders of the individuals granted privileges by the medical staff, and
 accepted standards of practice.

   (A) All drugs and biologicals shall be administered by, or under supervision of, nursing or other
 personnel in accordance with federal and state laws and regulations, including applicable licensing
 mles, and in accordance with the approved medical staff policies and procedures.

   (B) All orders for dmgs and biologicals shall be in writing, dated, timed, and signed by the
 individual responsible for the care of the patient as specified under subsection (f)(6)(A) of this
 section. When telephone or verbal orders must be used, they shall be:

    (i) accepted only by personnel who are authorized to do so by the medical staff policies and
 procedures, consistent with federal and state laws;

      (ii) dated, timed, and authenticated within 96 hours by the prescriber or another practitioner who
 is responsible for the care of the patient and has been credentialed by the medical staff and granted
 privileges which are consistent with the written orders; and

     (iii) used infrequently.

    (C) There shall be a hospital procedure for immediately reporting transfusion reactions, adverse
 dmg reactions, and errors in administration of drugs to the attending physician and, if appropriate, to
 the hospital-wide quality assessment and performance improvement program.

  (5) Blood transfusions.

    (A) Transfusions shall be prescribed in accordance with hospital policy and administered in
 accordance with a written protocol for the administration of blood and blood components and the use
 of infusion devices and ancillary equipment.

    (B) Personnel administering blood transfusions and intravenous medications shall have special
 training for this duty according to written, adopted, implemented and enforced hospital policy.

   (C) Blood and blood components shall be transfused through a sterile, pyrogen-free transfusion set
 that has a filter designed to retain particles potentially harmful to the recipient.

   (D) The patient must be observed during the transfusion and for an appropriate time thereafter for
 suspected adverse reactions.

    (E) Pretransfusion and posttransfusion vital signs shall be recorded.

    (F) When warming of blood is indicated, this shall be accomplished during its passage through the
 transfusion set. The warming system shall be equipped with a visible thermometer and may have an
 audible warning system. Blood shall not be warmed above 42 degrees Celsius.

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                                                           Back to List

                   TEXAS REGISTER       TEXAS ADMINISTRATIVE CODE          OPEN MEETINGS

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                          Texas Administrative Code
             TITLE 25                  HEALTH SERVICES
             PART I                    DEPARTMENT OF STATE HEALTH SERVICES
             CHAPTER 133               HOSPITAL LICENSING
             SUBCHAPTER C              OPERATIONAL REQUIREMENTS
             RULE §133.41              Hospital Functions and Services

   (G) Drugs or medications, including those intended for intravenous use, shall not be added to
 blood or blood components. A 0.9% sodimn chloride injection, United States Pharmacopeia, may be
 added to blood or blood components. Other solutions intended for intravenous use may be used in an
 administration set or added to blood or blood components under either of the following conditions:

     (i) they have been approved for this use by the Federal Drug Administration; or

     (ii) there is documentation available to show that addition to the component involved is safe and
 efficacious.

    (H) There shall be a system for detection, reporting and evaluation of suspected complications of
 transfusion. Any adverse event experienced by a patient in association with a transfusion is to be
 regarded as a suspected transfusion complication. In the event of a suspected transfusion
 complication, the personnel attending the patient shall notify immediately a responsible physician
 and the transfusion service and document the complication in the patient's medical record. All
 suspected transfusion complications shall be evaluated promptly according to an established
 procedure.

   (I) Following the transfusion, the blood transfusion record or a copy shall be made a part of the
 patient's medical record.

  (6) Reporting and peer review of a vocational or registered nurse. A hospital shall adopt,
 implement, and enforce a policy to ensure that the hospital complies with the Occupations Code
 §§301.401- 301.403, 301.405 and Chapter 303 (relating to Grounds for Reporting Nurse, Duty of
 Nurse to Report, Duty of Peer Review Committee to Report, Duty of Person Employing Nurse to
 Report, and Nursing Peer Review respectively), and with the rules adopted by the Board of Nurse
 Examiners in 22 T AC §217.16 (relating to Minor Incidents), §217.19 (relating to Incident-Based
 Nursing Peer Review and Whistleblower Protections), and §217.20 (relating to Safe Harbor Peer
 Review for Nurses and Whistleblower Protections).

  (7) Policies and procedures related to workplace safety.

   (A) The hospital shall adopt, implement and enforce policies and procedures related to the work
 environment for nurses which:

     (i) improve workplace safety and reduce the risk of injury, occupational illness, and violence; and

    (ii) increase the use of ergonomic principles and ergonomically designed devices to reduce injury
 and fatigue.
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   (B) The policies and procednres adopted under subparagraph (A) of this paragraph, at a minimum,
 must include:

     (i) evaluating new products and technology that incorporate ergonomic principles;

     (ii) educating nurses in the application of ergonomic practices;

     (iii) conducting workplace audits to identify areas of risk of injury, occupational illness, or
 violence and recommending ways to reduce those risks;

     (iv) controlling access to those areas identified as having a high risk of violence; and

     (v) promptly reporting crimes committed against nurses to appropriate law enforcement agencies.

  (8) Safe patient handling and movement practices.

    (A) The hospital shall adopt, implement and enforce policies and procednres to identify, assess,
 and develop strategies to control risk of injnry to patients and nurses associated with the lifting,
 transfening, repositioning, or movement of a patient.

    (B) The policies and procedures shall establish a process that, at a minimum, includes the
 following:

     (i) analysis of the risk of injury to both patients and nurses posed by the patient handling needs of
 the patient populations served by the hospital and the physical environment in which patient handling
 and movement occurs;

    (ii) education of nurses in the identification, assessment, and control of risks of injnry to patients
 and nurses during patient handling;

    (iii) evaluation of alternative ways to reduce risks associated with patient handling, including
 evaluation of equipment and the environment;

     (iv) restriction, to the extent feasible with existing equipment and aids, of manual patient
 handling or movement of all or most of a patient's weight to emergency, life-threatening, or
 otherwise exceptional circumstances;

     (v) collaboration with and annual report to the nurse staffing committee;

     (vi) procedures for nurses to refuse to perform or be involved in patient handling or movement
 that the nnrse believes in good faith will expose a patient or a nnrse to an unacceptable risk of injnry;

     (vii) submission of an annual report to the governing body on activities related to the
 identification, assessment, and development of strategies to control risk of injury to patients and
 nurses associated with the lifting, transfening, repositioning, or movement of a patient; and

     (viii) development of architectural plans for constructing or remodeling a hospital or a unit of a
 hospital in which patient handling and movement occurs, with consideration of the feasibility of
 incorporating patient handling equipment or the physical space and construction design needed to
 incorporate that equipment at a later date.

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 (p) Outpatient services. If the hospital provides outpatient services, the services shall meet the needs
 of the patients in accordance with acceptable standards of practice.

  (1) Organization. Outpatient services shall be appropriately organized and integrated with inpatient
 services.

   (2) Personnel.

    (A) The hospital shall assign an individual to be responsible for outpatient services.

   (B) The hospital shall have appropriate physicians on staff and other professional and
 nonprofessional personnel available.

 (q) Phmmacy services. The hospital shall provide pharmaceutical services that meet the needs of the
 patients.

  (1) Compliance. The hospital shall provide a pharmacy which is licensed, as required, by the Texas
 State Board of Pharmacy. Pharmacy services shall comply with all applicable statutes and rules.

   (2) Organization. The hospital shall have a pharmacy directed by a licensed pharmacist.

  (3) Medical staff. The medical staff shall be responsible for developing policies and procedures that
 minimize drug errors. This function may be delegated to the hospital's organized pharmaceutical
 services.

  (4) Pharmacy management and administration. The pharmacy or drug storage area shall be
 administered in accordance with accepted professional principles.

   (A) Standards of practice as defined by state law shall be followed regarding the provision of
 pharmacy services.

   (B) The pharmaceutical services shall have an adequate number of personnel to ensure quality
 pharmaceutical services including emergency services.

     (i) The staff shall be sufficient in number and training to respond to the pharmaceutical needs of
 the patient population being served. There shall be an arrangement for emergency services.

    (ii) Employees shall provide pharmaceutical services within the scope of their license and
 education.

   (C) Drugs and biologicals shall be properly stored to ensure ventilation, light, security, and
 temperature controls.

    (D) Records shall have sufficient detail to follow the flow of drugs from entry through
 dispensation.

    (E) There shall be adequate controls over all drugs and medications including the floor stock. Drug
 storage m·eas shall be approved by the pharmacist, and floor stock lists shall be established.

   (F) Inspections of drug storage areas shall be conducted throughout the hospital under phmmacist
 supervision.
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    (G) There shall be a drug recall procedure.

   (H) A full-time, part-time, or consulting pharmacist shall be responsible for developing,
 supervising, and coordinating all the activities of the pharmacy services.

    (i) Direction ofphatmaceutical services may not require on-premises supervision but may be
 accomplished through regularly scheduled visits in accordance with state law.

    (ii) A job description or other written agreement shall clearly define the responsibilities of the
 pharmacist.

    (I) Current and accurate records shall be kept of the receipt and disposition of all scheduled drugs.

     (i) There shall be a record system in place that provides the information on controlled substances
 in a readily retrievable manner which is separate from the patient record.

      (ii) Records shall trace the movement of scheduled drugs throughout the services, documenting
 utilization or wastage.

     (iii) The pharmacist shall be responsible for determining that all drug records ru·e in order and
 that an account of all scheduled drugs is maintained and reconciled with written orders.

   (5) Delivery of services. In order to provide patient safety, drugs and biologicals shall be controlled
 and distributed in accordance with applicable standards of practice, consistent with federal and state
 laws.

   (A) All compounding, packaging, and dispensing of dmgs and biologicals shall be under the
 supervision of a pharmacist and performed consistent with federal and state laws.

    (B) All drugs and biologicals shall be kept in a secure area, and locked when appropriate.

    (i) A policy shall be adopted, implemented, and enforced to ensure the safeguarding, transferring,
 and availability of keys to the locked storage area.

    (ii) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and
 Control Act of 1970 shall be kept locked within a secure area.

   (C) Outdated, mislabeled, or otherwise unusable drugs and biologicals shall not be available for
 patient use.

   (D) When a pharmacist is not available, drugs and biologicals shall be removed from the
 pharmacy or storage area only by personnel designated in the policies of the medical staff and
 pharmaceutical service, in accordance with federal and state laws.

     (i) There shall be a current list of individuals identified by name and qualifications who are
 designated to remove drugs from the pharmacy.

     (ii) Only amounts sufficient for immediate therapeutic needs shall be removed.

   (E) Drugs and biologicals not specifically prescribed as to time or number of doses shall
 automatically be stopped after a reasonable time that is predetermined by the medical staff.
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    (i) Stop order policies and procedures shall be consistent with those of the nursing staff and the
 medical staff rules and regulations.

     (ii) A protocol shall be established by the medical staff for the implementation of the stop order
 policy, in order that drugs shall be reviewed and renewed, or automatically stopped.

     (iii) A system shall be in place to determine compliance with the stop order policy.

    (F) Drug administration e!Tors, adverse drug reactions, and incompatibilities shall be immediately
 reported to the attending physician and, if appropriate, to the hospital-wide quality assessment and
 performance improvement program. There shall be a mechanism in place for capturing, reviewing,
 and tracking medication elTors and adverse drug reactions.

    (G) Abuses and losses of controlled substances shall be reported, in accordance with applicable
 federal and state laws, to the individual responsible for the pharmaceutical services, and to the chief
 executive officer, as appropriate.

    (H) Information relating to drug interactions and information on drug therapy, side effects,
 toxicology, dosage, indications for use, and routes of administration shall be immediately available
 to the professional staff.

     (i) A pharmacist shall be readily accessible by telephone or other means to discuss chug therapy,
 interactions, side effects, dosage, assist in drug selection, and assist in the identification of drug
 induced problems.

    (ii) There shall be staff development programs on drug therapy available to facility staff to cover
 such topics as new drugs added to the formulary, how to resolve drug therapy problems, and other
 general information as the need arises.

    (I) A formulary system shall be established by the medical staff to ensure quality pharmaceuticals
 at reasonable costs.

 (r) Quality assessment and performance improvement. The governing body shall ensure that there is
 an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement
 (QAPI) program to evaluate the provision of patient care.

  (1) Program scope. The hospital-wide QAPI program shall reflect the complexity of the hospital's
 organization and services and have a written plan of implementation. The program must include an
 ongoing program that shows measurable improvements in the indicators for which there is evidence
 that they will improve health outcomes, and identify and reduce medical errors.

    (A) All hospital departments and services, including services furnished under contract or
 arrangement shall be evaluated.

    (B) Health care associated infections shall be evaluated.

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                            L- -
                               List of Titles    ]I_       Back to List   ==:J
         IIIII     TEXAS REGISTER        TEXAS ADMINISTRATIVE CODE           OPEN MEETINGS

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                          Texas Administrative Code
             TITLE 25                  HEALTH SERVICES
             PART I                    DEPARTMENT OF STATE HEALTH SERVICES
             CHAPTER 133               HOSPITAL LICENSING
             SUBCHAPTER C              OPERATIONAL REQUIREMENTS
             RULE §133.41              Hospital Functions and Services

    (C) Medication therapy shall be evaluated.

   (D) All medical and surgical services performed in the hospital shall be evaluated as they relate to
 appropriateness of diagnosis and treatment

   (E) The program must measure, analyze and track quality indicators, including adverse patients'
 events, and other aspects of performance that assess processes of care, hospital services and
 operations.

   (F) Data collected must be used to monitor the effectiveness and safety of service and quality of
 care, and to identify opportunities for changes that will lead to improvement

   (G) Priorities must be established for performance improvement activities that focus on high-risk,
 high-volume, or problem-prone areas, taking into consideration the incidence, prevalence and
 severity of problems in those areas, and how health outcomes and quality of care may be affected.

    (H) Performance improvement activities which affect patient safety, including analysis of medical
 errors and adverse patient events, must be established, and preventive actions implemented.

   (I) Success of actions implemented as a result of performance improvement activities must be
 measured, and ongoing performance must be tracked to ensure improvements are sustained.

  (2) Responsibility and accountability. The hospital's governing body, medical staff and
 administrative staff are responsible and accountable for ensuring that:

   (A) an ongoing program for quality improvement is defined, implemented and maintained, and
 that program requirements are met;

   (B) an ongoing program for patient safety, including reduction of medical errors, is defined,
 implemented and maintained;

    (C) the hospital-wide QAPI efforts address priorities for improved quality of care and patient
 safety, and that all improvement actions are evaluated; and

   (D) adequate resources are allocated for measuring, assessing, improving and sustaining the
 hospital's resources, and for reducing risk to patients.

  (3) Medically-related patient care services. The hospital shall have an ongoing plan, consistent with
 available community and hospital resources, to provide or make available social work,
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 psychological, and educational services to meet the medically-related needs of its patients. The
 hospital also shall have an effective, ongoing discharge planning program that facilitates the
 provision of follow-up care.

    (A) Discharge planning shall be completed prior to discharge.

   (B) Patients, along with necessary medical information, shall be transfened or refened to
 appropriate facilities, agencies, or outpatient services, as needed for follow-up or ancillary care.

    (C) Screening and evaluation before patient discharge from hospital. In accordance with 42 Code
 of Federal Regulations (CFR), Part 483, Subpart C (relating to Requirements for Long Term Care
 Facilities) and the rules of the Department of Aging and Disability Services (DADS) set forth in 40
 T AC Chapter 17 (relating to Preadmission Screening and Resident Review (PASRR)), all patients
 who are being considered for discharge from the hospital to a nursing facility shall be screened, and
 if appropriate, evaluated, prior to discharge by the hospital and admission to the nursing facility to
 determine whether the patient may have a mental illness, intellectual disability or developmental
 disability. If the screening indicates that the patient has a mental illness, intellectual disability or
 developmental disability, the hospital shall contact and arrange for the local mental health authority
 designated pursuant to Health and Safety Code, §533.035, to conduct prior to hospital discharge an
 evaluation of the patient in accordance with the applicable provisions of the PASRR rules. The
 purpose ofPASRR is:

     (i) to ensure that placement of the patient in a nursing facility is necessary;

     (ii) to identifY alternate placement options when applicable; and

     (iii) to identity specialized services that may benefit the person with a diagnosis of mental illness,
 intellectual disability, or developmental disability.

  (4) Implementation. The hospital must take actions aimed at performance improvement and, after
 implementing those actions, the hospital must measure its success, and track performance to ensure
 that improvements are sustained.

 (s) Radiology services. The hospital shall maintain, or have available, diagnostic radiologic services
 according to needs of the patients. All radiology equipment, including X-ray equipment,
 mammography equipment and laser equipment, shall be licensed and registered as required under
 Chapter 289 of this title (relating to Radiation Control). Iftherapeutic services are also provided, the
 services, as well as the diagnostic services, shall meet professionally approved standards for safety
 and personnel qualifications as required in §§289.227, 289.229, 289.230 and 289.231 of this title
 (relating to Registration Regulations). In a special hospital, portable X-ray equipment may be
 acceptable as a minimum requirement.

  (1) Policies and procedures. Policies and procedures shall be adopted, implemented and enforced
 which will describe the radiology services provided in the hospital and how employee and patient
 safety will be maintained.

  (2) Safety for patients and personnel. The radiology services, particularly ionizing radiology
 procedures, shall minimize hazards to patients and personnel.

   (A) Proper safety precautions shall be maintained against radiation hazards. This includes
 adequate radiation shielding, safety procedures and equipment maintenance and testing.
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   (B) Inspection of equipment shall be made by or under the supervision of a licensed medical
 physicist in accordance with §289.227(o) of this title (relating to Use of Radiation Machines in the
 Healing Arts). Defective equipment shall be promptly repaired or replaced.

   (C) Radiation workers shall be provided personnel monitoring dosimeters to measure the amount
 of radiation exposure they receive. Exposure reports and documentation shall be available for review.

   (D) Radiology services shall be provided only on the order of individuals granted privileges by the
 medical staff.

  (3) Personnel.

    (A) A qualified full-time, part-time, or consulting radiologist shall supervise the ionizing radiology
 services and shall interpret only those radiology tests that are determined by the medical staff to
 require a radiologist's specialized knowledge. For purposes of this section a radiologist is a physician
 who is qualified by education and experience in radiology in accordance with medical staff bylaws.

   (B) Only personnel designated as qualified by the medical staff shall use the radiology equipment
 and administer procedures.

   (4) Records. Records of radiology services shall be maintained. The radiologist or other individuals
 who have been granted privileges to perform radiology services shall sign reports of his or her
 interpretations.

 (t) Renal dialysis services.

  (1) Hospitals may provide inpatient dialysis services without an additional license under HSC
 Chapter 251. Hospitals providing outpatient dialysis services shall be licensed under HSC Chapter
 251.

  (2) Hospitals may provide outpatient dialysis services when the governor or the president of the
 United States declares a disaster in this state or another' state. The hospital may provide outpatient
 dialysis only during the term of the disaster declaration.

  (3) Equipment.

   (A) Maintenance and repair. All equipment used by a facility, including backup equipment, shall
 be operated within manufacturer's specifications, and maintained free of defects which could be a
 potential hazard to patients, staff, or visitors. Maintenance and repair of all equipment shall be
 performed by qualified staff or contract personnel.

    (i) Staff shall be able to identify malfunctioning equipment and repmt such equipment to the
 appropriate staff for immediate repair.

     (ii) Medical equipment that malfunctions must be clearly labeled and immediately removed from
 service until the malfunction is identified and corrected.

     (iii) Written evidence of all maintenance and repairs shall be maintained.

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     (iv) After repairs or alterations are made to any equipment or system, the equipment or system
 shall be thoroughly tested for proper operation before returning to service. This testing must be
 documented.

    (v) A facility shall comply with the federal Food, Drug, and Cosmetic Act, 21 United States Code
 (USC), §360i(b ), concerning reporting when a medical device as defined in 21 USC §321 (h) has or
 may have caused or contributed to the injury or death of a patient of the facility.

   (B) Preventive maintenance. A facility shall develop, implement and enforce a written preventive
 maintenance program to ensure patient care related equipment used in a facility receives electrical
 safety inspections, if appropriate, and maintenance at least annually or more frequently as
 recommended by the manufacturer. The preventive maintenance may be provided by facility staff or
 by contract.

    (C) Backup machine. At least one complete dialysis machine shall be available on site as backup
 for every ten dialysis machines in use. At least one of these backup machines must be completely
 operational during hours of treatment. Machines not in use during a patient shift may be counted as
 backup except at the time of an initial or an expansion survey.

    (D) Pediatric patients. If pediatric patients are treated, a facility shall use equipment and supplies,
 to include blood pressure cuffs, dialyzers, and blood tubing, appropriate for this special population.

   (E) Emergency equipment and supplies. A facility shall have emergency equipment and supplies
 immediately accessible in the treatment area.

     (i) At a minimum, the emergency equipment and supplies shall include the following:

      (I) oxygen;

     (II) mechanical ventilatory assistance equipment, to include airways, manual breathing bag, and
 mask;

      (III) suction equipment;

      (IV) supplies specified by the medical director;

      (V) electrocardiograph; and

      (VI) automated external defibrillator or defibrillator.

    (ii) If pediatric patients are treated, the facility shall have the appropriate type and size
 emergency equipment and supplies listed in clause (i) of this subparagraph for this special
 population.

    (iii) A facility shall establish, implement, and enforce a policy for the periodic testing and
 maintenance of the emergency equipment. Staff shall properly maintain and test the emergency
 equipment and supplies and document the testing and maintenance.

    (F) Transducer protector. A transducer protector shall be replaced when wetted during a dialysis
 treatment and shall be used for one treatment only.

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   (4) Water treatment and dialysate concentrates.

    (A) Compliance required. A facility shall meet the requirements of this section. A facility may
 follow more stringent requirements than the minimum standards required by this section.

     (i) The facility administrator and medical director shall each demonstrate responsibility for the
 water treatment and dialysate supply systems to protect hemodialysis patients from adverse effects
 arising from known chemical and microbial contaminates that may be found in improperly prepared
 dialysate, to ensure that the dialysate is conectly formulated and meets the requirements of all
 applicable quality standards.

     (ii) The facility administrator and medical director must assure that policies and procedures
 related to water treatment and dialysate are understandable and accessible to the operator(s) and that
 the training program includes quality testing, risks and hazards of improperly prepared concentrate
 and bacterial issues.

    (iii) The facility administrator and medical director must be inf01med prior to any alteration of, or
 any device being added to, the water system.

    (B) Water treatment. These requirements apply to water intended for use in the delivery of
 hemodialysis, including the preparation of concentrates from powder at a dialysis facility and
 dialysate.

    (i) The design for the water treatment system in a facility shall be based on considerations of the
 source water for the facility and designed by a water quality professional with education, training, or
 experience in dialysis system design.

     (ii) When a public water system supply is not used by a facility, the source water shall be tested
 by the facility at monthly intervals in the same manner as a public water system as described in 30
 TAC §290.1 04 (relating to Summary of Maximum Contaminant Levels, Maximum Residual
 Disinfectant Levels, Treatment Techniques, and Action Levels), and §290.109 (relating to Microbial
 Contaminants) as adopted by the Texas Commission on Environmental Quality (TCEQ).

 Cont'd ...

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                    TEXAS REGISTER         TEXAS ADMINISTRATIVE CODE         OPEN MEETINGS

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                          Texas Administrative Code
             TITLE25                   HEALTH SERVICES
             PART I                    DEPARTMENT OF STATE HEALTH SERVICES
             CHAPTER 133               HOSPITAL LICENSING
             SUBCHAPTER C              OPERATIONAL REQUIREMENTS
             RULE §133.41              Hospital Functions and Services

     (iii) The physical space in which the water treatment system is located must be adequate to allow
 for maintenance, testing, and repair of equipment. If mixing of dialysate is performed in the same
 area, the physical space must also be adequate to house and allow for the maintenance, testing, and
 repair of the mixing equipment and for performing the mixing procedure.

     (iv) The water treatment system components shall be aJTanged and maintained so that bacterial
 and chemical contaminant levels in the product water do not exceed the standm·ds for hemodialysis
 water quality described in §4.2.1 (concerning Water Bacteriology) and §4.2.2 (concerning Maximum
 Level of Chemical Contaminants) of the American National Standard, Water Treatment Equipment
 for Hemodialysis Applications, August 2001 Edition, published by the Association for the
 Advancement of Medical Instrumentation (AAMI). All documents published by the AAMI as
 referenced in this section may be obtained by writing the following address: 1110 North Glebe Road,
 Suite 220, Arlington, Virginia 22201.

     (v) Written policies and procedures for the operation of the water treatment system must be
 developed and implemented. Parameters for the operation of each component of the water treatment
 system must be developed in writing and known to the operator. Each major water system
 component shall be labeled in a manner that identifies the device; describes its function, how
 performance is verified and actions to take in the event performance is not within an acceptable
 range.

      (vi) The materials of any components of water treatment systems (including piping, storage,
 filters and distribution systems) that contact the purified water shall not interact chemically or
 physically so as to affect the purity or quality of the product water adversely. Such components shall
 be fabricated from unreactive materials (e. g. plastics) or appropriate stainless steel. The use of
 materials that are known to cause toxicity in hemodialysis, such as copper, brass, galvanized
 material, or aluminum, is prohibited.

     (vii) Chemicals infused into the water such as iodine, acid, flocculants, and complexing agents
 shall be shown to be nondialyzable or shall be adequately removed from product water. Monitors or
 specific test procedures to verify removal of additives shall be provided and documented.

     (viii) Each water treatment system shall include reverse osmosis membranes or deionization
 tanks and a minimum of two carbon tanks in series. If the source water is from a private supply
 which does not use chlorine/chloramine, the water treatment system shall include reverse osmosis
 membranes or deionization tanks and a minimum of one carbon tank.

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          (I) Reverse osmosis membranes. Reverse osmosis membranes, if used, shall meet the standards
     in §4.3.7 (concerning Reverse Osmosis) of the American National Standard, Water Treatment
     Equipment for Hemodialysis Applications, August 200 I Edition, published by the AAMI.

          (II) Deionization systems.

            (-a-) Deionization systems, if used, shall be monitored continuously to produce water of one
     megohm-centimeter (em) or greater specific resistivity (or conductivity of one microsiemen/cm or
     less) at 25 degrees Celsius. An audible and visual alarm shall be activated when the product water
     resistivity falls below this level and the product water stream shall be prevented from reaching any
     point of use.

          (-b-) Patients shall not be dialyzed on deionized water with a resistivity less than 1.0 megohm-
     em measured at the output of the deionizer.

           (-c-) A minimum of two deionization (DI) tanks in series shall be used with resistivity
     monitors including audible and visual alarms placed pre and post the final DI tank in the system. The
•    alarms must be audible in the patient care area.

            (-d-) Feed water for deionization systems shall be pretreated with activated carbon adsorption,
     or a comparable alternative, to prevent nitrosamine formation.

           (-e-) If a deionization system is the last process in a water treatment system, it shall be
     followed by an ultrafilter or other bacteria and endotoxin reducing device.

          (III) Carbon tallies.

           (-a-) The carbon tanks must contain acid washed carbon, 30-mesh or smaller with a minimum
     iodine number of900.

           (-b-) A minimum of two carbon adsorption beds shall be installed in a series configuration.

           (-c-) The total empty bed contact time (EBCT) shall be at least ten minutes, with the final tank
     providing at least five minutes EBCT. Carbon adsorption systems used to prepare water for portable
     dialysis systems are exempt from the requirement for the second carbon and a ten minute EBCT if
     removal of chloramines to below 0.1 milligram (mg)/1 is verified before each treatment.

           (-d-) A means shall be provided to sample the product water immediately prior to the final bed
     (s). Water from this port(s) must be tested for chlorine/chloramine levels immediately prior to each
     patient shift.

           (-e-) All samples for chlorine/chloramine testing must be drawn when the water treatment
     system has been operating for at least 15 minutes.

           (-f-) Tests for total chlorine, which include both free and combined forms of chlorine, may be
     used as a single analysis with the maximum allowable concentration of0.1 mg/liter (L). Test results
     of greater than 0.5 parts per million (ppm) for chlorine or 0.1 ppm for chloramine from the pmi
     between the initial tank(s) and final tan1c(s) shall require testing to be perfmmed at the final exit and
     replacement of the initial tan1c(s).

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        (-g-) In a system without a holding tank, if test results at the exit of the final tank(s) are greater
 than the parameters for chlorine or chloramine described in this subclause, dialysis treatment shall be
 immediately terminated to protect patients from exposure to chlorine/chloramine and the medical
 director shall be notified. In systems with holding tanks, if the holding tank tests <1 mg/L for total
 chlorine, the reverse osmosis (RO) may be turned off and the product water in the holding tank may
 be used to finish treatments in process. The medical director shall be notified.

        (-h-) If means other than granulated carbon are used to remove chlorine/chloramine, the
 facility's governing body must approve such use in writing after review of the safety of the intended
 method for use in hemodialysis applications. If such methods include the use of additives, there must
 be evidence the product water does not contain unsafe levels of these additives.

      (ix) Water softeners, if used, shall be tested at the end of the treatment day to verify their capacity
 to treat a sufficient volume of water to supply the facility for the entire treatment day and shall be
 fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used
 during regeneration from entering the product water line during regeneration.

     (x) If used, the face(s) oftimer(s) used to control any component of the water treatment or
 dialysate delivery system shall be visible to the operator at all times. Written evidence that timers are
 checked for operation and accuracy each day of operation must be maintained.

    (xi) Filter housings, if used during disinfectant procedures, shall include a means to clear the
 lower portion of the housing of the disinfecting agents. Filter housings shall be opaque.

     (xii) Ultrafilters, or other bacterial reducing filters, if used, shall be fitted with pressure gauges on
 the inlet and outlet water lines to monitor the pressure drop across the membrane. Ultrafilters shall be
 included in routine disinfection procedures.

     (xiii) If used, storage tanks shall have a conical or bowl shaped base and shall drain from the
 lowest point of the base. Storage tanks shall have a tight-fitting lid and be vented through a
 hydrophobic 0.2 micron air filter. Means shall be provided to effectively disinfect any storage tank
 installed in a water distribution system.

    (xiv) Ultraviolet (UV) lights, if used, shall be monitored at the frequency recommended by the
 manufacturer. A log sheet shall be used to record monitoring.

     (xv) Water treatment system piping shall be labeled to indicate the contents of the pipe and
 direction of flow.

     (xvi) The water treatment system must be continuously monitored during patient treatment and
 be guarded by audible and visual alarms which can be seen and heard in the dialysis treatment area
 should water quality drop below specific parameters. Quality monitor sensing cells shall be located
 as the last component of the water treatment system and at the beginning of the distribution system.
 No water treatment components that could affect the quality of the product water as measured by this
 device shall be located after the sensing cell.

     (xvii) When deionization tanks do not follow a reverse osmosis system, parameters for the
 rejection rate of the membranes must assure that the lowest rate accepted would provide product
 water in compliance with §4.2.2 (concerning Maximum Level of Chemical Contan1inants) of the

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  American National Standard, Water Treatment Equipment for Hemodialysis Applications, August
  2001 Edition published by the AAMI.

     (xviii) A facility shall maintain written logs of the operation of the water treatment system for
 each treatment day. The log book shall include each component's operating parameter and the action
 taken when a component is not within the facility's set parameters.

     (xix) Microbiological testing of product water shall be conducted.

      (I) Frequency. Microbiological testing shall be conducted monthly and following any repair or
 change to the water treatment system. For a newly installed water distribution system, or when a
 change has been made to an existing system, weekly testing shall be conducted for one month to
 verify that bacteria and endotoxin levels are consistently within the allowed limits.

      (II) Sample sites. At a minimum, sample sites chosen for the testing shall include the beginning
 of the distribution piping, at any site of dialysate mixing, and the end of the distribution piping.

      (III) Technique. Samples shall be collected immediately before sanitization/disinfection of the
 water treatment system and dialysis machines. Water testing results shall be routinely trended and
 reviewed by the medical director in order to determine if results seem questionable or if there is an
 opportunity for improvement. The medical director shall determine if there is a need for retesting.
 Repeated results of "no growth" shall be validated via an outside laboratory. A calibrated loop may
 not be used in microbiological testing of water samples. Colonies shall be counted using a
 magnifying device.

      (IV) Expected results. Product water used to prepare dialysate, concentrates from powder, or to
 reprocess dialyzers for multiple use, shall contain a total viable microbial count less than 200 colony
 forming units (CFU)/millimeter (ml) and an endotoxin concentration less than 2 endotoxin units
 (EU)/ml. The action level for the total viable microbial count in the product water shall be 50
 CFU/ml and the action level for the endotoxin concentration shall be 1 EU/ml.

       (V) Required action for unacceptable results. If the action levels described at subclause (IV) of
 this clause are observed in the product water, corrective measures shall be taken promptly to reduce
 the levels into an acceptable range.

      (VI) Records. All bacteria and endotoxin results shall be recorded on a log sheet in order to
 identify trends that may indicate the need for corrective action.

      (xx) If ozone generators are used to disinfect any portion of the water or dialysate delivery
 system, testing based on the manufacturer's direction shall be used to measure the ozone
 concentration each time disinfection is performed, to include testing for safe levels of residual ozone
 at the end of the disinfection cycle. Testing for ozone in the ambient air shall be conducted on a
 periodic basis as recommended by the manufacturer. Records of all testing must be maintained in a
 log.

     (xxi) If used, hot water disinfection systems shall be monitored for temperature and time of
 exposure to hot water as specified by the manufacturer. Temperature of the water shall be recorded at
 a point furthest from the water heater, where the lowest water temperature is likely to occur. The
 water temperature shall be measured each time a disinfection cycle is performed. A record that
 verifies successful completion of the heat disinfection shall be maintained.
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     (xxii) After chemical disinfection, means shall be provided to restore the equipment and the
 system in which it is installed to a safe condition relative to residual disinfectant prior to the product
 water being used for dialysis applications.

     (xxiii) Samples of product water must be submitted for chemical analysis every six months and
 must demonstrate that the quality of the product water used to prepare dialysate or concentrates from
 powder, meets §4.2.2 (concerning Maximum Level of Chemical Contaminants) of the American
 National Standard, Water Treatment Equipment for Hemodialysis Applications, August 2001
 Edition, published by the AAMI.

      (I) Samples for chemical analysis shall be collected at the end of the water treatment
 components and at the most distal point in each water distribution loop, if applicable. All other
 outlets from the distribution loops shall be inspected to ensure that the outlets are fabricated from
 compatible materials. Appropriate containers and pH adjustments shall be used to ensure accurate
 determinations. New facilities or facilities that add or change the Cont'd ...

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                                   List of Titles   ]   ~~____B_a_c_kt_o_L_is_t__~

                    TEXAS REGISTER          TEXAS ADMINISTRATIVE CODE           OPEN MEETINGS

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 <>
                          Texas Administrative Code
             TITLE 25                   HEALTH SERVICES
             PART I                     DEPARTMENT OF STATE HEALTH SERVICES
             CHAPTER 133                HOSPITAL LICENSING
             SUBCHAPTER C               OPERATIONAL REQUIREMENTS
             RULE §133.41               Hospital Functions and Services

 configuration ofthe water distribution system must draw samples at the most distal point for each
 water distribution loop, if applicable, on a one time basis.

      (II) Additional chemical analysis shall be submitted if substaotial changes are made to the water
 treatment system or if the percent rejection of a reverse osmosis system decreased 5.0% or more
 from the percent rejection measured at the time the water sample for the preceding chemical analysis
 was taken.

     (xxiv) Facility records must include all test results and evidence that the medical director has
 reviewed the results of the water quality testing and directed corrective action when indicated.

    (xxv) Only persons qualified by the education or experience may operate, repair, or replace
 components of the water treatment system.

    (C) Dialysate.

    (i) Quality control procedures shall be established to ensure ongoing conformance to policies and
 procedures regarding dialysate quality.

    (ii) Each facility shall set all hemodialysis machines to use only one family of concentrates.
 When new machines are put into service or the concentrate family or concentrate manufacturer is
 chaoged, samples shall be sent to a laboratory for verification.

    (iii) Prior to each patient treatment, staff shall verify the dialysate conductivity aod pH of each
 machine with an independent device.

     (iv) Bacteriological testing shall be conducted.

      (I) Frequency. Responsible facility staff shall develop a schedule to ensure each hemodialysis
 machine is tested quarterly for bacterial growth aod the presence of endotoxins. Hemodialysis
 machines of home patients shall be cultured monthly until results not exceeding 200 CFU/ml are
 obtained for three consecutive months, then quarterly samples shall be cultured.

     (II) Acceptable limits. Dialysate shall contain less than 200 CFU/ml and an endotoxin
 concentration ofless than 2 EU/ml. The action level for total viable microbial count shall be 50
 CFU/ml and the action level for endotoxin concentration shall be 1 EU/ml.

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      (III) Action to be taken. Disinfection and retesting shall be done when bacterial or endotoxin
 counts exceed the action levels. Additional samples shall be collected when there is a clinical
 indication of a pyrogenic reaction and/or septicemia.

     (v) Only a licensed nurse may use an additive to increase concentrations of specific electrolytes
 in the acid concentrate. Mixing procedures shall be followed as specified by the additive
 manufacturer. When additives are prescribed for a specific patient, the container holding the
 prescribed acid concentrate shall be labeled with the name of the patient, the final concentration of
 the added electrolyte, the date the prescribed concentrate was made, and the name of the person who
 mixed the additive.

     (vi) All components used in concentrate preparation systems (including mixing and storage tanks,
 pumps, valves and piping) shall be fabricated from materials (e.g., plastics or appropriate stainless
 steel) that do not interact chemically or physically with the concentrate so as to affect its purity, or
 with the germicides used to disinfect the equipment. The use of materials that are known to cause
 toxicity in hemodialysis such as copper, brass, galvanized material and aluminum is prohibited.

     (vii) Facility policies shall address means to protect stored acid concentrates from tampering or
 from degeneration due to exposure to extreme heat or cold.

     (viii) Procedures to control the transfer of acid concentrates from the delivety container to the
 storage tank and prevent the inadvertent mixing of different concentrate formulations shall be
 developed, implemented and enforced. The storage tanks shall be clearly labeled.

    (ix) Concentrate mixing systems shall include a purified water source, a suitable drain, and a
 ground fault protected electrical outlet.

     (I) Operators of mixing systems shall use personal protective equipment as specified by the
 manufacturer during all mixing processes.

      (II) The manufacturer's instructions for use of a concentrate mixing system shall be followed,
 including instructions for mixing the powder with the correct amount of water. The number of bags
 or weight of powder added shall be determined and recorded.

      (III) The mixing tank shall be clearly labeled to indicate the fill and final volumes required to
 correctly dilute the powder.

     (IV) Systems for preparing either bicarbonate or acid concentrate from powder shall be
 monitored according to the manufacturer's instructions.

       (V) Concentrates shall not be used, or transferred to holding tanks or distribution systems, until
 all tests are completed.

      (VI) If a facility designs its own system for mixing concentrates, procedures shall be developed
 and validated using an independent laboratory to ensure proper mixing.

    (x) Acid concentrate mixing tanks shall be designed to allow the inside of the tank to be rinsed
 when changing concentrate formulas.

      (I) Acid mixing systems shall be designed and maintained to prevent rust and corrosion.

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      (II) Acid concentrate mixing tanks shall be emptied completely and rinsed with product water
 before mixing another batch of concentrate to prevent cross contamination between different batches.

     (III) Acid concentrate mixing equipment shall be disinfected as specified by the equipment
 manufacturer or in the case where no specifications are given, as defined by facility policy.

     (IV) Records of disinfection and rinsing of disinfectants to safe residual levels shall be
 maintained.

     (xi) Bicarbonate concentrate mixing tanks shall have conical or bowl shaped bottoms and shall
 drain from the lowest point of the base. The tank design shall allow all internal surfaces to be
 disinfected and rinsed.

      (I) Bicarbonate concentrate mixing tanks shall not be prefilled the night before use.

      (II) If disinfectant remains in the mixing tank overnight, this solution must be completely
 drained, the tank rinsed and tested for residual disinfectant prior to preparing the first batch of that
 day of bicarbonate concentrate.

      (III) Unused portions of bicarbonate concentrate shall not be mixed with fresh concentrate.

      (IV) At a minimum, bicarbonate distribution systems shall be disinfected weekly. More frequent
 disinfection shall be done if required by the manufacturer, or if dialysate culture results are above the
 action level.

      (V) If jugs are reused to deliver bicarbonate concentrate to individual hemodialysis machines:

       (-a-) jugs shall be emptied of concentrate, rinsed and inverted to drain at the end of each
 treatment day;

       (-b-) at a minimum, jugs shall be disinfected weekly, more frequent disinfection shall be
 considered by the medical director if dialysate culture results are above the action level; and

       (-c-) following disinfection, jugs shall be drained, rinsed free of residual disinfectant, and
 inverted to dry. Testing for residual disinfectant shall be done and documented.

    (xii) All mixing tanks, bulk storage tanks, dispensing tanks and containers for single
 hemodialysis treatments shall be labeled as to the contents.

      (I) Mixing tanks. Prior to batch preparation, a label shall be affixed to the mixing tank that
 includes the date of preparation and the chemical composition or formulation of the concentrate
 being prepared. This labeling shall remain on the mixing tank until the tank has been emptied.

     (II) Bulk storage/dispensing tanks. These tanks shall be permanently labeled to identifY the
 chemical composition or formulation of their contents.

       (III) Single machine containers. At a minimum, single machine containers shall be labeled with
 sufficient information to differentiate the contents from other concentrate formulations used in the
 facility and permit positive identification by users of container contents.

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    (xiii) Permanent records of batches produced shall be maintained to include the concentrate
 formula produced, the volume of the batch, lot number(s) of powdered concentrate packages, the
 manufacturer of the powdered concentrate, date and time of mixing, test results, person performing
 mixing, and expiration date (if applicable).

     (xiv) If dialysate concentrates are prepared in the facility, the manufacturers' recommendations
 shall be followed regarding any preventive maintenance. Records shall be maintained indicating the
 date, time, person performing the procedure, and the results (if applicable).

   (5) Prevention requirements concerning patients.

    (A) Hepatitis B vaccination.

     (i) With the advice and consent of a patient's attending nephrologist, facility staff shall make the
 hepatitis B vaccine available to a patient who is susceptible to hepatitis B, provided that the patient
 has coverage or is willing to pay for vaccination.

    (ii) The facility shall make available to patients literature describing the risks and benefits of the
 hepatitis B vaccination.

    (B) Serologic screening of patients.

     (i) A patient new to dialysis shall have been screened for hepatitis B surface antigen (HBsAg)
 within one month before or at the time of admission to the facility or have a !mown hepatitis B
 surface antibody (anti-HBs) status of at least 10 milli-international units per milliliter no more than
 12 months prior to admission. The facility shall document how this screening requirement is met.

     (ii) Repeated serologic screening shall be based on the antigen or antibody status of the patient.

      (I) Monthly screening for HBsAg is required for patients whose previous test results are
 negative for HBsAg.

      (II) Screening ofHBsAg-positive or anti-HBs-positive patients may be performed on a less
 frequent basis, provided that the facility's policy on this subject remains congruent with Appendices i
 and ii of the National Surveillance of Dialysis Associated Disease in the United States, 2000,
 published by the United States Department of Health and Human Services.

    (C) Isolation procedures for the HBsAg-positive patient.

     (i) The facility shall treat patients positive for HBsAg in a segregated treatment area which
 includes a hand washing sink, a work area, patient care supplies and equipment, and sufficient space
 to prevent cross-contamination to other patients.

    (ii) A patient who tests positive for HBsAg shall be dialyzed on equipment reserved and
 maintained for the HBsAg-positive patient's use only.

     (iii) When a caregiver is assigned to both HBsAg-negative and HBsAg-positive patients, the
 HBsAg-negative patients assigned to this grouping must be Hepatitis B antibody positive. Hepatitis
 B antibody positive patients are to be seated at the treatment stations nearest the isolation station and
 be assigned to the same staff member who is caring for the HBsAg-positive patient.

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     (iv) If an HBsAg-positive patient is discharged, the equipment which had been reserved for that
 patient shall be given intermediate level disinfection prior to use for a patient testing negative for
 HBsAg.

     (v) In the case of patients new to dialysis, if these patients are admitted for treatment before
 results ofHBsAg or anti-HBs testing are known, these patients shall undergo treatment as if the
 HBsAg test results were potentially positive, except that they shall not be treated in the HBsAg
 isolation room, area, or machine.

     (I) The facility shall treat potentially HBsAg-positive patients in a location in the treatment area
 which is outside of traffic patterns until the HBsAg test results are known.

       (II) The dialysis machine used by this patient shall be given intermediate level disinfection prior
 to its use by another patient.

     (III) The facility shall obtain HBsAg status results of the patient no later than three days from
 admission.

 (u) Respiratory care services. The hospital shall meet the needs of the patients in accordance with
 acceptable standards of practice.

  (1) Policies and procedures shall be adopted, implemented, and enforced which describe the
 provision of respiratory care services in the hospital.

  (2) The organization of the respiratory care services shall be appropriate to the scope and
 complexity of the services offered.

  (3) There shall be a medical director or clinical director of respiratmy care services who is a
 physician with the knowledge, experience, and capabilities to supervise and administer the services
 properly. The medical director or clinical director may serve on either a full-time or part-time basis.

   (4) There shall be adequate numbers of respiratory therapists, respiratmy therapy technicians, and
 other personnel who meet the qualifications specified by the medical staff, consistent with the state
 law.

  (5) Personnel qualified to perform specific procedures and the amount of supervision required for
 personnel to carry out specific procedures shall be designated in writing.

   (6) If blood gases or other clinical laboratory tests are performed by the respiratory care services
 staff, the respiratmy care staff shall comply with CLIA 1988 in accordance with the requirements
 specified in 42 CPR, Part 493.

 Cont'd ...

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                            1____   ~L~is~t~o~f~T~itl~e~s--~l   L I_ _ _ _   ~B~a~c~k~to~L~is~t--~

                   TEXAS REGISTER              TEXAS ADMINISTRATIVE CODE                        OPEN MEETINGS

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                            Texas Administrative Code
              TITLE 25                     HEALTH SERVICES
              PART!                        DEPARTMENT OF STATE HEALTH SERVICES
              CHAPTER 133                  HOSPITAL LICENSING
              SUBCHAPTER C                 OPERATIONAL REQUIREMENTS
              RULE §133.41                 Hospital Functions and Services

  (7) Services shall be provided only on, and in accordance with, the orders of a physician.

 (v) Sterilization and sterile supplies.

  (1) Supervision. The sterilization of all supplies and equipment shall be under the supervision of a
 person qualified by education, training and experience. Staff responsible for the sterilization of
 supplies and equipment shall participate in a documented continuing education program; new
 employees shall receive initial orientation and on-the-job training.

  (2) Equipment and procedures.

    (A) Sterilization. Every hospital shall provide equipment adequate for sterilization of supplies and
 equipment as needed. Equipment shall be maintained and operated to perfotm, with accuracy, the
 sterilization of the various materials required.

    (B) Written policy. Written policies and procedures for the decontamination and sterilization
 activities performed shall be adopted, implemented and enforced. Policies shall include the receiving,
 cleaning, decontaminating, disinfecting, preparing and sterilization of reusable items, as well as those
 for the assembly, wrapping, storage, distribution and quality control of sterile items and equipment.
 These written policies shall be reviewed at least every other year and approved by the infection
 control practitioner or committee.

    (C) Separation. Where cleaning, preparation, and sterilization functions are performed in the same
 room or unit, the physical facilities, equipment, and the policies and procedures for their use, shall be
 such as to effectively separate soiled or contaminated supplies and equipment from the clean or
 sterilized supplies and equipment. Hand washing facilities shall be provided and a separate sink shall
 be provided for safe disposal ofliquid waste.

    (D) Labeling. All containers for solutions, drugs, flammable solvents, ether, alcohol, and
 medicated supplies shall be clearly labeled to indicate contents. Those which are sterilized by the
 hospital shall be labeled so as to be identifiable both before and after sterilization. Sterilized items
 shall have a load control identification that indicates the sterilizer used, the cycle or load number, and
 the date of sterilization.

    (E) Preparation for sterilization.

     (i) All items to be sterilized shall be prepared to reduce the bioburden. All items shall be
 thoroughly cleaned, decontaminated and prepared in a clean, controlled environment.
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     (ii) All articles to be sterilized shall be arranged so all surfaces will be directly exposed to the
 sterilizing agent for the prescribed time and temperature.

    (F) Packaging. All wrapped articles to be sterilized shall be packaged in materials recommended
 for the specific type of sterilizer and material to be sterilized.

    (G) External chemical indicators.

    (i) External chemical indicators, also known as sterilization process indicators, shall be used on
 each package to be sterilized, including items being flash sterilized to indicate that items have been
 exposed to the sterilization process.

     (ii) The indicator results shall be interpreted according to manufacturer's written instructions and
 indicator reaction specifications.

     (iii) A log shall be maintained with the load identification, indicator results, and identification of
 the contents of the load.

   (H) Biological indicators. Biological indicators are commercially-available microorganisms (e.g.,
 United States Food and Drug Administration (FDA) approved strips or vials of Bacillus species
 endospores) which can be used to verify the performance of waste treatment equipment and
 processes (or sterilization equipment and processes).

    (i) The efficacy of the sterilizing process shall be monitored with reliable biological indicators
 appropriate for the type of sterilizer used.

     (ii) Biological indicators shall be included in at least one run each week of use for steam
 sterilizers, at least one run each day of use for low-temperature hydrogen peroxide gas sterilizers, and
 every load for ethylene oxide (EO) sterilizers.

     (iii) Biological indicators shall be included in eve1y load that contains implantable objects.

     (iv) A log shall be maintained with the load identification, biological indicator results, and
 identification of the contents of the load.

     (v) If a test is positive, the sterilizer shall immediately be talcen out of service.

      (!)Implantable items shall be recalled and reprocessed if a biological indicator test (spore test)
 is positive.

       (II) All available items shall be recalled and reprocessed if a sterilizer malfunction is found and
 a list of those items not retrieved in the recall shall be submitted to infection control.

      (III) A malfunctioning sterilizer shall not be put back into use until it has been serviced and
 successfully tested according to the manufacturer's recommendations.

   (!) Sterilizers.

     (i) Steam sterilizers (saturated steam under pressure) shall be utilized for sterilization of heat and
 moisture stable items. Steam sterilizers shall be used according to manufacturer's written
 instructions.
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    (ii) EO sterilizers shall be used for processing heat and moistme sensitive items. EO sterilizers
 and aerators shall be used and vented according to the manufacturer's written instructions.

    (iii) Flash sterilizers shall be used for emergency sterilization of clean, unwrapped instruments
 and porous items only.

    (J) Disinfection.

    (i) Written policies, approved by the infection control committee, shall be adopted, implemented
 and enforced for the use of chemical disinfectants.

     (ii) The manufacturer's written instructions for the use of disinfectants shall be followed.

    (iii) An expiration date, determined according to manufacturer's written recommendations, shall
 be marked on the container of disinfection solution cunently in use.

     (iv) Disinfectant solutions shall be kept covered and used in well-ventilated areas.

    (v) Chemical germicides that are registered with the United States Environmental Protection
 Agency as "sterilants" may be used either for sterilization or high-level disinfection.

     (vi) All staff personnel using chemical disinfectants shall have received training on their use.

    (K) Performance records.

     (i) Performance records for all sterilizers shall be maintained for each cycle. These records shall
 be retained and available for review for a minimum of five years.

    (ii) Each sterilizer shall be monitored continuously during operation for pressure, temperature,
 and time at desired temperature and pressure. A record shall be maintained and shall include:

      (I) the sterilizer identification;

      (II) sterilization date;

      (III) cycle number;

      (IV) contents of each load;

      (V) duration and temperature ofexposme phase (if not provided on sterilizer recording charts);

      (VI) identification of operator(s);

      (VII) results of biological tests and dates perfmmed;

      (VIII) time-temperature recording charts from each sterilizer;

      (IX) gas concentration and relative humidity (if applicable); and

      (X) any other test results.

    (L) Storage of sterilized items.
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    (i) Sterilized items shall be transpmied so as to maintain cleanliness and sterility and to prevent
 physical damage.

    (ii) Sterilized items shall be stored in well-ventilated, limited access areas with controlled
 temperature and humidity.

    (iii) The hospital shall adopt, implement and enforce a policy which describes the mechanism
 used to determine the shelf life of sterilized packages.

   (M) Preventive maintenance. Preventive maintenance of all sterilizers shall be performed
 according to individual adopted, implemented and enforced policy on a scheduled basis by qualified
 personnel, using the sterilizer manufacturer's service manual as a reference. A preventive
 maintenance record shall be maintained for each sterilizer. These records shall be retained at least
 two years and shall be available for review.

 (w) Surgical services. If a hospital provides surgical services, the services shall be well-organized
 and provided in accordance with acceptable standards of practice. If outpatient surgical services are
 offered, the services shall be consistent in quality with inpatient care in accordance with the
 complexity of services offered. A special hospital may not offer surgical services.

  (1) Organization and staffing. The organization ofthe surgical services shall be appropriate for the
 scope of the services offered.

    (A) The operating rooms shall be supervised by an experienced RN or physician.

   (B) Licensed vocational nmses (LVNs) and surgical technologists (operating room technicians)
 may serve as scrub nmses or technologists under the supervision of an RN.

    (C) Circulating duties in the operating room must be performed by qualified RNs. In accordance
 with approved medical staff polices and procedures, LVNs and surgical technologists may assist in
 circulatory duties under the direct supervision of a qualified RN circulator.

   (D) Surgical privileges shall be delineated for all physicians, podiatrists, and dentists performing
 surgery in accordance with the competencies of each. The surgical services shall maintain a roster
 specifYing the surgical privileges of each.

   (E) If the facility employs smgical technologists, the facility shall adopt, implement, and enforce
 policies and procedures to comply with Health and Safety Code, Chapter 259 (relating to Surgical
 Technologists at Health Care Facilities).

  (2) Delivery of service. Surgical services shall be consistent with needs and resources. Written
 policies governing surgical care which are designed to ensure the achievement and maintenance of
 high standards of medical practice and patient care shall be adopted, implemented and enforced.

   (A) There shall be a complete medical history and physical examination, as required under
 subsection (k)(3 )(F) of this section, in the medical record of every patient prior to smgery, except in
 emergencies. If this has been dictated, but not yet recorded in the patient's medical record, there shall
 be a statement to that effect and an admission note in the record by the individual who admitted the
 patient.

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    (B) A properly executed informed consent form for the operation shall be in the patient's medical
 record before surgery, except in emergencies.

    (C) The following equipment shall be available in the operating room suites:

     (i) communication system;

     (ii) cardiac monitor;

     (iii) resuscitator;

     (iv) defibrillator;

     (v) aspirator; and

     (vi) tracheotomy set.

    (D) There shall be adequate provisions for immediate postoperative care.

   (E) The operating room register shall be complete and up-to-date. The register shall contain, but
 not be limited to, the following:

     (i) patient's name and hospital identification number;

     (ii) date of operation;

     (iii) operation performed;

     (iv) operating surgeon and assistant( s);

     (v) type of anesthesia used and name of person administering it;

     (vi) time operation began and ended;

     (vii) time anesthesia began and ended;

     (viii) disposition of specimens;

     (ix) names of scrub and circulating personnel;

     (x) unusual occmrences; and

     (xi) disposition of the patient.

   (F) An operative report describing techniques, findings, and tissue removed or altered shall be
 written or dictated immediately following surgery and signed by the surgeon.

 (x) Therapy services. If the hospital provides physical therapy, occupational therapy, audiology, or
 speech pathology services, the services shall be organized and staffed to ensure the health and safety
 of patients.

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Texas Administrative Code                                                                      Page 6 of6

   (1) Organization and staffing. The organization of the services shall be appropriate to the scope of
 the services offered.

    (A) The director of the services shall have the necessary knowledge, experience, and capabilities
 to properly supervise and administer the services.

    (B) Physical therapy, occupational therapy, speech therapy, or audiology services, if provided,
 shall be provided by staff who meet the qualifications specified by the medical staff, consistent with
 state law.

  (2) Delivery of services. Services shall be furnished in accordance with a written plan of treatment.
 Services to be provided shall be consistent with applicable state laws and regulations, and in
 accordance with orders of the physician, podiatrist, dentist or other licensed practitioner who is
 authorized by the medical staffto order the services. Therapy orders shall be incorporated in the
 patient's medical record.

 Cont'd ...

                                   Next Page             Previous Page

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          Iiiii     TEXAS REGISTER        TEXAS ADMINISTRATIVE CODE               OPEN MEETINGS

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Texas Administrative Code                                                                       Page 1 of2

 <>
                           Texas Administrative Code
             TITLE 25                  HEALTH SERVICES
             PART!                     DEPARTMENT OF STATE HEALTH SERVICES
             CHAPTER 133               HOSPITAL LICENSING
             SUBCl:IAPTER C            OPERATIONAL REQUIREMENTS
             RULE §133.41              Hospital Functions and Services

 (y) Waste and waste disposal.

  (1) Special waste and liquid/sewage waste management.

    (A) The hospital shall comply with the requirements set forth by the depmtment in §§1.131 - 1.137
 of this title (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-
 Related Facilities) and the TCEQ requirements in 30 TAC §330.1207 (relating to Generators of
 Medical Waste).

    (B) All sewage and liquid wastes shall be disposed of in a municipal sewerage system or a septic
 tank system permitted by the TCEQ in accordance with 30 TAC Chapter 285 (relating to On-Site
 Sewage Facilities).

  (2) Waste receptacles.

    (A) Waste receptacles shall be conveniently available in all toilet rooms, patient areas, staff work
 areas, and waiting rooms. Receptacles shall be routinely emptied of their contents at a central
 location(s) into closed containers.

    (B) Waste receptacles shall be properly cleaned with soap and hot water, followed by treatment of
 inside surfaces of the receptacles with a germicidal agent.

   (C) All containers for other municipal solid waste shall be leak-resistant, have tight-fitting covers,
 and be rodent-proof.

   (D) Nonreusable containers shall be of suitable strength to minimize animal scavenging or rupture
 during collection operations.

 Source Note: The provisions of this §133.41 adopted to be effective June 21, 2007, 32 TexReg
 3587; amended to be effective December 9, 2010, 35 TexReg 10716; mnended to be effective
 November 11, 2012, 37 TexReg 8809; amended to be effective May 24,2013,38 TexReg 3001;
 amended to be effective September 14,2014, 39 TexReg 7140

                                                       Previous Page

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         IIIII     TEXAS REGISTER       TEXAS ADMINISTRATIVE CODE          OPEN MEETINGS

                                                                                                 67

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APPENDIX - ''9''
Texas Administrative Code

   <               •    ·.·.·.·.·.. . · .· ..•.·..•••... ·· •·••••··••·••••·•
                           access. and "1aintenanc,e:                                >              .··,· ·.•..•.·.··      ·..   ..                 .         .·.      •       <   • ·.      •.   •••      •       .         .   .• •.   '   •.-..     ' > ..·.•·.·•·   >,    '     ..•..••.·.
        4.A.7 Hand hygiene is performed before and after manipulating                                                   (' Yes                                                                                 (' Yes
            catheter.
                                                                                                                        (' No                                                                                  (' No

                                                                                                                        (' Unable to                                                                           ('Unable to
                                                                                                                             observe                                                                               observe

        4.A.8 Urine bag is kept below 1eve1 of bladder at au times.                                                     (' Yes                                                                                 (' Yes

                                                                                                                        (' No                                                                                  (' No

        4.A.9 Catheter tubing is unobstructed and free of kinking.                                                      (' Yes                                                                                 C       Yes

                                                                                                                        (' No                                                                              • ('No
                                                                                                                                                                                                           '

        4.A.10 Urine bag is emptied using aseptic technique, using a                                                    (' Yes                                                                             ! (:        Yes
            separate, clean collection container for each patient; drainage                                                                                                                                I
            spigot does not touch collecting container.                                                                 (' No                                                                                  CNo

                                                                                                                        (' Unable to                                                                           Cunableto
                                                                                                                            observe                                                                                     observe

                                                                                                                                                                                                                                                                                          29
4.A.11 Urine samples are obtained aseptically (via needleless port     (   Yes        ('Yes
    for small volume).                                                                             '

                                                                       (' No          (' No

                                                                       \Unable to     \Unable to
                                                                            observe      observe

                                                                                                   •

 If no to any of 4.A.7 through 4.A.ll, cite at to 42 CFR 482.42(a) (Tag A-0749)

4.A.12 Need for urinary catheters is reviewed and documented           ('Yes          ('Yes
    daily with prompt removal of urinary catheters no longer
     needed.                                                           \No            ('No

No citation risk 4.A.12; for information only.

                                                                                                       30
                                              ----------· -·---                                                     ~~~··-~~~~~~~~~~~~-

                                                                                              questions 4.8.2- 4.8.7 RIGHT column will be
                                                                                              blocked)

                                                                         (' No            \   No

                                                                          \Unable to      \Unable to
                                                                          observe             observe

to insertion (If contraindicated [e.g., neonatal populationL tincture
of iodine, an iodophor, or 70% alcohol can be used as alternatives).    I ("·   No        \ No

                                                                         C Unable to      ('Unable to
                                                                                observe       observe

        gauze
used to cover catheter site (may not apply for well-healed
tunneled catheters).                                                      ('.No           (' No

                                                                                                                                            31
                                               -~   ~"   __,__   ~   -'-                                          -~~'

4.B.61fthe femoral site is used for central venous catheter insertion for              (' Yes                                                ('Yes
adults, justification for this site is in the medical record.
                                                                                       (' No                                                 (' No

                                                                                       ('Unable to                                           (Unable to
                                                                                                    observe                                        observe

If no to any of4.6.2 to 4.6.6, cite at 42 CFR 482.42(a) (Tag A-0749)
4.8.7 Central venous line insertion and indication are documented.                     (' Yes                                                C Yes

                                                                                       C       No                                            C    No

                                                                                                                                                                                                                ''

If no to 4.6.7, cite at to 42 CFR 482.24(c)(2)(vi) (Tag A-0467)
Accessing/Maintenance                                                           .··            .·                 '       ·.
                                                                                                                                                                                     ··.··
   '

                   •
                                                                           ..
                                                                                                                               ••
                                                                                                                                    ·.·                  .   ·.    ·· ...   .·   .
                                                                                                                                                                                             •   •
                                                                                                                                                                                                     ·..

4.8.8 The hospital can provide evidence that only properly trained                     (       Yes
       personnel who demonstrate competence for access and
       maintenance of central intravascular catheters are given this                   (' No
       responsibility.

If unable to observe the access or maintenance of any central venous                   (       No observations available (If selected, ALL   ('Second observation not available (If selected,
       catheters, skip 4.8.9 through 4.8.13.                                                    questions from 4.8.9 -4.8.13 will be             questions 4.8.9- 4.8.13 RIGHT column will be
                                                                                                blocked)                                         blocked)
4.8.9 Hand hygiene is performed before and after manipulating                         1(   ·   Yes                                           .C   Yes
       catheter.
                                                                                       (' No                                                 (No

                                                                                       ('Unable to                                           C    Unable to
                                                                                                    observe                                        observe
                                                                                                                                                                                                                j
4.8.10 Dressings that are wet, soiled, or dislodged are changed                        (' Yes                                                ('Yes
     promptly.
                                                                                       ('No                                                  ('No

                                                                                       (' Unable to                                          ('Unable to
                                                                                                    observe                                        observe

                                                                                                                                                                                                           32
                ·~·--~~"'~-"""                                                       '"'."   "~       "'"'"""'""~-.--·~~~~~~~~~~~~~~~~~~~~~~~~~~-~

4.8.11 Dressing is changed with aseptic technique using clean or sterile   \   Yes                        \Yes
    gloves.
                                                                           \   No                         \No

                                                                           \Unable to                     \Unable to
                                                                              observe                         observe

4.8.12 Access port is scrubbed with an appropriate antiseptic              (   Yes                        ('Yes
     (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol)
    prior to accessing.                                                    \   No                         \   No
                                                                                                                        !

                                                                           \Unable to                     \Unable to
                                                                                observe                       observe

4.8.13 Catheter is accessed only with sterile devices.                     \Yes                           ('Yes

                                                                           \No                            \No

                                                                           \Unable to                     \unable to
                                                                                observe           -           observe

 If no to any of 4.8.8 to 4.8.13, cite at 42 CFR 482.42(a) (Tag A-0749}
4.8.14 Need for central venous catheters is reviewed .daily and            \Yes
    documented with prompt removal of lines when no longer
    needed.                                                                \   No

No citation risk; for information only.

                                                                                                                                        33
·-·~~~,,~~~~~"

       If no observations available, skip questions 4.C.1 through 4.C.8.   ("', No observations available (If selected, ALL   t  Second observation not available (If selected,
                                                                            questions from 4,C.l- 4.C.8 will be blocked)      questions 4.C.l- 4.C.8 RIGHT column will be
                                                                                                                              blocked)

           patient or any respiratory equipment used on patient.
                                                                           (   No                                             (   No

                                                                           (Unable to                                         (Unable to
                                                                              observe                                            observe

                   are worn when 1n contact With respiratory secretions
           and changed before contact with another patient, object, or
           environmental surface.                                          (   No                                             (No

                                                                           (Unable to                                         C Unable to
                                                                              observe                                             observe

           nebulization.
                                                                           C No                                               (No

                                                                           (Unable to                                         (Unable to
                                                                              observe                                            observe

           for more than one patient.
                                                                           (No                                                (   No

                                                                           (Unable to                                         (Unable to
                                                                              observe                                            observe

                                                                                                                                                                                  34
4.C.5 If mutti-dose vials for aerosolized medications are used,       ('Yes           1   ('Yes
     manufacturers' instructions for handling, storing, and
     dispensing the medications are followed.                         ('No                \   No

                                                                      \   N/A             tN/A

                                                                      C   Unable to       C   Unable to
                                                                           observe             observe

4.C.6 If mUlti-dose vials for aerosolized medications are used for    C   Yes             c   Yes
     more than one patient, they are stored appropriately and do
     not enter the immediate patient treatment area.                  C   No              C   No

                                                                      tN/A                tN/A

                                                                                                               i
 If no to anyof4.C.l to 4.C.6, cite at to 42 CFR 482.42(a) (Tag A-0749)
4.C.7 Jet nebulizers are for single patient use and are cleaned as        Yes                 Yes
    per hospital policy, rinsed with sterile water, and air-dried
                                                                      (
                                                                                      Ic
    between treatments on the same patient.                           C   No              C   No

Note: Mesh nebulizers, which remain in the ventilator circuit and
    are not cleaned or disinfected, are changed at an interval
    recommended by manufacturer's instructions. Nebulizer/drug
    combination systems are cleaned and disinfected according to
    manufacturer's instructions.

No citation risk; for information only.

4.C.8 Head of bed is elevated at an angle of 30--45 degrees, in the   C Yes               c   Yes
    absence of medical contraindication(s), for patients at high
    risk for aspiration (e.g., a person receiving mechanically        \No                 (' No
    assisted ventilaf1on and/or who has an enteral tube in place).
                                                                                                               i

 If no to 4.C.8, cite at 42 CFR 482.42(a) (Tag A-0749)

                                                                                                          35
     ,~~~~~~~~~~~~~~~~----~~~~~~~~~~~~~~~~~--~~~~~--~~~--~~~~~

Ventilators:        ·   ...·.   ,·                  ..
                                                                          ..•.... ,.·.·.·..····              ......        '      .                  .. ·. . '             '   .,..       '. ·.,                . ' cc:·,
                                             ..
                                                                      ·                                                                  '

     ,.    ·.·.      · .. ·..
                              ··'· ,.,·, .. . ' ·.·... ..·,,'     ' .· .··.. · · ......'     ..... ·,.   '            . ...,...
                                                                                                                           '       .· .       ·.·.··,  '   '.··  .......              .            '·•·.·, .... ·,•.
Ventilators are used in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease
including the following:
If no observations available, skip questions 4.C.9 through 4.C.13.                (' No observations available (If selected, ALL 0 Second observation not available (If selected,
                                                                                   questions from 4.C.9 -4.C.15 will be blocked) questions 4.C.9- 4.C.15 RIGHT column will be
                                                                                                                                 blocked)
4.C.9 Ventilator circuit (i.e., ventilator tubing and exhalation valve            (' Yes                                         (' Yes
      and the attached humidifier) is changed if visibly soiled or
      mechanically malfunctioning.                                                 \No                                           ('No

                                                                                       l      Unable to                                          ('Unable to
                                                                                                  observe                                            observe

4.C.10 Steri e water is used to fill humidifiers.                                      c          Yes                                            (       Yes

                                                                                      (' No                                                      ('No

4.C.11 Condensate that collects in the tubing of a mechanical                         (' Yes                                                 .   (       Yes
ventilator is periodically drained and discarded, taking precautions
not to allow condensate to drain toward the patient.                                  (' No                                                      ('No

                                                                                      (' Unable to                                               ('Unable to
                                                                                                   observe                                                 observe

4.C.12 If single-use open-system suction catheter is employed, a                       (          Yes                                            ('Yes
     sterile, single-use catheter is used.
                                                                                      (' No                                                      C No

                                                                                      (' N/A                                                     CN/A

4.C.13 Only sterile fluid is used to remove secretions from the                        (' Yes                                                    r       Yes
     suction catheter if the catheter is used for re-entry into the                                                                                                                                                         I
                                                                                                                                                                                                                            I
     patient's lower respiratory tract.                                                (' No                                                     ('No

                                                                                       ('Unable to                                               tUnable to
                                                                                                   observe                                                 observe

 If no to any of 4.C.9 to 4.C.13, cite at 42 CFR 482.42(a) (Tag A-0749)
                                                                                                                                  ----

                                                                                                                                                                                                                       36
----~-~~~~

      4.C.14 Hospital has a program for sedation to be lightened daily in   ('Yes   ('Yes              I
          eligible patients.
                                                                            \No     ('No

      4.C.15 Assessment of readiness to wean (e.g., spontaneous             ('Yes   ('Yes              I
           breathing trials) are performed daily in eligible patients.
                                                                            ('No    ('No
                                                                                                       I
                                                                                                       I

                                                                                                       i

      No citation risk for 4.C.14 and 4.C.15; for information only.
                                                                                       -----------------

                                                                                                           37
                                                        ··----·--.. ----·           ==""        ""'""""

                                                                            (' No

   a catheter or injecting materials into the epidural or subdural
   space.                                                                   (' No

If no to any of4.0.1 to 4.0.3, cite at 42 CFR 482.42(a) (Tag A-0749)

                                                                                           38
                                       """""""--··~···~-~-~---~

Note: This includes both the lancet and the lancet holding device.       ('No         (No

                                                                         (Unable to   (Unable to
                                                                            observe      observe

    device (e.g., blood glucose meter, INR monitor) is cleaned and
    disinfected after every use according to manufacturer's              (' No        (' No
    instructions.
                                                                         tN/A         (' N/A
Note: if manufacturer does not provide instructions for cleaning and
disinfection, then the device should not be used for >1 patient.
 If no to any of 4.E.l to 4.E.4, cite at 42 CFR 482.42(a) (Tag A-0749)

                                                                                                   39
                                              ·.~~-=                                 -~   _, ..   ~

elements in multiple patient care areas in the hospital.                     questions from 4.F.l- 4.F.12 will be blocked)   questions 4.F.l- 4.F.12 RIGHT column will be
                                                                                                                             blocked)
If unable to observe a patient on Contact Precautions skip elements
4.F.l to 4.F.12.

                                                                                                                             ('No

                                                                                                                             ('No

                                                                                                                             (' No

                                                                                                                             C   No

    environment.
                                                                           (' No                                             C   No
Note: Soap and water must be used when bare hands are visibly
    soiled (e.g., blood, body fluids) or after caring for a patient with
    known or suspected C. difficife or norovirus during an outbreak.
    In all other situations, alcohol-based hand rub is preferred.

                                                                                                                                                                            40
4.F.6 Gloves and gowns are donned upon entry into the room or             (' Yes                          (' Yes
    cubicle.    '
                                                                          C   No                          (' No

4.F.7 Gloves and gowns are removed and discarded, and hand                (   Yes                         (' Yes
    hygiene is performed before leaving the patient care
    environment.                                                          C   No                          ('No

4.F.8 Dedicated or disposable noncritical patient-care equipment          (' Yes                          (   Yes
    (e.g., blood pressure cuffs) is used, or if not available, then
    equipment is cleaned and disinfected prior to use on another          C   No                          ('No

    patient according to manufacturers' instructions.

4.F.9 The hospital limits the movement of patients on Contact             (   Yes                         {   Yes
    Precautions outside of their room to medically necessary
    purposes only.                                                        (' No                           C   No

                                                                          C   Unable to                   ('Unable to
                                                                               observe                        observe

4.F.10 If a patient on Contact Precautions must leave their room for      {   Yes                         (' Yes
    medically necessary purposes, there are methods followed to
    communicate that patient's status and to prevent transmission         C   No                          (' No
    of infectious disease.
                                                                          C   Unable to                   C Unable to
                                                                               observe                         observe

4.F.11 Objects and environmental surtaces in patient care areas that      (' Yes                          {   Yes
    are touched frequently (e.g., bed rails, overbed table, bedside
    commode, lavatory surfaces in patient bathrooms) are cleaned          C   No                          (' No

    and disinfected with an EPA-registered disinfectant frequently
                                                                          C   Unable to                   Cunableto
    (at least daily) and when visibly soiled.                                                                observe
                                                                               observe

4.F.l2 After patient discharge, all visibly or potentially contaminated   (' Yes                          (   Yes
    surfaces are thoroughly cleaned and disinfected and all textiles
    (e.g. linens and towels) are replaced with clean textiles.            C   No                          C   No

                                                                          ('Unable to                     ('Unable to
                                                                              observe                         observe

 If no to any of 4.F.l to 4.F.12, cite at 42 CFR 482.42(a) (Tag A-0749)
                                                                                    -------------------

                                                                                                                         41
                                                                         questions from 4.G.2- 4.G.9 will be blocked)   questions 4.G.2- 4.G.9 RIGHT column will be
                                                                                                                        blocked)
If unable to observe a patient on Droplet Precautions, skip elements
4.G.2 to 4.G.9.
                                                        use.

    environment or private room.
                                                                       (' No                                            C   No

                                                                                                                                                                      42
----------~---~"~--~~·-·                                   -·~---~--·--·-~-----~-~-~--·--~---------------""C"-------------------------------

          4.G.7 Facemask is removed and discarded and hand hygiene is              (   Yes             (' Yes
              performed upon leaving the patient care environment.
                                                                                   ('No                (' No

          4.G.8 The hospital limits movement of patients on Droplet                (   Yes             ('Yes
              Precautions outside of their rooms to medically necessary
              purposes only.                                                       (' No               (' No

                                                                                   Cunableto           ('Unable to
                                                                                      observe               observe

          4.G.9 If a patient on Droplet Precautions must leave their room for      (   Yes             (   Yes
               medically necessary purposes, there are methods followed to
              communicate that patient's status and to prevent transmission        (' No               (' No
              of infectious disease, including the use of a facemask by the
              patient if possible.                                                 ('Unable to         ('Unable to
                                                                                       observe             observe
          Note: The hospital may have specific policies regarding the use of
              PPE for pediatric patients.

           If no to any of 4.G.l to 4.G.9, cite at 42 CFR 482.42(a) [rag A·0749)

                                                                                                                                  43
                                                                                                ----

transmitted person-to-person by the airborne route (e.g.J TB,
measles, chickenpox, disseminated herpes zoster) are placed on           C   No
Airborne Isolation Precautions.

Precautions elements in multiple patient care areas in the hospital.

If unable to observe a patient on Airborne Isolation Precautions, skip
elements 4.H.2 to 4.H.8.

    available and located near point of use.
                                                                         C   No   ('No

    are dear and visible.
                                                                         (No      C   No

                  wear a
    or higher) when entering the airborne infection isolation room
    (AIIR) for patients with confirmed or suspected TB. Hospital         ('No     ('No
    policies are followed for other pathogens requiring AIIR.

                                                                                           44
·--------------~·~                                 --~-~·-·----~-~·----                    --------

         4.H.S Hand hygiene is performed before contact with the patient.          (    Yes               (   Yes

                                                                                   (' No                  (' No

         4.H.6 Patients on Airborne Precautions are housed in AIIR that meet       J    Yes               (.Yes
             all of the following specifications:
         .   At least 6 (existing facility) or 12 (new construction/renovation)    (' No                  (' No
             air changes per hour or per state licensure rules;
         .   Direct exhaust of air to outside. If not possible, all air returned
             to air handling system or adjacent spaces is directed through
             HEPA filters;
         .   When AIIR is in use for a patient on Airborne Precautions, air
             pressure is monitored daily with visual indicators (e.g., smoke
             tubes.. flutter strips), regardless of the presence of differential
             pressure sensing devices (e.g., manometers);
         .   AIIR door kept dosed when not required for entry and exit

         Note: If AIIR is not available, hospital policy should address patient
             transfer to a hospital that has an available AIIR.

         4.H.7 The hospital limits movement of patients on Airborne                c·   Yes           I   c   Yes
                                                                                                                         I
                                                                                                                         •

             Precautions outside of their room to medically-necessary                                                    i
             purposes.                                                             ('No                   (' No          I
                                                                                                                         i
                                                                                   (' Unable to           C Unable to    i
                                                                                                                         !
                                                                                       observe                 observe

         4.H.8 If a patient on Airborne Precautions must leave their room for      (    Yes               (' Yes
             medically necessary purposes, there are methods followed to
             communicate that patient's status and to prevent transmission         C No                   (' No
             of infectious disease, including the use of a facemask by the
             patient if possible.                                                  (' Unable to           Cunableto
                                                                                       observe               observe
         Note: The hospital may have specific policies regarding the use of
             PPE for pediatric patients.

          If no to any of 4.H.l to 4.H.8, cite at 42 CFR 482.42(a) (Tag A-0749)

                                                                                                                             45
                                     -- --    --·-~   ---·-~----                        --- -   -

    sterile gloves for surgical procedures {in OR) using either an
    antimicrobial surgical scrub agent or an FDA-approved alcohol-      C   No                      (' No
    based antiseptic surgical hand rub.
                                                                        C Unable to                 Cunableto
Note: If visibly soiled, hands and forearms should be prewashed with         observe                   observe
    soap and water before using an alcohol-based antiseptic surgical
    hand rub.
                                       arms are
    towel (if applicable), and sterile surgical gown and gloves are
    donned in the OR.                                                   C No                        C   No

                                                                        C   Unable to               C Unable to
                                                                             observe                    observe

    head and facial hair are worn by all personnel and visitors in
    semi restricted and restricted areas.                               C No                        C No
Note: Restricted area includes DRs, procedure rooms, and the clean
    core (sterile supply) area. The semi restricted area includes the
    peripheral support areas of the surgical suite.

    personnel in restricted areas where open sterile supplies or
    scrubbed personnel are located.                                     C No                        C No

                                                                                                                  46
                                             -- - -         -------

4.1.5 A rresn, clean surgical masK is worn ror every proceoure.           (       Yes           (' Yes

                                                                              (' No             (' No

                                                                              ('Unable to       ('Unable to
                                                                                  observe           observe

4.1.6 Sterile drapes are used to establish sterile field.                     ('Yes             (   Yes

                                                                              (' No             (' No

                                                                              ('Unable to       (Unable to
                                                                                  observe          observe

4.1.7 Sterile field is maintained and monitored constantly. Ensure            (' Yes        1   (   Yes
     that:
• Items used within sterile field are sterile .                               (No               (' No

•    Items introduced into sterile field are opened, dispensed, and
                                                                                                (' Unable to
                                                                              ('Unable to
    transferred in a manner to maintain sterility.
                                                                                  observe           observe
•   Sterile field is prepared in the location where it will be used and
    as close as possible to time of use.
•   Movement in or around sterile field is done in a manner to
    maintain sterility.

4.1.8 Traffic in and out of OR is kept to minimum and limited to              (   Yes           (' Yes
     essential personnel.
             .                                                                C   No            C   No

                                                                                                               •

 If no to any of 4.1.1 to 4.1.8, cite at 42 CFR 482.42(a) (Tag A-0749)

                                                                                                                   47
Processes ensuring infection control in the OR are accomplished in a manner consistent with hospital infection control policies and procedures to maximize the prevention of
infection and communicable disease including the following:

If the hospital does not provide any surgical services, skip 4.1.9         (   No surgical services (If selectedJ questions 4.1.9   4.1.17 will be blocked)
     through 4.1.17.
4.1.9 Cleaners and EPA-registered hospital disinfectants are used and      ('Yes
     dated in accordance with hospital policies and procedures and
     manufacturer's instructions (e.g., dilution, storage, shelf-life,     (' No
     contact time).
                                                                           ('Unable to
Note: The cleaners and disinfectants can be dated by the hospital              observe
    with either the date opened or the discard date as per hospital
    policy, as long as it is clear what the date represents and the
    same policy is used consistently throughout the hospital.

4.1.10 All horizontal surfaces (e.g., furniture, surgical lights, booms,   ('Yes
     equipment) are damp dusted before the first procedure of the
     day using a dean, lint-free cloth and EPA-registered hospital         l   No
     detergent/disinfectant.
                                                                           l   Unable to
                                                                                observe

4.1.11 High touch environmental surfaces are Cleaned and                   (   Yes
     disinfected between patients.
                                                                           (' No

                                                                           ('Unable to
                                                                               observe

4.1.12 ORs are terminally cteaned alter last proceoure or tne oay          ('Yes
     {including weekends) and each 24-hour period during regular
     work week. Terminal cleaning includes wet-vacuuming or                (' No
     mopping floor with an EPA-registered disinfectant.
                                                                           tUnable to
                                                                              observe

                                                                                                                                                                           48
                                                          ---------------------------------------------------------

4.1.13 Anesthesia equipment surfaces that are touched by personnel         ('Yes
     while providing patient care or while handling contaminated
     items are cleaned and low-level disinfected between use on            (' No
    patients, according to manufacturers' instructions.
                                                                           ('Unable to
                                                                               observe

4.1.14 Exterior surfaces of anesthesia equipment that are not              l:   Yes
     knowingly contaminated during patient care are terminally low-
    level disinfected at the end of the day, according to                  (' No
    manufacturers' instructions.
                                                                           ('Unable to
                                                                               observe

4.1.15 Internal components of the anesthesia machine breathing             (    Yes
     circuit are cleaned per hospital policy or manufacturer's
    instructions.                                                          ('No

                                                                           [Unable to
                                                                                 observe

4.1.16 Reusable noncritical items (e.g., blood pressure cuffs, ECG         (' Yes
     leads, tourniquets, oximeter probes) are cleaned and disinfected
     between patients.                                                     C    No

                                                                           ('Unable to
                                                                               observe

4.1.17 Ventilation requirements meet the tollowmg:                         ('Yes
•   Positive pressure, ~15 air exchanges per hour (at least 3 of which
    are fresh air)                                                         (' No

•   90% filtration (HEPA is optional), air filters checked regularly and
    replaced according to hospital policies and procedures
•   Temperature and relative humidity levels are maintained at
    required levels
•   Doors are self-closing

•    Air vents and grill work are clean and dry .

If no to any of 4.1.9 to 4.1.17, cite at 42 CFR 482.42(a) (Tag A-0749)

                                                                                                                      49
APPENDIX- ''13''
Guideline lor Disinfection and StmiliznHon in Healtrtcaro Facilities, 2008

Guideline for Disinfection and Sterilization
in Healthcare Facilities, 2008

William A Rutala, Ph.D., M.P.HY, David J. Weber, M.D., M.P.H. 1 •2, and the Healthcare

                  Infection Control Practices Advisory Committee (HICPAC) 3

1
 Hospital Epidemiology
University of North Carolina Health Care System
Chapel Hill, NC 27514
2
 Division of Infectious Diseases
University of North Carolina School of Medicine
Chapel Hill, NC 27599-7030
C?uidelinc for Dtsintection and Sterilization in Hoolthcnro Faci!\ties, 2008

3HICPAC Members

Robert A Weinstein, MD (Chair)
Cook County Hospital
Chicago, JL

Jane D. Siegel, MD (Co-Chair)
University ofTexas Southwestern Medical Center
Dallas, TX

Michele L. Pearson, MD
(Executive Secretary)
Centers for Disease Control and Prevention
Atlanta, GA

Raymond Y.W. Chinn, MD
Sharp Memorial Hospital
San Diego, CA

Alfred DeMaria, Jr, MD
Massachusetts Department of Public Health
Jamaica Plain, MA

James T. Lee, MD, PhD
University of Minnesota
Minneapolis, MN

William A Rutala, PhD, MPH
University of North Carolina Health Care System
Chapel Hill, NC

William E. Scheckler, MD
University of Wisconsin
Madison, WI

Beth H. Stover, RN
Kosair Children's Hospital
Louisville, KY

Marjorie A Underwood, RN, BSN CIC
Mt. Diablo Medical Center
Concord, CA

This guideline discusses use of products by healthcare personnel in healthcare settings such as
hospitals, ambulatory care and home care; the recommendations are not intended for consumer use of
the products discussed.

                                                                                                     2
Guideline ·for Dis!nfc~ction and Stori!izstion in He8!thcnce Ft;\d!:ties, 2008

                           Disinfection and Sterilization in Healthcare Facilities

Executive Summary
Introduction
Methods
Definition ofTerms
Approach to Disinfection and Sterllization
         Critical Items
         Semi critical Items
         Noncritical Items
         Changes in Disinfection and Sterilization Since 1981
Disinfection of Healthcare Equipment
         Concerns with Implementing the Spaulding Scheme
         Reprocessing of Endoscopes
         Laparoscopes and Arthroscopes
         Tonometers, Cervical Diaphragm Fitting Rings, Cryosurgical Instruments, Endocavitary Probes
         Dental Instruments
         Disinfection of HBV, HCV, HIV or Tuberculosis-Contaminated Devices
         Disinfection in the Hemodialysis Unit
         Inactivation of Clostridium difficile
         OSHA Bloodborne Pathogen Standard
         Emerging Pathogens (Cryptosporidium, Helicobacter pylori, E. coli 0157:H7, Rotavirus, Human
         Papilloma Virus, Norovirus, Severe Acute Respiratory Syndrome Coronavirus)
         Inactivation of Bioterrorist Agents
         Toxicological, Environmental, and Occupational Concerns
         Disinfection in Ambulatory Care, Home Care, and the Home
         Susceptibility of Antibiotic-Resistant Bacteria to Disinfectants
         Surface Disinfection: Should We Do It?
         Contact Time for Surface Disinfectants
         Air Disinfection
         Microbial Contamination of Disinfectants
Factors Affecting the Efficacy of Disinfection and Sterilization
         Number and Location of Microorganisms
         Innate Resistance of Microorganisms
         Concentration and Potency of Disinfectants
         Physical and Chemical Factors
         Organic and Inorganic Matter
         Duration of Exposure
         Biofilms
Cleaning
Disinfection
         Chemical Disinfectants
                   Alcohol
                           Overview
                           Mode of Action
                           Microbicidal Activity
                           Uses
                   Chlorine and Chlorine Compounds
                           Overview
                           Mode of Action
                           Microbicidal Activity

                                                                                                       3
Guido!ine for Disinfection and S!nH!ization in Hea!th~are rm~i!itios, 2008

                         Uses
                Formaldehyde
                         Overview
                         Mode of Action
                         Microbicidal Activity
                         Uses
                Glutaraldehyde
                         Overview
                         Mode of Action
                         Microbicidal Activity
                         Uses
                Hydrogen Peroxide
                         Overview
                         Mode of Action
                         Microbicidal Activity
                         Uses
                lodophors
                         Overview
                         Mode of Action
                         Microbicidal Activity
                         Uses
                Ortho-phthalaldehyde
                         Overview
                         Mode of Action
                         Microbicidal Activity
                         Uses
                Peracetic Acid
                         Overview
                         Mode of Action
                         Microbicidal Activity
                         Uses
                Peracetic Acid and Hydrogen Peroxide
                         Overview
                         Mode of Action
                         Microbicidal Activity
                         Uses
                Phenolics
                         Overview
                         Mode of Action
                         Microbicidal Activity
                         Uses
                Quaternary Ammonium Compounds
                         Overview
                         Mode of Action
                         Microbicidal Activity
                         Uses
        Miscellaneous Inactivating Agents
                Other Germicides
                Ultraviolet Radiation
                Pasteurization
                Flushing- and Washer-Disinfectors
        Regulatory Framework for Disinfectants and Sterilants
        Neutralization of Germicides

                                                                             4
CJuidc:!ine for Disinfection and SteHiizahon ln Hocllthccwe F acilitios, 2008

Sterilization
         Steam Sterilization
                   Overview
                   Mode of Action
                   Microbicidal Activity
                   Uses
         Flash Sterilization
                   Overview
                   Uses
         Low-Temperature Sterilization Technologies
         Ethylene Oxide "Gas" Sterilization
                   Overview
                   Mode of Action
                   Microbicidal Activity
                   Uses
         Hydrogen Peroxide Gas Plasma
                   Overview
                   Mode of Action
                   Microbicidal Activity
                   Uses
         Peracetic Acid Sterilization
                   Overview
                   Mode of Action
                   Microbicidal Activity
                   Uses
         Microbicidal Activity of Low-Temperature Sterilization Technology
         Bioburden of Surgical Devices
         Effect of Cleaning on Sterilization Efficacy
         other Sterilization Methods
                   Ionizing Radiation
                   Dry-Heat Sterilizers
                   Liquid Chemicals
                   Performic Acid
                   Filtration
                   Microwave
                   Glass Bead "Sterilizer"
                   Vaporized Hydrogen Peroxide
                   Ozone
                   Formaldehyde Steam
                   Gaseous Chlorine Dioxide
                   Vaporized Peracetic Acid
                   Infrared radiation
         Sterilizing Practices
                   Overview
                   Sterilization Cycle Validation
                   Physical Facilities
                   Cleaning
                   Packaging
                   Loading
                   Storage
                   Monitoring (Mechanical, Chemical, Biological Indicators)
Reuse of Single-Use Medical Devices
Conclusion

                                                                                5
Cuidclino for Disinfrc1Ction cnd Sterilization in Hc2% glutaraldehyde at 25'C
range from 20-90 minutes, depending upon the product based on three tier testing which includes AOAC
sporicidal tests, simulated use testing with mycobacterial and in-use testing. The studies supporting the
efficacy of >2% glutaraldehyde for 20 minutes at 20'C assume adequate cleaning prior to disinfection,
whereas the FDA-cleared label claim incorporates an added margin of safety to accommodate possible
lapses in cleaning practices. Facilities that have chosen to apply the 20 minute duration at 20'C have
done so based on the lA recommendation in the July 2003 SHEA position paper, "Multi-society Guideline
                                                                     57 83 94 106 111 116 121
for Reprocessing Flexible Gastrointestinal Endoscopes" 19 • • • • • • ' •

                                                                                                                   14
Guideline for   Di~;infcct.ion   and SterHi.%ntion in Heu!tltcarn r·nd!ititSs, 2008

                                                                           122
         Flexible endoscopes are particularly difficult to disinfect  and easy to damage because of their
                                          123
intricate design and delicate materials.      Meticulous cleaning must precede any sterilization or high-
level disinfection of these instruments. Failure to perform good cleaning can result in sterilization or
disinfection failure, and outbreaks of infection can occur. Several studies have demonstrated the
                                                                                       106 124       125
importance of cleaning in experimental studies with the duck hepatitis B virus (HBV)      ·    , HIV     and
                      126
He/icobacter pylori.

          An examination of health-care-associated infections related only to endoscopes through July
1992 found 281 infections transmitted by gastrointestinal endoscopy and 96 transmitted by
bronchoscopy. The clinical spectrum ranged from asymptomatic colonization to death. Salmonella
species and Pseudomonas aeruginosa repeatedly were identified as causative agents of infections
transmitted by gastrointestinal endoscopy, and M. tuberculosis, atypical mycobacteria, and P. aeruginosa
                                                                                12
were the most common causes of infections transmitted by bronchoscopy • Major reasons for
transmission were inadequate cleaning, improper selection of a disinfecting agent, and failure to follow
                                                            8
recommended cleaning and disinfection procedures'· ' 37 • 98 , and flaws in endoscope design 127 • 128 or
                                        7 98
automated endoscope reprocessors. '           Failure to follow established guidelines has continued to result
in infections associated with gastrointestinal endoscopes 8 and bronchoscopes 7• 12 • Potential device-
associated problems should be reported to the FDA Center for Devices and Radiologic Health. One
multi state investigation found that 23.9% of the bacterial cultures from the internal channels of 71
gastrointestinal endoscopes grew <:1 00,000 colonies of bacteria after completion of all disinfection and
sterilization procedures (nine of 25 facilities were using a product that has been removed from the
marketplace [six facilities using 1:16 glutaraldehyde phenate], is not FDA-cleared as a high-level
disinfectant [an iodophor] or no disinfecting agent) and before use on the next patient"'. The incidence
of postendoscopic procedure infections from an improperly processed endoscope has not been
rigorously assessed.

         Automated endoscope reprocessors (AER) offer several advanta~es over manual reprocessing:
they automate and standardize several important reprocessing steps 130' 13 , reduce the likelihood that an
essential reprocessing step will be skipped, and reduce personnel exposure to hi~h-level disinfectants or
                                                                                                        134
chemical sterilants. Failure of AERs has been linked to outbreaks of infections 13 or colonization 7• ,
and the AER water filtration system might not be able to reliably provide "sterile" or bacteria-free rinse
      135 136
water ' • Establishment of correct connectors between the AER and the device is critical to ensure
                                                   137
complete flow of disinfectants and rinse water 7• • In addition, some endoscopes such as the
duodenoscopes (e.g., endoscopic retrograde cholangiopancreatography [ERCP]) contain features (e.g.,
elevator-wire channel) that require a flushing pressure that is not achieved by most AERs and must be
reprocessed manually using a 2- to 5-ml syringe, until new duodenoscopes equipped with a wider
elevator-channel that AERs can reliably reprocess become available 132 . Outbreaks involving removable
                      139
endoscope parts 138 •     such as suction valves and endoscopic accessories designed to be inserted
through flexible endoscopes such as biopsy forceps emphasize the importance of cleaning to remove all
                                                                140
foreign matter before high-level disinfection or sterilization.     Some types of valves are now available as
single-use, disposable products (e.g., bronchoscope valves) or steam sterilizable products (e.g.,
gastrointestinal endoscope valves).
                                                                7                     123 142
         AERs need further development and redesign • 141 , as do endoscopes ' , so that they do not
represent a potential source of infectious agents. Endoscopes employing disposable components (e.g.,
protective barrier devices or sheaths) might provide an alternative to conventional liquid chemical high-
                                143 144
level disinfection/sterilization ' . Another new technology is a swallowable camera-in-a-capsule that
travels through the digestive tract and transmits color pictures of the small intestine to a receiver worn
outside the body. This capsule currently does not replace colonoscopies.

          Published recommendations for cleaning and disinfecting endoscopic equipment should be
                      38 108 113 14 148
strictly followed 12 • • • ' 116• '- • Unfortunately, audits have shown that personnel do not consistently
                                        149 151                                              152
adhere to guidelines on reprocessing '          and outbreaks of infection continue to occur. ' 154 To ensure

                                                                                                            15
Guideline for D:sinfection and Sturilization in Hon!thcme Facilit:os, 2008

reprocessing personnel are properly trained, each person who reprocesses endoscopic instruments
should receive initial and annual competency testing 38 • 155 •

        In general, endoscope disinfection or sterilization with a liquid chemical sterilant involves five
steps after leak testing:

    1.   Clean: mechanically clean internal and external surfaces, including brushing internal channels
         and flushing each internal channel with water and a detergent or enzymatic cleaners (leak testing
         is recommended for endoscopes before immersion).
    2.   Disinfect: immerse endoscope in high-level disinfectant (or chemical sterilant) and perfuse
         (eliminates air pockets and ensures contact of the germicide with the internal channels)
         disinfectant into all accessible channels, such as the suction/biopsy channel and air/water
         channel and expose for a time recommended for specific products.
    3.   Rinse: rinse the endoscope and all channels with sterile water, filtered water (commonly used
         with AERs) or tap water (i.e., high-quality potable water that meets federal clean water standards
         at the point of use).
    4.   Dry: rinse the insertion tube and inner channels with alcohol, and dry with forced air after
         disinfection and before storage.

Store: store the endoscope in a way that prevents recontamination and promotes drying (e.g., hung
vertically). Drying the endoscope (steps 3 and 4) is essential to greatly reduce the chance of
                                                                                                        116 156
recontamination of the endoscope by microorganisms that can be present in the rinse water " • One
study demonstrated that reprocessed endoscopes (i.e., air/water channel, suction/biopsy channel)
generally were negative (100% after 24 hours; 90% after 7 days [1 CFU of coagulase-negative
Staphylococcus in one channel]) for bacterial growth when stored by hanging vertically in a ventilated
         157
cabinet . Other investigators found all endoscopes were bacteria-free immediately after high-level
disinfection, and only four of 135 scopes were positive during the subsequent 5-day assessment (skin
bacteria cultured from endoscope surfaces). All ftush-through samples remained sterile 158 • Because
                                                            159
tapwater can contain low levels of microorganisms , some researchers have suggested that only sterile
                                                  160
water (which can be prohibitively expensive)           or AER filtered water be used. The suggestion to use
only sterile water or filtered water is not consistent with published guidelines that allow tapwater with an
                                      38 108 113                                   93
alcohol rinse and forced air-drying " •          or the scientific literature. 39• In addition, no evidence of
disease transmission has been found when a tap water rinse is followed by an alcohol rinse and forced-
air drying. AERs produce filtered water by passage through a bacterial filter (e.g., 0.2 f.l). Filtered rinse
water was identified as a source of bacterial contamination in a study that cultured the accessory and
suction channels of endoscopes and the internal chambers of AERs during 1996-2001 and reported
8.7% of samples collected during 1996-1998 had bacterial growth, with 54% being Pseudomonas
species. After a system of hot water flushing of the piping (6o'c for 60 minutes daily) was introduced, the
                                                                                                          161
frequency of positive cultures fell to approximately 2% with only rare isolation of >1 0 CFU/ml               • In
addition to the endoscope reprocessing steps, a protocol should be developed that ensures the user
knows whether an endoscope has been appropriately cleaned and disinfected (e.g., using a room or
cabinet for processed endoscopes only) or has not been reprocessed. When users leave endoscopes on
movable carts, confusion can result about whether the endoscope has been processed. Although one
guideline recommended endoscopes (e.g., duodenoscopes) be reprocessed immediately before use 147 ,
other guidelines do not require this activity 38 " 108 • 115 and except for the Association of periOperative
Registered Nurses (AORN), professional organizations do not recommended that reprocessing be
repeated as long as the original processing is done correctly. As part of a quality assurance program,
healthcare facility personnel can consider random bacterial surveillance cultures of processed
endoscopes to ensure high-level disinfection or sterilization'·"'-"' . Reprocessed endoscopes should be
free of microbial pathogens except for small numbers of relatively avirulent microbes that represent
exogenous environmental contamination (e.g., coagulase-negative Staphylococcus, Bacillus species,
diphtheroids). Although recommendations exist for the final rinse water used during endoscope
                                                                       165
reprocessing to be microbiologically cultured at least monthly             , a microbiologic standard has not been

                                                                                                                16
Guid01ina for Disinfection Qnti Stedltzation in Healfhcmnlacil;ties, 200/l

                                                                         166
set, and the value of routine endoscope cultures has not been shown . In addition, neither the routine
culture of reprocessed endoscopes nor the final rinse water has been validated by correlating viable
counts on an endoscope to infection after an endoscopic procedure. If reprocessed endoscopes were
cultured, sampling the endoscope would assess water quality and other important steps (e.g., disinfectant
effectiveness, exposure time, cleaning) in the rep,rocessin~ procedure. A number of methods for sampling
                                              23 57 161     7 168
endoscopes and water have been described ' ' • 16'· 1 ' • Novel approaches \e.g., detection of
                                                                                      170
adenosine triphosphate [ATP]) to evaluate the effectiveness of endoscope cleaning "·      or endoscope
               171
reprocessing       also have been evaluated, but no method has been established as a standard for
assessing the outcome of endoscope reprocessing.

        The carrying case used to transport clean and reprocessed endoscopes outside the health-care
environment should not be used to store an endoscope or to transport the instrument within the health-
care facility. A contaminated endoscope should never be placed in the carrying case because the case
can also become contaminated. When the endoscope is removed from the case, properly reprocessed,
and put back in the case, the case could recontaminate the endoscope. A contaminated carrying case
should be discarded (Olympus America, June 2002, written communication).

         Infection-control professionals should ensure that institutional policies are consistent with national
guidelines and conduct infection-control rounds periodically (e.g., at least annually) in areas where
endoscopes are reprocessed to ensure policy compliance. Breaches in policy should be documented and
corrective action instituted. In incidents in which endoscopes were not exposed to a high-level disinfection
process, patients exposed to potentially contaminated endoscopes have been assessed for possible
acquisition of HIV, HBV, and hepatitis C virus (HCV). A 14-step method for managing a failure incident
associated with high-level disinfection or sterilization has been described [Rutala WA, 2006 #12512]. The
possible transmission of bloodborne and other infectious agents highlights the importance of rigorous
                 172 173
infection control ' .

Laparoscopes and Arthroscopes
           Although high-level disinfection appears to be the minimum standard for processing
                                                        28                                                89 90
laparoscopes and arthroscopes between patients ' "· 174 • 175 , this practice continues to be debated ' '
17
    • However, neither side in the high-level disinfection versus sterilization debate has sufficient data on
                                                                                                       29
which to base its conclusions. Proponents of high-level disinfection refer to membership surveys or
                              87
institutional experiences involving more than 117,000 and 10,000 laparoscopic procedures,
respectively, that cite a low risk for infection (<0.3%) when high-level disinfection is used for gynecologic
laparoscopic equipment. Only one infection in the membership survey was linked to spores. In addition,
growth of common skin microorganisms (e.g., Staphylococcus epiderm/dis, diphtheroids) has been
documented from the umbilical area even after skin preparation with povidone-iodine and ethyl alcohol.
Similar organisms were recovered in some instances from the pelvic serosal surfaces or from the
laparoscopic telescop,es, suggesting that the microorganisms probably were carried from the skin into the
                          78
peritoneal cavity 177 • • Proponents of sterilization focus on the possibility of transmitting infection by
spore-forming organisms. Researchers have proposed several reasons why sterility was not necessary
for alllaparoscopic equipment: only a limited number of organisms (usually _::10) are introduced into the
peritoneal cavity during laparoscopy; minimal damage is done to inner abdominal structures with little
devitalized tissue; the peritoneal cavity tolerates small numbers of spore-forming bacteria; equipment is
simple to clean and disinfect; surgical sterility is relative; the natural bioburden on rigid lumened devices
       179
is low ; and no evidence exists that high-level disinfection instead of sterilization increases the risk for
infection 87 • "· 90 . With the advent of laparoscopic cholecystectomy, concern about high-level disinfection
is justifiable because the degree of tissue damage and bacterial contamination is greater than with
laparoscopic procedures in gynecology. Failure to completely dissemble, clean, and high-level disinfect
                                                        180
laparoscope parts has led to infections in patients • Data from one study suggested that disassembly,
cleaning, and proper reassembly of laparoscopic equipment used in gynecologic procedures before
                                                    181
steam sterilization presents no risk for infection .

                                                                                                             17
Guideline for Disinfection nml c)terilization in Henlthcnre I"5 log 10 of E. coli 0157:H7 within 30 seconds: a quaternary
ammonium compound, a phenolic, a hypochlorite (1 :10 dilution of 5.25% bleach), and ethanol 53.
Disinfectants including chlorine compounds can reduce E. coli 0157:H7 experimentally inoculated onto
alfalfa seeds or sprouts 275· 276 or beef carcass surfaces •
                                                          277

         Data are limited on the susceptibility of H. pylori to disinfectants. Using a suspension test, one
                                                                                                  60
study assessed the effectiveness of a variety of disinfectants against nine strains of H. pylori . Ethanol
(80%) and glutaraldehyde (0.5%) killed all strains within 15 seconds; chlorhexidine gluconate (0.05%,
1.0%), benzalkonium chloride (0.025%, 0.1 %), alkyldiaminoethylglycine hydrochloride (0.1 %), povidone-
iodine (0.1 %), and sodium hypochlorite (150 ppm) killed all strains within 30 seconds. Both ethanol

                                                                                                                      23
Guideline for Dimnloction and Stct·ifiza\ion in HeaKixoaro Faciltt!es, 2008

(80%) and glutaraldehyde (0.5%) retained similar bactericidal activity in the presence of organic matter;
the other disinfectants showed reduced bactericidal activity. In particular, the bactericidal activity of
povidone-iodine (0.1%) and sodium hypochlorite (150 ppm) markedly decreased in the presence of dried
yeast solution with killing times increased to 5- 10 minutes and 5-30 minutes, respectively.

           Immersing biopsy forceps in formalin before obtaining a specimen does not affect the ability to
culture H. pylori from the biopsy specimen 278 • The followin~ methods are ineffective for eliminating H.
pylori from endoscopes: cleaning with soap and water 119 • 27 , immersion in 70% ethanol for 3 minutes280 ,
instillation of 70% ethanol 126 , instillation of 30 ml of 83% methanol 279 , and instillation of 0.2% Hyamine
solution 281 • The differing results with regard to the efficacy of ethyl alcohol against Helicobacterare
unexplained. Cleaning followed by use of 2% alkaline glutaraldehyde (or automated peracetic acid) has
                                                                               119 279 282
been demonstrated by culture to be effective in eliminating H. pylori • ' • Epidemiologic
investigations of patients who had undergone endoscopy with endoscopes mechanically washed and
disinfected with 2. 0%-2.3% glutaraldehyde have revealed no evidence of person-to-person transmission
               126 283
of H. pylori ' • Disinfection of experimentally contaminated endoscopes using 2% glutaraldehyde (1 0-
minute, 20-minute, 45-minute exposure times) or the peracetic acid system (with and without active
                                                                                           119
peracetic acid) has been demonstrated to be effective in eliminating H. pylori • H. pylori DNA has been
detected by PCR in fiuid fiushed from endoscope channels after cleaning and disinfection with 2%
                    284
glutaraldehyde          • The clinical significance of this finding is unclear. In vitro experiments have
demonstrated a >3.5-log 10 reduction in H. pylori after exposure to 0.5 mgiL of free chlorine for 80
seconds 285 .

        An outbreak of healthcare-associated rotavirus gastroenteritis on a pediatric unit has been
         286
reported     • Person to person through the hands of health-care workers was proposed as the
mechanism of transmission. Prolonged survival of rotavirus on environmental surfaces (90 minutes to
>1 0 days at room temperature) and hands (>4 hours) has been demonstrated. Rotavirus suspended in
                                                                                                 288 289
feces can survive longer 287 ' 288 . Vectors have included hands, fomites, air, water, and food     '    •
Products with demonstrated efficacy (>3 log 10 reduction in virus) against rotavirus within 1 minute include:
95% ethanol, 70% isopropanol, some ~henolics, 2% glutaraldehyde, 0.35% peracetic acid, and some
                                             293
quaternary ammonium compounds"· ",. • In a human challenge study, a disinfectant spray (0.1%
ortho-phenylphenol and 79% ethanol), sodium hypochlorite (800 ppm free chlorine), and a phenol-based
product (14.7% phenol diluted 1:256 in tapwater) when sprayed onto contaminated stainless steel disks,
were effective in interrupting transfer of a human rota virus from stainless steel disk to fingerpads of
volunteers after an exposure time of 3- 10 minutes. A quaternary ammonium product (7.05% quaternary
                                                                                             52
ar+!monium compound diluted 1:128 in tapwater) and tapwater allowed transfer of virus •

         No data exist on the inactivation of HPV by alcohol or other disinfectants because in vitro
replication of complete virions has not been achieved. Similarly, little is known about inactivation of
noroviruses (members of the family Ca/iciviridae and important causes of gastroenteritis in humans)
because they cannot be grown in tissue culture. Improper disinfection of environmental surfaces
contaminated by feces or vomitus of infected patients is believed to play a role in the spread of
                                294 296
noroviruses in some settings - • Prolonged survival of a norovirus surrogate (i.e., feline calicivirus
virus [FCV], a closely related cultivable virus) has been demonstrated (e.g., at room temperature, FCV in
a dried state survived for 21-18 days) 297 • Inactivation studies with FCV have shown the effectiveness of
chlorine, glutaraldehyde, and iodine-based products whereas the quaternary ammonium compound,
                                                                   297
detergent, and ethanol failed to inactivate the virus completely.      An evaluation of the effectiveness of
several disinfectants against the feline calicivirus found that bleach diluted to 1000 ppm of available
chlorine reduced infectivity of FCV by 4.5 logs in 1 minute. Other effective (log 10 reduction factor of >4 in
virus) disinfectants included accelerated hydrogen peroxide, 5,000 ppm (3 min); chlorine dioxide, 1,000
ppm chlorine (1 min); a mixture of four quaternary ammonium compounds, 2,470 ppm (1 0 min); 79%
                                                                                             298
ethanol with 0.1% quaternary ammonium compound (3 min); and 75% ethanol (1 0 min)                . A quaternary
ammonium compound exhibited activity against feline calicivirus supensions dried on hard surface
carriers in 1 0 minutes 299 • Seventy percent ethanol and 70% 1-propanol reduced FCV by a 3-4-log 10

                                                                                                             24
Gu1del1110 for Disinfection and !3terililation in 1-ieal\!'lcarn Facilities, 2008

                           300
reduction in 30 seconds       •

         CDC announced that a previously unrecognized human virus from the coronavirus family is the
                                                                         301
leading hypothesis for the cause of a described syndrome of SARS • Two coronaviruses that are
known to infect humans cause one third of common colds and can cause gastroenteritis. The virucidal
efficacy of chemical germicides against coronavirus has been investigated. A study of disinfectants
against coronavirus 229E found several that were effective after a 1-minute contact time; these included
sodium hypochlorite (at a free chlorine concentration of 1,000 ppm and 5,000 ppm), 70% ethyl alcohol,
                                     186
and povidone-iodine (1% iodine) • In another study, 70% ethanol, 50% isopropanol, 0.05%
benzalkonium chloride, 50 ppm iodine in iodophor, 0.23% sodium chlorite, 1% cresol soap and 0.7%
formaldehyde inactivated >3 logs of two animal coronaviruses (mouse hepatitis virus, canine coronavirus)
                                    302
after a 10-minute exposure time • The activity of povidone-iodine has been demonstrated against
                                           303
human coronaviruses 229E and OC43 • A study also showed complete inactivation of the SARS
coronavirus by 70% ethanol and povidone-iodine with an exposure times of 1 minute and 2.5%
                                                       304
glutaraldehyde with an exposure time of 5 minute • Because the SARS coronavirus is stable in feces
and urine at room temperature for at least 1-2 days (WHO, 2003;
http://www.who.int/csr/sars/survival_2003_05_04/en/index.html), surfaces might be a possible source of
contamination and lead to infection with the SARS coronavirus and should be disinfected. Until more
precise information is available, environments in which SARS patients are housed should be considered
heavily contaminated, and rooms and equipment should be thoroughly disinfected daily and after the
patient is discharged. EPA-registered disinfectants or 1:100 dilution of household bleach and water
should be used for surface disinfection and disinfection on noncritical patient-care equipment. High-level
disinfection and sterilization of semicritical and critical medical devices, respectively, does not need to be
altered for patients with known or suspected SARS.

         Free-living amoeba can be pathogenic and can harbor agents of pneumonia such as Legionella
pneumophila. Limited studies have shown that 2% glutaraldehyde and peracetic acid do not completely
inactivate Acanthamoeba polyphaga in a 20-minute exposure time for high-level disinfection. If amoeba
are found to contaminate instruments and facilitate infection, longer immersion times or other
                                        305
disinfectants may need to be considered     •

Inactivation of Bloterrorist Agents
                                                                                              306 307
        Publications have highlighted concerns about the potential for biological terrorism • • CDC
has categorized several agents as "high priority" because they can be easily disseminated or transmitted
                                                                                                          308
from person to person, cause high mortality, and are likely to cause public panic and social disruption •
 These agents include Bacillus anthracis (the cause of anthrax), Yersinia pestis (plague), variola major
(smallpox), Clostridium botulinum toxin (botulism), Franc/sella tularensis (tularemia), filoviruses (Ebola
hemorrhagic fever, Marburg hemorrhagic fever); and arenaviruses (Lassa [Lassa fever], Junin [Argentine·
hemorrhagic fever]), and related viruses".,

         A few comments can be made regarding the role of sterilization and disinfection of potential
agents of bioterrorism • First, the susceptibility of these agents to ~ermicides in vitro is similar to that of
                         309

other related pathogens. For exam~le, variola is similar to vaccinia '· • 311 and B. anthracis is similar to
                                                                            310
                                       12 313
B. atrophaeus (formerly B. subtilis) • • B. subtilis spores, for instance, proved as resistant as, if not
more resistant than, B. anthracis spores (>6 log 10 reduction of B. anthracis spores in 5 minutes with
                                         313
acidified bleach [5,250 ppm chlorine]) • Thus, one can extrapolate from the larger database available on
                                                     314
the susceptibility of genetically similar organisms • Second, many of the potential bioterrorist agents are
stable enough in the environment that contaminated environmental surfaces or fomites could lead to
transmission of agents such as B. anthracis, F. tularensis, variola major, C. botulinum toxin, and C.
burnett/ 315 • Third, data suggest that current disinfection and sterilization practices are appropriate for
managing patient-care equipment and environmental surfaces when potentially contaminated patients are
evaluated and/or admitted in a health-care facility after exposure to a bioterrorist agent. For example,

                                                                                                            25
Gutdeline fm Disinfeclion and Sterilization in lloslt!x;ane F8ciltties, 2008

sodium hypochlorite can be used for surface disinfection (see
http://www.epa.gov/pesticides/factsheets/chemicals/bleachfactsheet.htm). In instances where the health-
care facility is the site of a bioterrorist attack, environmental decontamination might require special
decontamination procedures (e.g., chlorine dioxide gas for 8. anthracis spores). Because no antimicrobial
products are registered for decontamination of biologic agents after a bioterrorist attack, EPA has granted
a crises exemption for each product (see
http://www. epa. gov/pesticides/factsheets/chemicals/bleachfactsheet. htm). Of only theoretical concern is
the possibility that a bioterrorist agent could be engineered to be less susceptible to disinfection and
sterilization processes 309.

Toxicological, Environmental and Occupational Concerns
          Health hazards associated with the use of germicides in healthcare vary from mucous membrane
irritation to death, with the latter involving accidental injection by mentally disturbed patients316 • Althou~h
                                 317 320
their degrees of toxicity vary - , all disinfectants should be used with the proper safety precautions 21
and only for the intended purpose.

          Key factors associated with assessing the health risk of a chemical exposure include the
duration, intensity (i.e., how much chemical is involved), and route (e.g., skin, mucous membranes, and
inhalation) of exposure. Toxicity can be acute or chronic. Acute toxicity usually results from an accidental
spill of a chemical substance. Exposure is sudden and often produces an emergency situation. Chronic
toxicity results from repeated exposure to low levels of the chemical over a prolonged period. Employers
are responsible for informing workers about the chemical hazards in the workplace and implementing
control measures. The OSHA Hazard Communication Standard (29 CFR 1910.1200, 1915.99, 1917.28,
1918.90, 1926.59, and 1928.21) requires manufacturers and importers of hazardous chemicals to
develop Material Safety Data Sheets (MSDS) for each chemical or mixture of chemicals. Employers must
have these data sheets readily available to employees who work with the products to which they could be
exposed.

          Exposure limits have been published for many chemicals used in health care to help provide a
safe environment and, as relevant, are discussed in each section of this guideline. Only the exposure
limits published by OSHA carry the legal force of regulations. OSHA publishes a limit as a time-weighted
average (TWA), that is, the average concentration for a normal 8-hour work day and a 40-hour work week
to which nearly all workers can be repeatedly exposed to a chemical without adverse health effects. For
example, the permissible exposure limit (PEL) for EtO is 1.0 ppm, 8 hour TWA. The CDC National
Institute for Occupational Safety and Health (NIOSH) develops recommended exposure limits (RELs).
RELs are occupational exposure limits recommended by NIOSH as being protective of worker health and
safety over a working lifetime. This limit is frequently expressed as a 40-hour TWA exposure for up to 10
hours per day during a 40-hour work week. These exposure limits are designed for inhalation exposures.
Irritant and allergic effects can occur below the exposure limits, and skin contact can result in dermal
effects or systemic absorption without inhalation. The American Conference on Governmental Industrial
                                                                   322
Hygienists (ACGIN) also provides guidelines on exposure limits         • Information about workplace
exposures and methods to reduce them (e.g., work practices, engineering controls, PPE) is available on
the OSHA (http://www.osha.gov) and NIOSH (http://www.cdc.gov/niosh) websites.

         Some states have excluded or limited concentrations of certain chemical germicides (e.g.,
glutaraldehyde, formaldehyde, and some phenols) from disposal through the sewer system. These rules
are intended to minimize environmental harm. If health-care facilities exceed the maximum allowable
concentration of a chemical (e.g., ;:_5.0 mg/L), they have three options. First, they can switch to alternative
products; for example, they can change from glutaraldehyde to another disinfectant for high-level
disinfection or from phenolics to quaternary ammonium compounds for low-level disinfection. Second, the
health-care facility can collect the disinfectant and dispose of it as a hazardous chemical. Third, the

                                                                                                             26
Guideline tor Dlslnfectlon and Sterilization In !·!calthcaro Facilities, 2008

facility can use a commercially available small-scale treatment method (e.g., neutralize glutaraldehyde
with glycine).

        Safe disposal of regulated chemicals is important throughout the medical community. For
disposal of large volumes of spent solutions, users might decide to neutralize the microbicidal activity
before disposal ~e.g., glutaraldehyde). Solutions can be neutralized by reaction with chemicals such as
                    324           325
sodium bisulfite "·     or glycine •

         European authors have suggested that instruments and ventilation therapy equipment should be
disinfected by heat rather than by chemicals. The concerns for chemical disinfection include toxic side
effects for the patient caused by chemical residues on the instrument or object, occupational exposure to
toxic chemicals, and recontamination by rinsing the disinfectant with microbially contaminated tap water
326

Disinfection in Ambulatory Care, Home Care, and the Home
          IJIJlth the advent of managed healthcare, increasing numbers of patients are now being cared for
in ambulatory-care and home settings. Many patients in these settings might have communicable
diseases, immunocompromising conditions, or invasive devices. Therefore, adequate disinfection in
these settings is necessary to provide a safe patient environment. Because the ambulatory-care setting
(i.e., outpatient facility) provides the same risk for infection as the hospital, the Spaulding classification
scheme described in this guideline should be followed (Table 1) "-

         The home environment should be much safer than hospitals or ambulatory care. Epidemics
should not be a problem, and cross-infection should be rare. The healthcare provider is responsible for
providing the responsible family member information about infection-control procedures to follow in the
home, including hand hygiene, proper cleaning and disinfection of equipment, and safe storage of
cleaned and disinfected devices. Among the products recommended for home disinfection of reusable
objects are bleach, alcohol, and hydrogen peroxide. APIC recommends that reusable objects (e.g.,
tracheostomy tubes) that touch mucous membranes be disinfected by immersion in 70% isopropyl
alcohol for 5 minutes or in 3% hydrogen peroxide for 30 minutes. Additionally, a 1:50 dilution of 5.25%-
6.15% sodium hypochlorite (household bleach) for 5 minutes should be effective 327-329 • Noncritical items
(e.g., blood pressure cuffs, crutches) can be cleaned with a detergent. Blood spills should be handled
according to OSHA regulations as previously described (see section on OSHA Bloodborne Pathogen
Standard). In general, sterilization of critical items is not practical in homes but theoretically could be
accomplished by chemical sterilants or boiling. Single-use disposable items can be used or reusable
                               330 331
items sterilized in a hospital • •

        Some environmental groups advocate "environmentally safe" products as alternatives to
commercial germicides in the home-care setting. These alternatives (e.g., ammonia, baking soda,
vinegar, Borax, liquid detergent) are not registered with EPA and should not be used for disinfecting
because they are ineffective against S. aureus. Borax, baking soda, and detergents also are ineffective
against Salmonella Typhi and E. coli; however, undiluted vinegar and ammonia are effective against S.
                     332
Typhi and E. coli 53• · 333 • Common commercial disinfectants designed for home use also are effective
against selected antibiotic-resistant bacteria 53 .

         Public concerns have been raised that the use of antimicrobials in the home can promote
development of antibiotic-resistant bacteria 334• 335 • This issue is unresolved and needs to be considered
further through scientific and clinical investigations. The public health benefits of using disinfectants in the
home are unknown. However, some facts are known: many sites in the home kitchen and bathroom are
                                                                                  337
microbially contaminated 336 , use of hypochlorites markedly reduces bacteria , and good standards of
                                                                                        338 339
hygiene (e.g., food hygiene, hand hygiene) can help reduce infections in the home " • In addition,
laboratory studies indicate that many commercially prepared household disinfectants are effective against
                     53                                                                     48
common pathogens and can interrupt surface-to-human transmission of pathogens • The "targeted

                                                                                                             27
Guideline tor D!sinfocf!on and SteHiizntion In Healti'JGcom Facilrt:r1s, 2008

                                                  CLEANING

        Cleaning is the removal of foreign material (e.g., soil, and organic material) from objects and is
normally accomplished using water with detergents or enzymatic products. Thorough cleaning is required
before high-level disinfection and sterilization because inorganic and organic materials that remain on the
surfaces of instruments interfere with the effectiveness of these processes. Also, if soiled materials dry or
bake onto the instruments, the removal process becomes more difficult and the disinfection or sterilization
process less effective or ineffective. Surgical instruments should be presoaked or rinsed to prevent drying
of blood and to soften or remove blood from the instruments.

         Cleaning is done manually in use areas without mechanical units (e.g., ultrasonic cleaners or
washer-disinfectors) or for fragile or difficult-to-clean instruments. \1\ilth manual cleaning, the two essential
components are friction and fluidics. Friction (e.g., rubbing/scrubbing the soiled area with a brush) is an
old and dependable method. Fluidics (i.e., fluids under pressure) is used to remove soil and debris from
internal channels after brushing and when the design does not allow passage of a brush through a
         445
channel      . \1\ilhen a washer-disinfector is used, care should be taken in loading instruments: hinged
instruments should be opened fully to allow adequate contact with the detergent solution; stacking of
instruments in washers should be avoided; and instruments should be disassembled as much as
possible.

          The most common types of mechanical or automatic cleaners are ultrasonic cleaners, washer-
decontaminators, washer-disinfectors, and washer-sterilizers. Ultrasonic cleaning removes soil by
cavitation and implosion in which waves of acoustic energy are propagated in aqueous solutions to
disrupt the bonds that hold particulate matter to surfaces. Bacterial contamination can be present in used
ultrasonic cleaning solutions (and other used detergent solutions) because these solutions generally do
                                     446
not make antibacterial label claims . Even though ultrasound alone does not significantly inactivate
                                                                                                 44
bacteria, sonication can act synergistically to increase the cidal efficacy of a disinfectant • Users of
ultrasonic cleaners should be aware that the cleaning fluid could result in endotoxin contamination of
                                                                             448
surgical instruments, which could cause severe inflammatory reactions • Washer-sterilizers are
modified steam sterilizers that clean by filling the chamber with water and detergent through which steam
passes to provide agitation. Instruments are subsequently rinsed and subjected to a short steam-
sterilization cycle. Another washer-sterilizer employs rotating spray arms for a wash cycle followed by a
steam sterilization cycle at 285'F 449• 450 . Washer-decontaminators/disinfectors act like a dishwasher that
uses a combination of water circulation and detergents to remove soil. These units sometimes have a
                                                                                      451
cycle that subjects the instruments to a heat process (e.g., 93'C for 10 minutes)         • Washer-disinfectors
are generally computer-controlled units for cleaning, disinfecting, and drying solid and hollow surgical and
medical equipment. In one study, cleaning (measured as 5-6 log 10 reduction) was achieved on surfaces
                                                                 452
that had adequate contact with the water ftow in the machine         • Detailed information about cleaning and
                                                                                            453 454          455
preparing supplies for terminal sterilization is provided by professional organizations • and books •
 Studies have shown that manual and mechanical cleaning of endoscopes achieves approximately a 4-
                                               83 104 456 457
log10 reduction of contaminating organisms ' · • • Thus, cleaning alone effectively reduces the
number of microorganisms on contaminated equipment. In a quantitative analysis of residual protein
contamination of reprocessed surgical instruments, median levels of residual protein contamination per
                                                                  458
instrument for five trays were 267, 260, 163, 456, and 756 ~g         . In another study, the median amount of
protein from reprocessed surgical instruments from different hospitals ranged from 8 ~g to 91 ~g •
                                                                                                       459

\1\ilhen manual methods were compared with automated methods for cleaning reusable accessory devices
used for minimally invasive surgical procedures, the automated method was more efficient for cleaning
biopsy forceps and ported and nonported laparoscopic devices and achieved a >99% reduction in soil
parameters (i.e., protein, carbohydrate, hemoglobin) in the ported and nonported laparoscopic devices
460, 461

       For instrument cleaning, a neutral or near-neutral pH detergent solution commonly is used
because such solutions generally provide the best material compatibility profile and good soil removal.

                                                                                                              36
Guideline for Disinfr"ction and Sterilization in Henltl>caro Fncilitins, 2008

Enzymes, usually proteases, sometimes are added to neutral pH solutions to assist in removing organic
material. Enzymes in these formulations attack proteins that make up a large portion of common soil
 (e.g., blood, pus). Cleaning solutions also can contain lipases (enzymes active on fats) and amylases
(enzymes active on starches). Enzymatic cleaners are not disinfectants, and proteinaceous enzymes can
be inactivated by germicides. As with all chemicals, enzymes must be rinsed from the equipment or
adverse reactions (e.g., fever, residual amounts of high-level disinfectants, proteinaceous residue) could
        462 463
result • • Enzyme solutions should be used in accordance with manufacturer's instructions, which
include proper dilution of the enzymatic detergent and contact with equipment for the amount of time
                         463
specified on the label       • Detergent enzymes can result in asthma or other allergic effects in users.
Neutral pH detergent solutions that contain enzymes are compatible with metals and other materials used
in medical instruments and are the best choice for cleaning delicate medical instruments, especially
                       457
flexible endoscopes . Alkaline-based cleaning agents are used for processing medical devices
because they efficiently dissolve protein and fat residues 464 ; however, they can be corrosive 457 . Some
                                                                                          465 466
data demonstrate that enzymatic cleaners are more effective than neutral detergents '             in removing
microorganisms from surfaces but two more recent studies found no difference in cleaning efficiency
                                                    443 464
between enzymatic and alkaline-based cleaners          '    • Another study found no significant difference
                                                                                             467
between enzymatic and non-enzymatic cleaners in terms of microbial cleaning efficacy • A new non-
enzyme, hydrogen peroxide-based formulation (not FDA-cleared) was as effective as enzymatic cleaners
in removing protein, blood, carbohydrate, and endotoxin from surface test carriers'" In addition, this
                                                                                                            468
product effected a 5-log 10 reduction in microbial loads with a 3-minute exposure at room temperature           •

         Although the effectiveness of high-level disinfection and sterilization mandates effective cleaning,
no "real-time" tests exist that can be employed in a clinical setting to verify cleaning. If such tests were
                                                                                         469
commercially available they could be used to ensure an adequate level of cleaning -472 • ). The only way
to ensure adequate cleaning is to conduct a reprocessing verification test (e.g., microbiologic sampling),
but this is not routinely recommended 473 • Validation of the cleaning processes in a laboratory-testing
program is possible by microorganism detection, chemical detection for organic contaminants,
                                                                 426 471
radionuclide tagging, and chemical detection for specific ions ' • During the past few years, data
have been published describing use of an artificial soil, protein, endotoxin, X-ray contrast medium, or
blood to verify the manual or automated cleaning process 169 ' 452 ' 474-478 and adenosine triphosphate
bioluminescence and microbiologic sampling to evaluate the effectiveness of environmental surface
              479
cleaning 170 • • At a minimum, all instruments should be individually inspected and be visibly clean.

                                                                                                              37
Guiddine for Disinfection ~mel ;.)toHiizahon ln I !enllhcaro Faci!ltie~, 2008

                                                DISINFECTION

         Many disinfectants are used alone or in combinations (e.g., hydrogen peroxide and peracetic
acid) in the health-care setting. These include alcohols, chlorine and chlorine compounds, formaldehyde,
glutaraldehyde, orlho-phthalaldehyde, hydrogen peroxide, iodophors, peracetic acid, phenolics, and
quaternary ammonium compounds. Commercial formulations based on these chemicals are considered
unique products and must be registered with EPA or cleared by FDA. In most instances, a given product
is designed for a specific purpose and is to be used in a certain manner. Therefore, users should read
labels carefully to ensure the correct product is selected for the intended use and applied efficiently.

          Disinfectants are not interchangeable, and incorrect concentrations and inappropriate
disinfectants can result in excessive costs. Because occupational diseases among cleaning personnel
have been associated with use of several disinfectants (e.g., formaldehyde, glutaraldehyde, and
chlorine), precautions (e.g., gloves and proper ventilation) should be used to minimize exposure 316 • 460 •
481
    • Asthma and reactive airway disease can occur in sensitized persons exposed to any airborne
chemical, including germicides. Clinically important asthma can occur at levels below ceiling levels
regulated by OSHA or recommended by NIOSH. The preferred method of control is elimination of the
chemical (through engineering controls or substitution) or relocation of the worker.

        The following overview of the performance characteristics of each provides users with sufficient
information to select an appropriate disinfectant for any item and use it in the most efficient way.

Chemical Disinfectants
Alcohol
         Overview. In the healthcare setting, "alcohol" refers to two water-soluble chemical compounds-
                                                                                                  48
ethyl alcohol and isopropyl alcohol-that have generally underrated germicidal characteristics        • FDA
has not cleared any liquid chemical sterilant or high-level disinfectant with alcohol as the main active
ingredient. These alcohols are rapidly bactericidal rather than bacteriostatic against vegetative forms of
bacteria; they also are tuberculocidal, fungicidal, and virucidal but do not destroy bacterial spores. Their
cidal activity drops sharply when diluted below 50% concentration, and the optimum bactericidal
                                                                  483 484
concentration is 60%-90% solutions in water (volume/volume)          '    •

         Mode of Action. The most feasible explanation for the antimicrobial action of alcohol is
denaturation of proteins. This mechanism is supported by the observation that absolute ethyl alcohol, a
dehydrating agent, is less bactericidal than mixtures of alcohol and water because proteins are denatured
                                        484 485
more quickly in the presence of water ' • Protein denaturation also is consistent with observations
                                                               486
that alcohol destroys the dehydrogenases of Escherichia coli , and that ethyl alcohol increases the lag
                                   487
phase of Enterobacter aerogenes        and that the lag phase effect could be reversed by adding certain
amino acids. The bacteriostatic action was believed caused by inhibition of the production of metabolites
essential for rapid cell division.

         Microbicidal Activity. Methyl alcohol (methanol) has the weakest bactericidal action of the
                                                   488
alcohols and thus seldom Is used in health care • The bactericidal activity of various concentrations of
ethyl alcohol (ethanol) was examined against a variety of microorganisms in exposure periods ranging
                            483
from 1 0 seconds to 1 hour • Pseudomonas aeruginosa was killed in 1 0 seconds by all concentrations
of ethanol from 30% to 100% (v/v), and Serratia marcescens, E, coli and Salmonella typhosa were killed
in 10 seconds by all concentrations of ethanol from 40% to 100%. The gram-positive organisms
Staphylococcus aureus and Streptococcus pyogenes were slightly more resistant, being killed in 10
seconds by ethyl alcohol concentrations of 60%-95%. Isopropyl alcohol (isopropanol) was slightly more
                                                         489
bactericidal than ethyl alcohol for E. coli and S. aureus •

          Ethyl alcohol, at concentrations of 60%-80%, is a potent virucidal agent inactivating all of the
lipophilic viruses (e.g., herpes, vaccinia, and influenza virus) and many hydrophilic viruses (e.g.,

                                                                                                               38
Guide!lne ior Disinfoctlon and Sterilization in Hea!thcm·e r.:·acl!ities, 2008

                                                                                            58               49
adenovirus, enterovirus, rhinovirus, and rotaviruses but not hepatitis A virus (HAV) or poliovirus) •
Isopropyl alcohol is not active against the nonlipid enteroviruses but is fully active against the lipid viruses
72
   • Studies also have demonstrated the ability of ethyl and isopropyl alcohol to inactivate the hepatitis B
                                            490
virus(HBV) 224 • 225 and the herpes virus,      and ethyl alcohol to inactivate human immunodeficiency virus
       227                                        491
(HIV)      , rotavirus, echovirus, and astrovirus     .

        In tests of the effect of ethyl alcohol against M. tuberculosis, 95% ethanol killed the tubercle bacilli
                                                     492
in sputum or water suspension within 15 seconds . In 1964, Spaulding stated that alcohols were the
germicide of choice for tuberculocidal activity, and they should be the standard by which all other
tuberculocides are compared. For example, he compared the tuberculocidal activity of iodophor (450
                                                                                                  6
ppm), a substituted phenol (3%), and isopropanol (70%/volume) using the mucin-loop test (10 M.
tuberculosis per loop) and determined the contact times needed for complete destruction were 120-180
minutes, 45-60 minutes, and 5 minutes, respectively. The mucin-loop test is a severe test developed to
produce long survival times. Thus, these figures should not be extrapolated to the exposure times needed
when these germicides are used on medical or surgical material 402 •

        Ethyl alcohol (70%) was the most effective concentration for killing the tissue phase of
Cryptococcus neoformans, Blastomyces dermatitidis, Coccidioides immitis, and Histoplasma capsulatum
and the culture phases of the latter three organisms aerosolized onto various surfaces. The culture phase
was more resistant to the action of ethyl alcohol and required about 20 minutes to disinfect the
                                                                      493 494
contaminated surface, compared with <1 minute for the tissue phase        •   •

        Isopropyl alcohol (20%) is effective in killin~ the cysts of Acanthamoeba culbertson/ (560) as are
                                                       6
chlorhexidine, hydrogen peroxide, and thimerosal 4 .

          Uses. Alcohols are not recommended for sterilizing medical and surgical materials principally
because they lack sporicidal action and they cannot penetrate protein-rich materials. Fatal postoperative
wound infections with Clostridium have occurred when alcohols were used to sterilize surgical
                                                       497
instruments contaminated with bacterial spores • Alcohols have been used effectively to disinfect oral
                             4 499                     500             501                     502
and rectal thermometers "· , hospital pagers               , scissors      , and stethoscopes      • Alcohols have
                                                    503 504
been used to disinfect fiberoptic endoscopes           '      but failure of this disinfectant have lead to Infection
280 505
   •    • Alcohol towelettes have been used for years to disinfect small surfaces such as rubber stoppers
of multiple-dose medication vials or vaccine bottles. Furthermore, alcohol occasionally is used to
disinfect external surfaces of equipment (e.~., stethoscopes, ventilators, manual ventilation bags)
                                                                                                                506
                                                                                                                    ,
                 507                            5 8
CPR manikins         , ultrasound instruments       or medication preparation areas. Two studies demonstrated
the effectiveness of 70% isopropyl alcohol to disinfect reusable transducer heads in a controlled
               509 510
environment       '    • In contrast, three bloodstream infection outbreaks have been described when
alcohol was used to disinfect transducer heads in an intensive-care setting 511 •

           The documented shortcomings of alcohols on equipment are that they damage the shellac
mountings of lensed instruments, tend to swell and harden rubber and certain plastic tubing after
prolonged and repeated use, bleach rubber and plastic tiles 482 and damage tonometer tips (by
                                                                                 512
deterioration of the glue) after the equivalent of 1 working year of routine use     • Tonometer biprisms
soaked in alcohol for 4 days developed rough front surfaces that potentially could cause corneal dama~e;
                                                                                                          13
this appeared to be caused by weakening of the cementing substances used to fabricate the biprisms           .
 Corneal opacification has been reported when tonometer tips were swabbed with alcohol immediately
before measurement of intraocular pressure 514 • Alcohols are flammable and consequently must be
stored in a cool, well-ventilated area. They also evaporate rapidly, making extended exposure time
difficult to achieve unless the items are immersed.

Chlorine and Chlorine Compounds
          Overview. Hypochlorites, the most widely used of the chlorine disinfectants, are available as
liquid (e.g., sodium hypochlorite) or solid (e.g., calcium hypochlorite). The most prevalent chlorine

                                                                                                                  39
products in the United States are aqueous solutions of 5.25%-6.15% sodium hypochlorite (see glossary),
usually called household bleach. They have a broad spectrum of antimicrobial activity, do not leave toxic
                                                                                328
residues, are unaffected by water hardness, are inexpensive and fast acting         , remove dried or fixed
organisms and biofilms from surfaces , and have a low incidence of serious toxicity 51 ,_ 517 • Sodium
                                        465

hypochlorite at the concentration used in household bleach (5.25-6. 15%) can produce ocular irritation or
                                                    318
oropharyngeal, esophageal, and gastric burns • , .., _ Other disadvantages of hypochlorites include
corrosiveness to metals in high concentrations (>500 ppm), inactivation by organic matter, discoloring or
"bleaching" of fabrics, release of toxic chlorine gas when mixed with ammonia or acid (e.g., household
                   52 525                       327
cleaning agents) ,_ , and relative stability • The microbicidal activity of chlorine is attributed largely
to undissociated hypochlorous acid (HOCI). The dissociation of HOCI to the less microbicidal form
(hypochlorite ion OCr) depends on pH. The disinfecting efficacy of chlorine decreases with an increase in
                                                                 329 526
pH that parallels the conversion of undissociated HOCI to ocr       '    • A potential hazard is production of
                                                                                               52
the carcinogen bis(chloromethyl) ether when hypochlorite solutions contact formaldehyde            and the
                                                                                            528
production of the animal carcinogen trihalomethane when hot water is hyperchlorinated             After
reviewing environmental fate and ecologic data, EPA has determined the currently registered uses of
                                                                                     529
hypochlorites will not result in unreasonable adverse effects to the environment •

         Alternative compounds that release chlorine and are used in the health-care setting include
demand-release chlorine dioxide, sodium dichloroisocyanurate, and chloramine-T. The advantage of
these compounds over the hypochlorites is that they retain chlorine longer and so exert a more prolonged
bactericidal effect. Sodium dichloroisocyanurate tablets are stable, and for two reasons, the microbicidal
activity of solutions prepared from sodium dichloroisocyanurate tablets might be greater than that of
sodium hypochlorite solutions containing the same total available chlorine. First, with sodium
dichloroisocyanurate, only 50% of the total available chlorine is free (HOC I and OCr), whereas the
remainder is combined (monochloroisocyanurate or dichloroisocyanurate), and as free available chlorine
is used up, the latter is released to restore the equilibrium. Second, solutions of sodium
dichloroisocyanurate are acidic, whereas sodium hypochlorite solutions are alkaline, and the more
                                                                   530
microbicidal type of chlorine (HOCI) is believed to predominate -533 . Chlorine dioxide-based
disinfectants are prepared fresh as required by mixing the two components (base solution [citric acid with
preservatives and corrosion inhibitors] and the activator solution (sodium chlorite]). In vitro suspension
tests showed that solutions containing about 140 ppm chlorine dioxide achieved a reduction factor
exceeding 10 6 of S. aureus in 1 minute and of Bacillus atrophaeus spores in 2.5 minutes in the presence
of 3 g/L bovine albumin. The potential for damaging equipment requires consideration because long-term
use can damage the outer plastic coat of the insertion tube 534 In another study, chlorine dioxide
solutions at either 600 ppm or 30 ppm killed Mycobacterium avium-intracellufare within 60 seconds after
                                                                                                   535
contact but contamination by organic material significantly affected the microbicidal properties .

          The microbicidal activity of a new disinfectant, "superoxidized water," has been examined The
concept of electrolyzing saline to create a disinfectant or antiseptics is appealing because the basic
materials of saline and electricity are inexpensive and the end product (i.e., water) does not damage the
environment. The main products of this water are hypochlorous acid (e.g., at a concentration of about 144
mg/L) and chlorine. As with any germicide, the antimicrobial activity of superoxidized water is strongly
                                                                                 536
affected by the concentration of the active ingredient (available free chlorine) • One manufacturer
generates the disinfectant at the point of use by passing a saline solution over coated titanium electrodes
at 9 amps. The product generated has a pH of 5.0-6.5 and an oxidation-reduction potential (redox) of
>950 mV. Although superoxidized water is intended to be generated fresh at the point of use, when
                                                                                                   537
tested under clean conditions the disinfectant was effective within 5 minutes when 48 hours old •
Unfortunately, the equipment required to produce the product can be expensive because parameters
such as pH, current, and redox potential must be closely monitored. The solution is nontoxic to biologic
tissues. Although the United Kingdom manufacturer claims the solution is noncorrosive and nondamaging
to endoscopes and processing equipment, one flexible endoscope manufacturer (Olympus Key-Med,
United Kingdom) has voided the warranty on the endoscopes if superoxidized water is used to disinfect
      538
them      , As with any germicide formulation, the user should check with the device manufacturer for

                                                                                                           40
Guideline for Dislnfl?;Ction and Stori!ization in Hnnltllcare Facilities, 2008

compatibility with the germicide. Additional studies are needed to determine whether this solution could
be used as an alternative to other disinfectants or antiseptics for hand washing, skin antisepsis, room
                                                                    400 539 540
cleaning, or equipment disinfection (e.g., endoscopes, dialyzers)      •   •    • In October 2002, the FDA
cleared superoxidized water as a high-level disinfectant (FDA, personal communication, September 18,
2002).

         Mode of Action. The exact mechanism by which free chlorine destroys microorganisms has not
been elucidated. Inactivation by chlorine can result from a number of factors: oxidation of sulfhydryl
enzymes and amino acids; ring chlorination of amino acids; loss of intracellular contents; decreased
uptake of nutrients; inhibition of protein synthesis; decreased oxygen uptake; oxidation of respiratory
components; decreased adenosine triphosphate production; breaks in DNA; and depressed DNA
           329 347
synthesis ' • The actual microbicidal mechanism of chlorine might involve a combination of these
factors or the effect of chlorine on critical sites 347 •

         Microbicidal Activity. Low concentrations of free available chlorine (e.g., HOCI, ocr, and
elemental chlorine-CI,) have a biocidal effect on mrcoplasma (25 ppm) and vegetative bacteria (<5 ppm)
                                                  329
in seconds in the absence of an organic load • 41 • Higher concentrations (1 ,000 ppm) of chlorine are
required to kill M. tuberculosis using the Association of Official Analytical Chemists (AOAC) tuberculocidal
     73                                                                                            541 542
test • A concentration of 100 ppm will kill ;':99.9% of B. atrophaeus spores within 5 minutes •            and
                                     329
destroy mycotic agents in <1 hour • Acidified bleach and regular bleach (5,000 ppm chlorine) can
             6                                              262
inactivate 10 Clostridium difficile spores in ,::10 minutes     • One study reported that 25 different viruses
                                                                    72
were inactivated in 10 minutes with 200 ppm available chlorine • Several studies have demonstrated
                                                                                              61
the effectiveness of diluted sodium hypochlorite and other disinfectants to inactivate HIV • Chlorine
                                                                           54
(500 ppm) showed inhibition of Candida after 30 seconds of exposure . In experiments using the AOAC
Use-Dilution Method, 100 pp,m of free chlorine killed 106-10 7 S. aureus, Salmonella choleraesuis, and P.
aeruginosa in <1 0 minutes 27 • Because household bleach contains 5.25%-6.15% sodium hypochlorite,
or 52,500-61,500 ppm available chlorine, a 1:1,000 dilution provides about 53-62 ppm available chlorine,
and a 1:10 dilution of household bleach provides about 5250-6150 ppm.

         Data are available for chlorine dioxide that sup~ort manufacturers' bactericidal, fungicidal,
                                                        543 46
sporicidal, tuberculocidal, and virucidal label claims     '   . A chlorine dioxide generator has been shown
                                                      534
effective for decontaminating flexible endoscopes         but it is not currently FDA-cleared for use as a high·
                   85
level disinfectant • Chlorine dioxide can be produced by mixing solutions, such as a solution of chlorine
                                   329
with a solution of sodium chlorite     • In 1986, a chlorine dioxide product was voluntarily removed from the
market when its use caused leakage of cellulose-based dialyzer membranes, which allowed bacteria to
migrate from the dialysis fluid side of the dialyzer to the blood side 547 •

       Sodium dichloroisocyanurate at 2,500 ppm available chlorine is effective against bacteria in the
presence of up to 20% plasma, compared with 10% plasma for sodium hypochlorite at 2,500 ppm "'-

         "Superoxidized water" has been tested against bacteria, mycobacteria, viruses, fungi, and spores
537 539 549
   •   •    Freshly generated superoxidized water is rapidly effective (<2 minutes) in achieving a 6-log10
            •
reduction of pathogenic microorganisms (i.e., M. tuberculosis, M. chelonae, poliovirus, HIV, multidrug-
resistant S. aureus, E. coli, Candida albicans, Enterococcus faecalis, P. aeruginosa) In the absence of
organic loading. However, the biocidal activit¥ of this disinfectant decreased substantially in the presence
                                             53 549 550
of organic material (e.g., 5% horse serum)      •  '     No bacteria or viruses were detected on artificially
                                                                                551
contaminated endoscopes after a 5-minute exposure to superoxidized water            and HBV-DNA was not
detected from any endoscope experimentally contaminated with HBV-positive mixed sera after a
                                         552
disinfectant exposure time of 7 minutes •
                                                                                                 328
         Uses. Hypochlorites are widely used in healthcare facilities in a variety of settings.      Inorganic
                                                           1
chlorine solution is used for disinfecting tonometer heads " and for spot-disinfection of countertoRs and
                                                                                                22 228 53 554
floors. A 1:10-1:100 dilution of 5.25%-6.15% sodium hypochlorite (i.e., household bleach) • • •               or

                                                                                                             41
Guideline lor Dlslnfection and Sterilization in !--!e~:l(thcarn Fad!1tins, 2008

an EPA-registered tuberculocidal disinfectant 17has been recommended for decontaminating blood spills.
For small spills of blood (i.e., drops of blood) on noncritical surfaces, the area can be disinfected with a
1:100 dilution of 5.25%-6.15% sodium hypochlorite or an EPA-registered tuberculocidal disinfectant.
                                                                                                                63
Because hypochlorites and other germicides are substantially inactivated in the presence of blood ' 548 ·
555 556
    •   , large spills of blood require that the surface be cleaned before an EPA-registered disinfectant or a
                                                                            557
1:10 (final concentration) solution of household bleach is applied              If a sharps injury is possible, the
                                                   69 318
surface initially should be decontaminated ' , then cleaned and disinfected (1:10 final concentration)
63
   . Extreme care always should be taken to prevent percutaneous injury. At least 500 ppm available
                                                                                                558
chlorine for 10 minutes is recommended for decontaminating CPR training manikins • Full-strength
bleach has been recommended for self-disinfection of needles and syringes used for illicit-drug injection
when needle-exchange programs are not available. The difference in the recommended concentrations
of bleach reflects the difficulty of cleaning the interior of needles and syringes and the use of needles and
                                      559
syringes for parenteral injection         • Clinicians should not alter their use of chlorine on environmental
                                                                                                             560 561
surfaces on the basis of testing methodologies that do not simulate actual disinfection practices • .
                                                                                          562
Other uses in healthcare include as an irrigating agent in endodontic treatment               and as a disinfectant
                                                                      23 41
for manikins, laundry, dental appliances, hydrotherapy tanks ' , regulated medical waste before
            328                                                                                                  563
disposal        , and the water distribution system in hemodialysis centers and hemodialysis machines                ,

         Chlorine long has been used as the disinfectant in water treatment. Hyperchlorination of a
Legionel/a-contaminated hospital water system 23 resulted in a dramatic decrease (from 30% to 1.5%) in
the isolation of L. pneumophifa from water outlets and a cessation of healthcare-associated Legionnaires'
                           528 564
disease in an affected unit ' • Water disinfection with monochloramine by municipal water-treatment
plants substantially reduced the risk for healthcare-associated Legionnaires disease 565 ' 566 , Chlorine
                                                                             567
dioxide also has been used to control Legionefla in a hospital water supply.     Chloramine T 568 and
               41
hypochlorites have been used to disinfect hydrotherapy equipment.

         Hypochlorite solutions in tap water at a pH >8 stored at room temperature (23'C) in closed,
opaque plastic containers can lose up to 40%-50% of their free available chlorine level over 1 month.
Thus, if a user wished to have a solution containing 500 ppm of available chlorine at day 30, he or she
should prepare a solution containing 1,000 ppm of chlorine at time 0. Sodium hypochlorite solution does
not decompose after 30 days when stored in a closed brown bottle 327 •

         The use of powders, composed of a mixture of a chlorine-releasing agent with highly absorbent
resin, for disinfecting spills of body fluids has been evaluated by laboratory tests and hospital ward trials.
The inclusion of acrylic resin particles in formulations markedly increases the volume of fluid that can be
soaked up because the resin can absorb 200-300 times its own weight of fluid, depending on the fluid
consistency, When experimental formulations containing 1%, 5%, and 10% available chlorine were
evaluated by a standardized surface test, those containing 10% demonstrated bactericidal activity. One
Problem with chlorine-releasing granules is that they can generate chlorine fumes when applied to urine
'"
Formaldehyde
          Ovetview. Formaldehyde is used as a disinfectant and sterilant in both its liquid and gaseous
states. Liquid formaldehyde will be considered briefly in this section, and the gaseous form is reviewed
elsewhere 570 . Formaldehyde is sold and used principally as a water-based solution called formalin,
which is 37% formaldehyde b~ weight. The aqueous solution is a bactericide, tuberculocide, fungicide,
                        72 82 57
virucide and sporicide ' ' ·"'. OSHA indicated that formaldehyde should be handled in the workplace
as a potential carcinogen and set an employee exposure standard for formaldehyde that limits an 8-hour
                                                                574 575
time-weighted average exposure concentration of 0.75 ppm            •   • The standard includes a second
permissible exposure limit in the form of a short-term exposure limit (STEL) of 2 ppm that is the maximum
                                               576
exposure allowed during a 15-minute period         . Ingestion of formaldehyde can be fatal, and long-term
exposure to low levels in the air or on the skin can cause asthma-like respiratory problems and skin
irritation, such as dermatitis and itching. For these reasons, employees should have limited direct contact

                                                                                                                   42
Gutdeline for Disinfection and Sterilization In HeEl!U!c8rn FacHities, 2008

with formaldehyde, and these considerations limit its role in sterilization and disinfection processes. Key
provisions of the OSHA standard that protects workers from exposure to formaldehyde appear in Title 29
of the Code of Federal Regulations (CFR) Part 1910.1048 (and equivalent regulations in states with
                            577
OSHA-approved state plans) .

        Mode of Action. Formaldehyde inactivates microorganisms b¥, alkylating the amino and
                                                                     3 6
sulfhydral groups of proteins and ring nitrogen atoms of purine bases •

         Microbicidal Activity. Varying concentrations of aqueous formaldehyde solutions destroy a
wide range of microorganisms. Inactivation of poliovirus in 10 minutes required an 8% concentration of
formalin, but all other viruses tested were inactivated with 2% formalin n Four percent formaldehyde is a
                                                                     82
tuberculocidal agent, inactivating 104 M. tuberculosis in 2 minutes , and 2.5% formaldehyde inactivated
         7                                                                    572
about 10 Salmonella Typhi in 10 minutes in the presence of organic matter • The sporicidal action of
formaldehyde was slower than that of glutaraldehyde in comparative tests with 4% aqueous
                                                                          82
formaldehyde and 2% glutaraldehyde against the spores of B. anthracis • The formaldehyde solution
                                                                   4
required 2 hours of contact to achieve an inactivation factor of 10 , whereas glutaraldehyde required only
15 minutes.

         Uses. Although formaldehyde-alcohol is a chemical sterilant and formaldehyde is a high-level
disinfectant, the health-care uses of formaldehyde are limited by its irritating fumes and its pungent odor
even at very low levels (<1 ppm). For these reasons and others-such as its role as a suspected human
                                                       578
carcinogen linked to nasal cancer and lung cancer          , this germicide is excluded from Table 1. When it
is used, , direct exposure to employees generally is limited; however, excessive exposures to
                                                                                     574 579
formaldehyde have been documented for employees of renal transplant units ' , and students in a
                            580
gross anatomy laboratory • Formaldehyde is used in the health-care setting to prepare viral vaccines
(e.g., poliovirus and influenza); as an embalming agent; and to preserve anatomic specimens; and
historically has been used to sterilize surgical instruments, especially when mixed with ethanol. A 1997
survey found that formaldehyde was used for reprocessing hemodialyzers by 34% of U.S. hemodialysis
                                        249 581
centers-a 60% decrease from 1983 ' . If used at room temperature, a concentration of 4% with a
minimum exposure of 24 hours is required to disinfect disposable hemodialyzers reused on the same
        582 583
patient • • Aqueous formaldehyde solutions (1 %-2%) also have been used to disinfect the internal
                                      583
fluid pathways of dialysis machines • To minimize a potential health hazard to dialysis patients, the
dialysis equipment must be thoroughly rinsed and tested for residual formaldehyde before use.

        Paraformaldehyde, a solid polymer of formaldehyde, can be vaporized by heat for the gaseous
decontamination of laminar flow biologic safety cabinets when maintenance work or filter changes require
access to the sealed portion of the cabinet.

Glutaraldehyde
          Overview. Glutaraldehyde is a saturated dialdehyde that has gained wide acceptance as a high-
                                           107
level disinfectant and chemical sterilant . Aqueous solutions of glutaraldehyde are acidic and generally
in this state are not sporicidal. Only when the solution is "activated" (made alkaline) by use of alkalinating
agents to pH 7.5-8.5 does the solution become sporicidal. Once activated, these solutions have a shelf-
life of minimally 14 days because of the polymerization of the glutaraldehyde molecules at alkaline pH
levels. This polymerization blocks the active sites (aldehyde groups) of the glutaraldehyde molecules that
are responsible for its biocidal activity.

         Novel glutaraldehyde formulations (e.g., glutaraldehyde-phenol-sodium phenate, potentiated acid
glutaraldehyde, stabilized alkaline glutaraldehyde) produced in the past 30 years have overcome the
problem of rapid loss of activity (e.g., use-life 28-30 days) while generally maintaining excellent
                      584 588
microbicidal activity ' • However, antimicrobial activity depends not only on age but also on use
conditions, such as dilution and organic stress. Manufacturers' literature for these preparations suggests
the neutral or alkaline glutaraldehydes possess microbicidal and anticorrosion properties superior to

                                                                                                            43
Guideline for Dislnf()Cfion and Ster!!1zotion in HL~B!tl1care FadlitJes, 2008

those of acid glutaraldehydes, and a few published reports substantiate these claims 542 • 569 • 590• However,
two studies found no difference in the microbicidal activity of alkaline and acid glutaraldehydes 73 • 591 • The
use of glutaraldehyde-based solutions in health-care facilities is widespread because of their advantages,
including excellent biocidal properties; activity in the presence of organic matter (20% bovine serum); and
noncorrosive action to endoscopic equipment, thermometers, rubber, or plastic equipment (Tables 4 and
5),

        Mode of Action. The biocidal activity of glutaraldehyde results from its alkylation of sulfhydryl,
hydroxyl, carboxyl, and amino groups of microorganisms, which alters RNA, DNA, and protein synthesis.
The mechanism of action of glutaraldehydes are reviewed extensively elsewhere 592 • 593 ,

         Microbicidal Activity. The in vitro inactivation of microorganisms by glutaraldehydes has been
extensively investigated and reviewed 592 ' 593 • Several investigators showed that :':2% aqueous solutions
of glutaraldehyde, buffered to pH 7.5-8.5 with sodium bicarbonate effectively killed vegetative bacteria in
<2 minutes; M. tuberculosis, fungi, and viruses in <10 minutes; and spores of Bacillus and Clostridium
species in 3 hours 542 • 592- 597• Spores of C. difficile are more rapidly killed by 2% glutaraldehyde than are
spores of other species of Clostridium and Bacillus 79 • 265 ' 266 • Microorganisms with substantial resistance
to glutaraldehyde have been reported, including some mycobacteria (M. chelonae, Mycobacterium
                                     598 601                                     602
avium-intracellulare, M. xenop1) - , Methylobacterium mesophilicum                   , Trichosporon, fungal
ascospores (e.g., Microascus cinereus, Cheatomium globosum), and Cryptosporidium 271 • 603 • M.
                                                                                                            604
chelonae persisted in a 0.2% glutaraldehyde solution used to store porcine prosthetic heart valves              •

          Two percent alkaline glutaraldehyde solution inactivated 105 M. tuberculosis cells on the surface
of penicylinders within 5 minutes at 1B'c 589 • However, subsequent studies" questioned the
mycobactericidal prowess of glutaraldehydes. Two percent alkaline glutaraldehyde has slow action (20 to
>30 minutes) against M. tuberculosis and compares unfavorably with alcohols, formaldehydes, iodine,
and phenol 82 • Suspensions of M. avium, M. intracellulare, and M. gordonae were more resistant to
inactivation by a 2% alkaline glutaraldehyde (estimated time to complete inactivation: -60 minutes) than
were virulent M. tuberculosis (estimated time to complete inactivation -25 minutes) 605 • The rate of kill
was directly proportional to the temperature, and a standardized suspension of M. tuberculosis could not
be sterilized within 10 minutes 84 • An FDA-cleared chemical sterilant containing 2.5% glutaraldehyde
uses increased temperature (35'C) to reduce the time required to achieve high-level disinfection (5
minutes) 85 • 606 , but its use is limited to automatic endoscope reprocessors equipped with a heater. In
another study employing membrane filters for measurement of mycobactericidal activity of 2% alkaline
glutaraldehyde, complete inactivation was achieved within 20 minutes at 2o'c when the test inoculum
was 106 M. tuberculosis per membrane 81 • Several investigators 55 ' 57 • 73 • 76 • 80 ' 81 ' 84 ' 605 have demonstrated
that glutaraldehyde solutions inactivate 2.4 to >5.0 log 10 of M. tuberculosis in 10 minutes (including
multidrug-resistant M. tuberculosis) and 4.0-6.4 log 10 of M. tuberculosis in 20 minutes. On the basis of
these data and other studies, 20 minutes at room temperature is considered the minimum exposure time
                                                                                                            17 19 27 57 83 94
needed to reliably kill Mycobacteria and other vegetative bacteria with :':2% glutaraldehyde • • • • • •
108,111,117-121,607

         Glutaraldehyde is commonly diluted during use, and studies showed a glutaraldehyde
                                                                                          608
concentration decline after a few days of use in an automatic endoscope washer ' 609 • The decline
occurs because instruments are not thoroughly dried and water is carried in with the instrument, which
increases the solution's volume and dilutes its effective concentration 610 • This emphasizes the need to
ensure that semicritical equipment is disinfected with an acceptable concentration of glutaraldehyde.
Data suggest that 1.0%-1.5% glutaraldehyde is the minimum effective concentration for >2%
glutaraldehyde solutions when used as a high-level disinfectant 76 ' 589 ' 590 ' 609 . Chemical test strips or liquid
chemical monitors 610' 611 are available for determining whether an effective concentration of
glutaraldehyde is present despite repeated use and dilution. The frequency of testing should be based
on how frequently the solutions are used (e.g., used daily, test daily; used weekly, test before use; used
30 times per day, test each 1Oth use), but the strips should not be used to extend the use life beyond the
expiration date. Data suggest the chemicals in the test strip deteriorate with time 612 and a

                                                                                                                          44
Guideline tor Disinfection and Sterilization in HonlthG[1tB r-·aci!itins, 2008

manufacturer's expiration date should be placed on the bottles. The bottle of test strips should be dated
when opened and used for the period of time indicated on the bottle (e.g., 120 days). The results of test
strip monitoring should be documented. The glutaraldehyde test kits have been preliminarily evaluated
                         612                                         613
for accuracy and range       but the reliability has been questioned     • To ensure the presence of
minimum effective concentration of the high-level disinfectant, manufacturers of some chemical test strips
recommend the use of quality-control procedures to ensure the strips perform properly. If the
manufacturer of the chemical test strip recommends a quality-control procedure, users should comply
with the manufacturer's recommendations. The concentration should be considered unacceptable or
unsafe when the test indicates a dilution below the product's minimum effective concentration (MEC)
(generally to .:o1.0%-1.5% glutaraldehyde) by the indicator not changing color.

         A 2.0% glutaraldehyde--7.05% phenol--1.20% sodium phenate product that contained 0.125%
glutaraldehyde--0.44% phenol--0.075% sodium phenate when diluted 1:16 is not recommended as a high-
level disinfectant because it lacks bactericidal activity in the ~resence of organic matter and lacks
                                                               49 5  71          614
tuberculocidal, fungicidal, virucidal, and sporicidal activity • • "· • 7 "' 79 • • In December 1991, EPA
issued an order to stop the sale of all batches of this product because of efficacy data showing the
product is not effective against spores and possibly other microorganisms or inanimate objects as
                      615
claimed on the label      • FDA has cleared a glutaraldehyde-phenol/phenate concentrate as a high-level
disinfectant that contains 1.12% glutaraldehyde with 1.93% phenol/phenate at its use concentration.
Other FDA cleared glutaraldehyde sterilants that contain 2.4%--3.4% glutaraldehyde are used undiluted
606

         Uses. Glutaraldeh¥,de is used most commonly as a high-level disinfectant for medical equipment
                      69   04                                616
such as endoscopes ' 107 ' , spirometry tubing, dialyzers        , transducers, anesthesia and respiratory
                    617                                                               249 618
therapy equipment , hemodialysis proportioning and dialysate delivery systems • , and reuse of
                                         619
laparoscopic disposable plastic trocars      • Glutaraldehyde is noncorrosive to metal and does not
damage lensed instruments, rubber. or plastics. Glutaraldehyde should not be used for cleaning
noncritical surfaces because it is too toxic and expensive.

          Colitis believed caused by glutaraldehyde exposure from residual disinfecting solution in
endoscope solution channels has been reported and is preventable by careful endoscope rinsing 31 ~ .
                                                                                                      620
630
     One study found that residual glutaraldehyde levels were higher and more variable after manual
                                                                                        631
disinfection {<0.2 mg/L to 159.5 mg/L) than after automatic disinfection (0.2--6.3 mg/L) • Similarly,
keratopathy and corneal decompensation were caused by ophthalmic instruments that were inadequately
                                            632 633
rinsed after soaking in 2% glutaraldehyde      •    •

          Health care personnel can be exposed to elevated levels of glutaraldehyde vapor when
equipment is processed in poorly ventilated rooms, when spills occur, when glutaraldehyde solutions are
                          634
activated or changed, , or when open immersion baths are used. Acute or chronic exposure can result
in skin irritation or dermatitis, mucous membrane irritation (eye, nose, mouth), or pulmonary symptoms
318 635 639
   •   '    • Epistaxis, allergic contact dermatitis, asthma, and rhinitis also have been reported in
                                                     636 64 647
health care workers exposed to glutaraldehyde • o.

         Glutaraldehyde exposure should be monitored to ensure a safe work environment. Testing can
be done by four techniques: a silica gel tube/gas chromatography with a fiame ionization detector,
dinitrophenylhydrazine (DNPH)-impregnated filter cassette/high-performance liquid chromatography
(HPLC) with an ultraviolet (UV) detector, a passive badge/HPLC, or a handheld glutaraldehyde air
monitor 648 • The silica gel tube and the DNPH-impregnated cassette are suitable for monitoring the 0.05
ppm ceiling limit. The passive badge, with a 0.02 ppm limit of detection, is considered marginal at the
America! Council of Governmental Industrial Hygienists (ACGIH) ceiling level. The ceiling level is
considered too close to the glutaraldehyde meter's 0.03 ppm limit of detection to provide confidence in
the readings 646 • ACGIH does not require a specific monitoring schedule for glutaraldehyde; however, a
monitoring schedule is needed to ensure the level is less than the ceiling limit. For example, monitoring

                                                                                                        45
Guideline for Disinlnction and Sto!'iliza\ion in Hoalthcare Facilitros, 2008

should be done initially to determine glutaraldehyde levels, after procedural or equipment changes, and in
                                  649
response to worker complaints • In the absence of an OSHA permissible exposure limit, if the
glutaraldehyde level is higher than the ACGIH ceiling limit of 0.05 ppm, corrective action and repeat
                               649
monitoring would be prudent •

          Engineering and work-practice controls that can be used to resolve these problems include
dueled exhaust hoods, air systems that provide 7-15 air exchanges per hour, ductless fume hoods with
absorbents for the glutaraldehyde vapor, tight-fitting lids on immersion baths, personal protection (e.g.,
nitrile or butyl rubber gloves but not natural latex ~loves, goggles) to minimize skin or mucous membrane
                                                           50
contact, and automated endoscope processors'· . If engineering controls fail to maintain levels below
the ceiling limit, institutions can consider the use of respirators (e.g., a half-face respirator with organic
                   640
vapor cartridge         or a type "C" supplied air respirator with a full facepiece operated in a positive
                    651
pressure mode) • In general, engineering controls are preferred over work-practice and administrative
controls because they do not require active participation by the health-care worker. Even thou?h
enforcement of the OSHA ceiling limit was suspended in 1993 by the U.S. Court of Appeals 57 , limiting
employee exposure to 0.05 ppm (according to ACGIH) is prudent because, at this level, glutaraldehyde
                                                       652
can irritate the eyes, throat, and nose 318 • 5 ' 639 ' • If glutaraldehyde disposal through the sanitary sewer
system is restricted, sodium bisulfate can be used to neutralize the glutaraldehyde and make it safe for
disposal.

Hydrogen Peroxide
        Overview. The literature contains several accounts of the properties, germicidal effectiveness,
and potential uses for stabilized hydrogen peroxide in the health-care setting. Published reports ascribe
good germicidal activit~ to hydrogen peroxide and attest to its bactericidal, virucidal, sporicidal, and
                      65 655
fungicidal properties        • (Tables 4 and 5) The FDA website lists cleared liquid chemical sterilants and
high-level disinfectants containing hydrogen peroxide and their cleared contact conditions.

        Mode of Action. Hydrogen peroxide works by producing destructive hydroxyl free radicals that
can attack membrane lipids, DNA, and other essential cell components. Catalase, produced by aerobic
organisms and facultative anaerobes that possess cytochrome systems, can protect cells from
metabolically produced hydrogen peroxide by degrading hydrogen peroxide to water and oxygen. This
defense is overwhelmed by the concentrations used for disinfection 653 • 654 •

            Microbicidal Activity. Hydrogen peroxide is active against a wide range of microorganisms,
                                                            654
including bacteria, yeasts, fungi, viruses, and spores 78 • • A 0.5% accelerated hydrogen peroxide
demonstrated bactericidal and virucidal activity in 1 minute and mycobactericidal and fungicidal activity in
              656
5 minutes • Bactericidal effectiveness and stability of hydrogen peroxide in urine has been
demonstrated against a variety of health-care-associated pathogens; organisms with high cellular
catalase activity (e.g., S. aureus,s.    marcescens, and Proteus m/rabilis) required 30-60 minutes of
                                                  8
exposure to 0.6% hydrogen peroxide for a 10 reduction in cell counts, whereas organisms with lower
catalase activity (e.Jl·· E. coli, Streptococcus species, and Pseudomonas species) required only 15
minutes' exposure 7 . In an investigation of 3%, 10%, and 15% hydrogen peroxide for reducing
spacecraft bacterial populations, a complete kill of 106 spores (i.e., Bacillus species) occurred with a 10%
                                                                                                6
concentration and a 50-minute exposure time. A 3% concentration for 150 minutes killed 10 spores in six
                            656                                                     3
of seven exposure trials • A 10% hydrogen peroxide solution resulted in a 10 decrease in B.
                                   5
atrophaeus spores, and a ;:1 0 decrease when tested against 13 other pathogens in 30 minutes at 2o"c
659 660
   '    • A 3.0% hydrogen peroxide solution was ineffective against VRE after 3 and 10 minutes exposure
        661
times        and caused only a 2-log 10 reduction in the number of Acanthamoeba cysts in approximately 2
hours."'. A 7% stabilized hydrogen peroxide proved to be sporicidal (6 hours of exposure),
mycobactericidal (20 minutes), fungicidal (5 minutes) at full strength, virucidal (5 minutes) and bactericidal
                                                                          655
(3 minutes) at a 1:16 dilution when a quantitative carrier test was used • The 7% solution of hydrogen
peroxide, tested after 14 days of stress (in the form of germ-loaded carriers and respiratory therapy
equipment), was sporicidal {> 7 log 10 reduction in 6 hours), mycobactericidal {>6.5 log 10 reduction in 25

                                                                                                             46
Guideline for Disinfection and StNilizn\ion in l·leal\hcare r:·01cililies, 2008

minutes), fungicidal {>51og 10 reduction in 20 minutes), bactericidal {>61og 10 reduction in 5 minutes) and
                                           663
virucidal (5 log 10 reduction in 5 minutes) • Synergistic sporicidal effects were observed when spores
                                                                                             664
were exposed to a combination of hydrogen peroxide (5.9%-23.6%) and peracetic acid • Other studies
                                                                              665
demonstrated the antiviral activity of hydrogen peroxide against rhinovirus • The time required for
inactivating three serotypes of rhinovirus using a 3% hydrogen peroxide solution was 6-8 minutes; this
time increased with decreasing concentrations (18-20 minutes at 1.5%, 5Q-60 minutes at 0.75%).

         Concentrations of hydrogen peroxide from 6% to 25% show promise as chemical sterilants. The
product marketed as a sterilant is a premixed, ready-to-use chemical that contains 7.5% hydrogen
                                                                69
peroxide and 0.85% phosphoric acid (to maintain a low pH) • The mycobactericidal activity of 7.5%
                                                                                        5
hydrogen peroxide has been corroborated in a study showing the inactivation of >10 multi drug-resistant
                                               666
M. tuberculosis after a 10-minute exposure , Thirty minutes were required for >99.9% inactivation of
                      667
poliovirus and HAV • Three percent and 6% hydrogen peroxide were unable to inactivate HAV in 1
                          58
minute in a earlier test • When the effectiveness of 7.5% hydrogen peroxide at 10 minutes was
compared with 2% alkaline glutaraldehyde at 20 minutes in manual disinfection of endoscopes, no
significant difference in germicidal activity was observed 668 • ). No complaints were received from the
nursing or medical staff regarding odor or toxicity. In one study, 6% hydrogen peroxide (unused product
was 7.5%) was more effective in the high-level disinfection of flexible endoscopes than was the 2%
                           456
glutaraldehyde solution • A new, rapid-acting 13.4% hydrogen peroxide formulation (that is not yet
FDA-cleared) has demonstrated sporicidal, mycobactericidal, fungicidal, and virucidal efficacy.
Manufacturer data demonstrate that this solution sterilizes in 30 minutes and provides high-level
disinfection in 5 minutes'". This product has not been used long enough to evaluate material
compatibility to endoscopes and other semicritical devices, and further assessment by instrument
manufacturers is needed.

        Under normal conditions, hydrogen peroxide is extremely stable when properly stored (e.g., in
dark containers). The decomposition or loss of potency in small containers is less than 2% per year at
                      670
ambient temperatures •

           Uses. Commercially available 3% hydrogen peroxide is a stable and effective disinfectant when
used on inanimate surfaces. It has been used in concentrations from 3% to 6% for disinfecting soft
                                        653 671 672                         513               673            397
contact lenses (e.g., 3% for 2-3 hrs)      '   •    , tonometer biprisms        , ventilators     , fabrics      , and
                  456                                                                                             397
endoscopes • Hydrogen peroxide was effective in spot-disinfecting fabrics in patients' rooms •
Corneal damage from a hydrogen peroxide-soaked tonometer tip that was not properly rinsed has been
            674
reported        • Hydrogen peroxide also has been instilled into urinary drainage bags in an attempt to
                                                                                                     675
eliminate the bag as a source of bladder bacteriuria and environmental contamination                     • Although the
instillation of hydrogen peroxide into the bag reduced microbial contamination of the bag, this procedure
                                                                      675
did not reduce the incidence of catheter-associated bacteriuria           •

         A chemical irritation resembling pseudomembranous colitis caused by either 3% hydrogen
                                                       621
peroxide or a 2% glutaraldehyde has been reported          • An epidemic of pseudomembrane-like enteritis
and colitis in seven patients in a gastrointestinal endoscopy unit also has been associated with
inadequate rinsing of 3% hydrogen peroxide from the endoscope 676 •

         As with other chemical sterilants, dilution of the hydrogen peroxide must be monitored by
regularly testing the minimum effective concentration (i.e., 7.5%-6.0%). Compatibility testing by Olympus
America of the 7.5% hydrogen peroxide found both cosmetic changes (e.g., discoloration of black
                          69
anodized metal finishes) and functional changes with the tested endoscopes (Olympus, written
communication, October 15, 1999).

lodophors
        Overview. Iodine solutions or tinctures long have been used by health professionals primarily as
antiseptics on skin or tissue. lodophors, on the other hand, have been used both as antiseptics and

                                                                                                                     47
Guideline for IJisinfeclion rmd Sterilization in Heslti1care Facilities, 2008

disinfectants. FDA has not cleared any liquid chemical sterilant or high-level disinfectants with iodophors
as the main active ingredient An iodophor is a combination of iodine and a solubilizing agent or carrier;
the resulting complex provides a sustained-release reservoir of iodine and releases small amounts of free
iodine in aqueous solution. The best-known and most widely used iodophor is povidone-iodine, a
compound of polyvinylpyrrolidone with iodine. This product and other iodophors retain the germicidal
                                                                                                            677
efficacy of iodine but unlike iodine generally are nonstaining and relatively free of toxicity and irritancy '
678

         Several reports that documented intrinsic microbial contamination of antiseptic formulations of
                                         67 661
povidone-iodine and poloxamer-iodine .,. caused a reappraisal of the chemistry and use of
           682
iodophors • "Free" iodine (1,) contributes to the bactericidal activity of iodophors and dilutions of
iodophors demonstrate more rapid bactericidal action than does a full-strength povidone-iodine solution.
The reason for the observation that dilution increases bactericidal activity is unclear, but dilution of
povidone-iodine might weaken the iodine linkage to the carrier polymer with an accompanying increase of
                       680
free iodine in solution • Therefore, iodophors must be diluted according to the manufacturers'
directions to achieve antimicrobial activity.
         Mode of Action. Iodine can penetrate the cell wall of microorganisms quickly, and the lethal
effects are believed to result from disruption of protein and nucleic acid structure and synthesis.

          Microbicidal Activity. Published reports on the in vitro antimicrobial efficacy of iodophors
demonstrate that iodophors are bactericidal, mycobactericidal, and virucidal but can require prolonged
                                                                      290 68 686
contact times to kill certain fungi and bacterial spores 14 ' 71 -73 ' ' ,_ • Three brands of povidone-iodine
solution have demonstrated more ra~id kill (seconds to minutes) of S. aureus and M. chelonae at a 1:100
                                      68
dilution than did the stock solution     • The virucidal activity of 75-150 ppm available iodine was
demonstrated against seven viruses • Other investi~ators have questioned the efficacy of iodophors
                                         72
                                                        68                                             290
against poliovirus in the presence of organic matter and rotavirus SA-11 in distilled or tapwater •
Manufacturers' data demonstrate that commercial iodophors are not sporicidal, but they are
tuberculocidal, fungicidal, virucidal, and bactericidal at their recommended use-dilution.

         Uses. Besides their use as an antiseptic, iodophors have been used for disinfecting blood
culture bottles and medical equipment, such as hydrotherapy tanks, thermometers, and endoscopes.
Antiseptic iodophors are not suitable for use as hard-surface disinfectants because of concentration
differences. lodophors formulated as antiseptics contain less free iodine than do those formulated as
              376
disinfectants • Iodine or iodine-based antiseptics should not be used on silicone catheters because
                                              687
they can adversely affect the silicone tubing •

Ortho-phthalaldehyde (OPA)
         Overview. Ortho-phthalaldehyde is a high-level disinfectant that received FDA clearance in
October 1999. It contains 0.55% 1,2-benzenedicarboxaldehyde (OPA). OPA solution is a clear, pale-
blue liquid with a pH of 7.5. (Tables 4 and 5)

          Mode of Action. Preliminary studies on the mode of action of OPA suggest that both OPA and
glutaraldehyde interact with amino acids, proteins, and microorganisms. However, OPA is a less potent
cross-linking agent This is compensated for by the lipophilic aromatic nature of OPA that is likely to
                                                                                     686 690
assist its uptake through the outer layers of mycobacteria and gram-negative bacteria - • OPA
                                                                  691
appears to kill spores by blocking the spore germination process      .

                                                                                                      69 100 271
         Microbicidal Activity. Studies have demonstrated excellent microbicidal activity in vitro • •             •
400 692 703
   •   '   For example, OPA has superior mycobactericidal activity (5-log 1o reduction in 5 minutes) to
            ,
glutaraldehyde. The mean times required to produce a 6-log 10 reduction forM. bovis using 0.21% OPA
                                                                       693
was 6 minutes, compared with 32 minutes using 1.5% glutaraldehyde • OPA showed good activity
against the mycobacteria tested, including the glutaraldehyde-resistant strains, but 0.5% OPA was not
sporicidal with 270 minutes of exposure. Increasing the pH from its unadjusted level (about 6.5) to pH 8
                                       694
improved the sporicidal activity of OPA • The level of biocidal activity was directly related to the

                                                                                                             48
Guideline tor Disinfccli0n and S!eriiiZfltion in Hcaltl'lcaro F'acilit!es, 2008

temperature. A greater than 5-log" reduction of B. atrophaeus spores was observed in 3 hours at 35"c,
than in 24 hours at 20"c. Also, with an exposure time _:::5 minutes, biocidal activity decreased with
increasin~ serum concentration. However, efficacy did not differ when the exposure time was ,::10
         6
minutes 7 • In addition, OPA is effective {>5-log 10 reduction) against a wide range of microorganisms,
                                                                              694
including glutaraldehyde-resistant mycobacteria and B. atrophaeus spores

         The influence of laboratory adaptation of test strains, such asP. aeruginosa, to 0.55% OPA has
been evaluated. Resistant and multiresistant strains increased substantially in susceptibility to OPA after
laboratory adaptation ~og 10 reduction factors increased by 0.54 and 0.91 for resistant and multiresistant
                       7
strains, respectively) 4• Other studies have found naturally occurring cells of P. aeurginosa were more
                                                                    705
resistant to a variety of disinfectants than were subcultured cells •

         Uses. OPA has several potential advantages over glutaraldehyde. It has excellent stability over
                                                                                      706
a wide pH range (pH 3-9), is not a known irritant to the eyes and nasal passages          , does not require
exposure monitoring, has a barely perceptible odor, and requires no activation. OPA, like glutaraldehyde,
has excellent material compatibility. A potential disadvantage of OPA is that it stains proteins gray
                                                                        69
(including unprotected skin) and thus must be handled with caution • However, skin staining would
indicate improper handling that requires additional training and/or personal protective equipment (e.g.,
gloves, eye and mouth protection, and fluid-resistant gowns). OPA residues remaining on inadequately
water-rinsed transesophageal echo probes can stain the patient's mouth 707 • Meticulous cleaning, using
the correct OPA exposure time (e.g., 12 minutes) and copious rinsing of the probe with water should
eliminate this problem. The results of one study provided a basis for a recommendation that rinsing of
instruments disinfected with OPA will require at least 250 ml of water per channel to reduce the chemical
                                                                                708
residue to a level that will not compromise patient or staff safety (<1 ppm)        • Personal protective
                                                                                                         400
equipment should be worn when contaminated instruments, equipment, and chemicals are handled
In addition, equipment must be thoroughly rinsed to prevent discoloration of a patient's skin or mucous
membrane.

         In April 2004, the manufacturer of OPA disseminated information to users about patients who
reportedly experienced an anaphylaxis-like reaction after cystoscopy where the scope had been
reprocessed using OPA. Of approximately 1 million urologic procedures performed using instruments
reprocessed using OPA, 24 cases (17 cases in the United States, six in Japan, one in the United
Kingdom) of anaphylaxis-like reactions have been reported after repeated cystoscopy (typically after four
to nine treatments). Preventive measures include removal of OPA residues by thorough rinsing and not
using OPA for reprocessing urologic instrumentation used to treat patients with a history of bladder
cancer (Nevine Erian, personal communication, June 4, 2004; Product Notification, Advanced
Sterilization Products, April 23, 2004) 709 •

         A few OPA clinical studies are available. In a clinical-use study, OPA exposure of 100
endoscopes for 5 minutes resulted in a >5-log 10 reduction in bacterial load. Furthermore, OPA was
                                   100
effective over a 14-day use cycle      • Manufacturer data show that OPA will last longer in an automatic
endoscope reprocessor before reaching its MEC limit (MEC after 82 cycles) than will glutaraldehyde
                       400
(MEC after 40 cycles)      • High-pressure liquid chromatography confirmed that OPA levels are
                                                706 710
maintained above 0.3% for at least 50 cycles       '    • OPA must be disposed in accordance with local and
state regulations. If OPA disposal through the sanitary sewer system is restricted, glycine (25
grams/gallon) can be used to neutralize the OPA and make it safe for disposal.

         The high-level disinfectant label claims for OPA solution at zo"c vary worldwide (e.g., 5 minutes
in Europe, Asia, and Latin America; 10 minutes in Canada and Australia; and 12 minutes in the United
States). These label claims differ worldwide because of differences in the test methodology and
requirements for licensure. In an automated endoscope reprocessor with an FDA-cleared capability to
maintain solution temperatures at 2s"c, the contact time for OPA is 5 minutes.

                                                                                                          49
Guidelrne lor Disinfeclion and Sterili:w\ion in H0aithcare l'acilitres, 200il

Peracetic Acid
          Overview. Peracetic, or peroxyacetic, acid is characterized by rapid action against all
microorganisms. Special advantages of peracetic acid are that it lacks harmful decomposition products
(i.e., acetic acid, water, oxygen, hydrogen peroxide), enhances removal of organic material 711 , and
leaves no residue. It remains effective in the presence of organic matter and is sporicidal even at low
temperatures (Tables 4 and 5). Peracetic acid can corrode copper, brass, bronze, plain steel, and
galvanized iron but these effects can be reduced by additives and pH modifications. It is considered
unstable, particularly when diluted; for example, a 1% solution loses half its strength through hydrolysis in
                                                                                         654
6 days, whereas 40% peracetic acid loses 1%--2% of its active ingredients per month •

        Mode of Action. Little is known about the mechanism of action of peracetic acid, but it is
believed to function similarly to other oxidizing agents-that is, it denatures proteins, disrupts the cell wall
                                                                                                       654
permeability, and oxidizes sulfhydryl and sulfur bonds in proteins, enzymes, and other metabolites

         Microbicidal Activity. Peracetic acid will inactivate gram-positive and gram-negative bacteria,
fungi, and yeasts in .::;5 minutes at <100 ppm. In the presence of organic matter, 200--500 ppm is
required. For viruses, the dosage range is wide (12--2250 ppm), with poliovirus inactivated in yeast
extract in 15 minutes with 1,500--2,250 ppm. In one study, 3.5% peracetic acid was ineffective against
                                                    58
HAV after 1-minute exposure using a carrier test . Peracetic acid (0.26%) was effective (log 10 reduction
factor >5) against all test strains of mycobacteria (M. tuberculosis, M. avium-intrace/lulare, M. chelonae,
                                                                                              712
and M. fortuitum) within 20--30 minutes in the presence or absence of an organic load 607 ' • With
bacterial spores, 500--10,000 ppm (0.05%--1 %) inactivates spores in 15 seconds to 30 minutes using a
spore suspension test 654 • 659 ' 711-715 •

          Uses. An automated machine using peracetic acid to chemically sterilize medical (e.g.,
                                                                                                     718
endoscopes, arthroscopes), surgical, and dental instruments is used in the United States 71 ,_ • As
previously noted, dental handpieces should be steam sterilized. The sterilant, 35% peracetic acid, is
diluted to 0.2% with filtered water at 5o'c. Simulated-use trials have demonstrated excellent microbicidal
         111 718 722
activity    •   -    , and three clinical trials have demonstrated both excellent microbial killing and no clinical
                                   723 724
failures leading to infection"· ' • The high efficacy of the system was demonstrated in a comparison
of the efficacies of the system with that of ethylene oxide. Only the peracetic acid system completely
killed 6 lo~ 10 of M. chelonae, E. faecalis, and B. atrophaeus spores with both an organic and inorganic
challenge 22 • An investigation that compared the costs, performance, and maintenance of urologic
endoscopic equipment processed by high-level disinfection (with glutaraldehyde) with those of the
peracetic acid system reported no clinical differences between the two systems. However, the use of this
system led to higher costs than the high-level disinfection, including costs for processing ($6.11 vs. $0.45
per cycle), purchasing and training ($24,845 vs. $16), installation ($5,800 vs. $0), and endoscope repairs
                        90
($6,037 vs. $445) • Furthermore, three clusters of infection using the peracetic acid automated
endoscope reprocessor were linked to inadequately processed bronchoscopes when inappropriate
                                                       725
channel connectors were used with the system               • These clusters highlight the importance of training,
proper model-specific endoscope connector systems, and quality-control procedures to ensure
compliance with endoscope manufacturer recommendations and professional organization guidelines. An
alternative high-level disinfectant available in the United Kingdom contains 0.35% peracetic acid.
                                                                                            466
Although this product is rapidly effective against a broad range of microorganisms • 7"· 727 , it tarnishes
                                                                                      727
the metal of endoscopes and is unstable, resulting in only a 24-hour use life             •

Peracetic Acid and Hydrogen Peroxide
        Overview. Two chemical steri\ants are available that contain peracetic acid plus hydrogen
peroxide (i.e., 0.08% peracetic acid plus 1.0% hydrogen peroxide [no longer marketed]; and 0.23%
peracetic acid plus 7.35% hydrogen peroxide (Tables 4 and 5).

         Microbicidal Activity. The bactericidal properties of peracetic acid and hydrogen peroxide have
                        728
been demonstrated             .   Manufacturer data demonstrated this combination of peracetic acid and

                                                                                                                50
Guideline tor Disinfection and Sterilization in Hoalt!lcme Facilitres, 2008

hydrogen peroxide inactivated all microorganisms except bacterial spores within 20 minutes. The 0.08%
peracetic acid p,lus 1.0% hydrogen peroxide product effectively inactivated glutaraldehyde-resistant
                9
mycobacteria' •

         Uses. The combination of peracetic acid and hydrogen peroxide has been used for disinfecting
                 730
hemodialyzers • The percentage of dialysis centers using a peracetic acid-hydrogen peroxide-based
                                                                                  249
disinfectant for reprocessing dialyzers increased from 5% in 1983 to 56% in 1997 • Olympus America
does not endorse use of 0.08% peracetic acid plus 1. 0% hydrogen peroxide (Olympus America, personal
communication, April 15, 1998) on any Olympus endoscope because of cosmetic and functional damage
and ~II not assume liability for chemical damage resulting from use of this product. This product is not
currently available. FDA has cleared a newer chemical sterilant ~th 0.23% peracetic acid and 7.35%
hydrogen peroxide (Tables 4 and 5). After testing the 7.35% hydrogen peroxide and 0.23% peracetic acid
product, Olympus America concluded it was not compatible ~th the company's flexible gastrointestinal
endoscopes; this conclusion was based on immersion studies where the test insertion tubes had failed
because of swelling and loosening of the black polymer layer of the tube (Olympus America, personal
communication, September 13, 2000).

Phenolics
          Overview. Phenol has occupied a prominent place in the field of hospital disinfection since its
initial use as a germicide by Lister in his pioneering work on antiseptic surgery. In the past 30 years,
however, work has concentrated on the numerous phenol derivatives or phenolics and their antimicrobial
properties. Phenol derivatives originate when a functional group (e.g., alkyl, phenyl, benzyl, halogen)
replaces one of the hydrogen atoms on the aromatic ring. Two phenol derivatives commonly found as
constituents of hospital disinfectants are ortho-phenylphenol and ortho-benzyl-para-chlorophenol. The
antimicrobial properties of these compounds and many other phenol derivatives are much improved over
those of the parent chemical. Phenolics are absorbed by porous materials, and the residual disinfectant
can irritate tissue. In 1970, depigmentation of the skin was reported to be caused by phenolic germicidal
                                                                                731
detergents containing para-tertiary butylphenol and para-tertiary amylphenol        •

        Mode of Action. In high concentrations, phenol acts as a gross protoplasmic poison,
penetrating and disrupting the cell wall and precipitating the cell proteins. Low concentrations of phenol
and higher molecular-weight phenol derivatives cause bacterial death by inactivation of essential enzyme
                                                                   732
systems and leakage of essential metabolites from the cell wall        •

        Microbicidal Activity. Published reports on the antimicrobial efficacy of commonly used
~henolics showed they were bactericidal, fungicidal, virucidal, and tuberculocidal
                                                                                     14 61 71 73 227 416 573 732
                                                                                       • • • •      •   •   •   -
 38. One study demonstrated little or no virucidal effect of a phenolic against coxsackie 84, echovirus 11,
                  736
and poliovirus 1 • Similarly, 12% ortho-phenylphenol failed to inactivate any of the three hydrophilic
                                                                                            72
viruses after a 10-minute exposure time, although 5% phenol was lethal for these viruses • A 0.5%
dilution of a phenolic (2.8% ortho-phenylphenol and 2.7% ortho-benzyl-para-chlorophenol) inactivated
HIV 227 and a 2% solution of a phenolic (15% ortho-phenylphenol and 6.3% para-tertiary-amylphenol)
inactivated all but one of 11 fungi tested 71 •

        Manufacturers' data using the standardized AOAC methods demonstrate that commercial
phenolics are not sporicidal but are tuberculocidal, fungicidal, virucidal, and bactericidal at their
recommended use-dilution. Attempts to substantiate the bactericidal label claims of phenolics using the
                                                          737
AOAC Use-Dilution Method occasionally have failed 416• • However, results from these same studies
have varied dramatically among laboratories testing identical products.

        Uses. Many phenolic germicides are EPA-registered as disinfectants for use on environmental
surfaces (e.g., bedside tables, bedrails, and laboratory surfaces) and noncritical medical devices.
Phenolics are not FDA-cleared as high-level disinfectants for use with semi critical items but could be
used to preclean or decontaminate critical and semicritical devices before terminal sterilization or high-

                                                                                                                51
Guid<~line   lor IJisinfcclion and Stm-ilizntion in Hefllihr:arn Faciltttcs, 2008

level disinfection,

         The use of phenolics in nurseries has been questioned because of hyperbilirubinemia in infants
placed in bassinets where phenolic detergents were used 739, In addition, bilirubin levels were reported to
increase in phenolic-exposed infants, compared with nonphenolio-exposed infants, when the phenolic
                                                                       740
was prepared according to the manufacturers' recommended dilution , If phenolics are used to clean
nursery ftoors, they must be diluted as recommended on the product label. Phenolics (and other
disinfectants) should not be used to clean infant bassinets and incubators while occupied, If phenolics are
used to terminally clean infant bassinets and incubators, the surfaces should be rinsed thoroughly with
water and dried before reuse of infant bassinets and incubators 17 ,

Quaternary Ammonium Compounds
         Overview. The quaternary ammonium compounds are widely used as disinfectants, Health-
care-associated infections have been reported from contaminated quaternary ammonium compounds
                                                                                                  741 742
used to disinfect patient-care supplies or equipment, such as cystoscofes or cardiac catheters ' •
                                                                        7 3
The quaternaries are good cleaning agents, but high water hardness          and materials such as cotton and
gauze pads can make them less microbicidal because of insoluble precipitates or cotton and gauze pads
absorb the active ingredients, respectively. One study showed a significant decline (-40%-50% lower at
1 hour) in the concentration of quaternaries released when cotton rags or cellulose-based wipers were
used in the open-bucket system, compared with the nonwoven spunlace wipers in the closed-bucket
        744
system      As with several other disinfectants (e.g., phenolics, iodophors) gram-negative bacteria can
survive or grow in them 404 •

         Chemically, the quaternaries are organically substituted ammonium compounds in which the
nitrogen atom has a valence of 5, four of the substituent radicals (R1-R4) are alkyl or heterocyclic radicals
                                                                                            745
of a given size or chain length, and the fifth (X') is a halide, sulfate, or similar radical • Each compound
exhibits its own antimicrobial characteristics, hence the search for one compound with outstanding
antimicrobial properties. Some of the chemical names of quaternary ammonium compounds used in
healthcare are alkyl dimethyl benzyl ammonium chloride, alkyl didecyl dimethyl ammonium chloride, and
dialkyl dimethyl ammonium chloride. The newer quaternary ammonium compounds (i.e., fourth
generation), referred to as twin-chain or dialkyl quaternaries (e.g. didecyl dimethyl ammonium bromide
and dioctyl dimethJel ammonium bromide), purportedly remain active in hard water and are tolerant of
                  7 6
anionic residues .

       A few case reports have documented occupational asthma as a result of exposure to
benzalkonium chloride 747 •

         Mode of Action. The bactericidal action of the quaternaries has been attributed to the
inactivation of energy-producing enzymes, denaturation of essential cell proteins, and disruption of the
                                                                               745 746
cell membrane"'. Evidence exists that supports these and other possibilities           •

          Microbicidal Activity. Results from manufacturers' data sheets and from published scientific
literature indicate that the quaternaries sold as hospital disinfectants are generally fungicidal, bactericidal,
and virucidal against lipophilic (enveloped) viruses; they are not sporicidal and a.enerally not
                                                                         14 54  56   61 71 7 166 297 746 749
tuberculocidal or virucidal against hydrophilic (nonenveloped) viruses • ·"· • • • • • • • • •
                                                                                                             73
The poor mycobactericidal activities of quaternary ammonium compounds have been demonstrated "·
Quaternary ammonium compounds (as well as 70% isopropyl alcohol, phenolic, and a chlorine-
containing wipe [80 ppm]) effectively (>95%) remove and/or inactivate contaminants (i.e., multidrug-
resistant S. aureus, vancomycin-resistant Entercoccus, P. aeruginosa) from computer keyboards with a
5-second application time. No functional damage or cosmetic changes occurred to the computer
                                                       45
keyboards after 300 applications of the disinfectants .

         Attempts to reproduce the manufacturers' bactericidal and tuberculocidal claims using the AOAC

                                                                                                              52
Guideline for Disinfection anrJ Sterilization in Hcalthcam Facilities, 2008

tests with a limited number of quaternary ammonium compounds occasionally have failed 73• 416• 737 •
However, test results have varied extensively among laboratories testing identical products 416• 737 •

        Uses. The quaternaries commonly are used in ordinary environmental sanitation of noncritical
surfaces, such as floors, furniture, and walls. EPA-registered quaternary ammonium compounds are
appropriate to use for disinfecting medical equipment that contacts intact skin (e.g., blood pressure cuffs).

                                                                                                           53
Guideline 'for Disinfection and SterHiLntlon ln HerillthC<3ro Facilities, 2008

                                MISCELLANEOUS INACTIVATING AGENTS

Other Germicides
        Several compounds have antimicrobial activity but for various reasons have not been
incorporated into the armamentarium of health-care disinfectants. These include mercurials, sodium
hydroxide, J3-propiolactone, chlorhexidine gluconate, cetrimide-chlorhexidine, glycols (triethylene and
propylene), and the Tego disinfectants. Two authoritative references examine these agents in detai1 16 ' 412 •

        A peroxygen-containing formulation had marked bactericidal action when used as a 1%
weight/volume solution and virucidal activity at 3% 49 , but did not have mycobactericidal activity at
concentrations of 2.3% and 4% and exf,'osure times ranging from 30 to 120 minutes 750• It also required
                                     7 1
20 hours to kill B. atrophaeus spores . A powder-based peroxygen compound for disinfecting
contaminated spill was strongly and rapidly bactericidal 752 •

         In preliminary studies, nanoemulsions (composed of detergents and lipids in water) showed
activity against vegetative bacteria, envelo,p,ed viruses and Candida. This product represents a potential
                                               755
agent for use as a topical biocidal agent. 7 "" .

                                                                                      756                  703
         New disinfectants that require further evaluation include glucoprotamin , tertiary amines • and
a light-activated antimicrobial coating 757 . Several other disinfection technologies might have potential
                                       758
applications in the healthcare setting     .

Metals as Microbicides
                                                 759                421                                   760
         Comprehensive reviews of antisepsis         , disinfection     , and anti-infective chemotherapy
                                                              761 762
barely mention the antimicrobial activity of heavy metals • • Nevertheless, the anti-infective activity of
some heavy metals has been known since antiquity. Heavy metals such as silver have been used for
prophylaxis of conjunctivitis of the newborn, topical therapy for burn wounds, and bonding to indwelling
                                                                                                      763
catheters, and the use of heavy metals as antiseptics or disinfectants is again being explored •
Inactivation of bacteria on stainless steel surfaces by zeolite ceramic coatings containing silver and zinc
                                     764 765
ions has also been demonstrated • •

          Metals such as silver, iron, and copper could be used for environmental control, disinfection of
                                                                                                              400
water, or reusable medical devices or incorporated into medical devices (e.g., intravascular catheters)           '
761 763 76 770
   '   • ..    . A comparative evaluation of six disinfectant formulations for residual antimicrobial activity
demonstrated that only the silver disinfectant demonstrated significant residual activity against S. aureus
                      763
and P. aeruginosa         • Preliminary data suggest metals are effective against a wide variety of
microorganisms.

        Clinical uses of other heavy metals include copper-8-quinolinolate as a fungicide against
                                                                 771 774
Aspergillus, copper-silver ionization for Legionella disinfection - , organic mercurials as an antiseptic
(e.g., mercurochrome) and preservative/disinfectant (e.g., thimerosal [currently being removed from
vaccines]) in pharmaceuticals and cosmetics 762 •

Ultraviolet Radiation (UV)
         The wavelength of UV radiation ranges from 328 nm to 210 nm (3280 A to 2100 A). Its maximum
bactericidal effect occurs at 240-280 nm. Mercury vapor lamps emit more than 90% of their radiation at
                                                             77
253.7 nm, which is near the maximum microbicidal activity . Inactivation of microorgani.sms results
from destruction of nucleic acid through induction of thymine dimers. UV radiation has been employed in
                                   776   775                    777                      778
the disinfection of drinking water , air , titanium implants        , and contact lenses     . Bacteria and
                                                                        775
viruses are more easily killed by UV light than are bacterial spores • UV radiation has several potential
applications, but unfortunately its germicidal effectiveness and use is influenced by organic matter;
wavelength; type of suspension; temperature; type of microorganism; and UV intensity, which is affected
by distance and dirty tubes779 . The application of UV radiation in the health-care environment (i.e.,

                                                                                                                 54
Guideline for Disinfection and Sterilizn\ion in Healthc;,tre Facilittes, 2008

operating rooms, isolation rooms, and biologic safety cabinets) is limited to destruction of airborne
organisms or inactivation of microorganisms on surfaces. The effect of UV radiation on postoperative
wound infections was investigated in a double-blind, randomized study in five university medical centers.
After following 14,854 patients over a 2-year period, the investigators reported the overall wound infection
rate was unaffected by UV radiation, although postoperative infection in the "refined clean" surgical
procedures decreased significantly (3.8%--2.9%) 780 • No data support the use of UV lamps in isolation
rooms, and this practice has caused at least one epidemic of UV-induced skin erythema and
keratoconjunctivitis in hospital patients and visitors 781 .

Pasteurization
         Pasteurization is not a sterilization process; its purpose is to destroy all pathogenic
microorganisms. However, pasteurization does not destroy bacterial spores. The time-temperature
relation for hot-water pasteurization is generally -70°C (158°F) for 30 minutes. The water temperature
                                                                           782
and time should be monitored as part of a ;t,uality-assurance program . Pasteurization of respiratory
         783 784                              78
therapy •        and anesthesia equipment is a recognized alternative to chemical disinfection. The
efficacy of this process has been tested using an inoculum that the authors believed might simulate
                                                                      7
contamination by an infected patient. Use of a large inoculum (1 0 ) of P. aeruginosa or Acinetobacter
ca/coaceticus in sets of respiratory tubing before processing demonstrated that machine-assisted
chemical processing was more efficient than machine-assisted pasteurization with a disinfection failure
                                     783
rate of 6% and 83%, respectively • Other investigators found hot water disinfection to be effective
(inactivation factor >5 log 10) against multiple bacteria, including multidrug-resistant bacteria, for
disinfecting reusable anesthesia or respiratory therapy equipment 784 _78.,

Flushing- and Washer-Disinfectors
         Flushing- and washer-disinfectors are automated and closed equipment that clean and disinfect
objects from bedpans and washbowls to surgical instruments and anesthesia tubes. Items such as
bedpans and urinals can be cleaned and disinfected in flushing-disinfectors. They have a short cycle of a
few minutes. They clean by flushing with warm water, possibly with a detergent, and then disinfect by
flushing the items with hot water or with steam. Because this machine empties, cleans, and disinfects,
manual cleaning is eliminated, fewer disposable items are needed, and fewer chemical germicides are
used. A microbiologic evaluation of one washer/disinfector demonstrated complete inactivation of
                                           787
suspensions of E. faeca/is or poliovirus . Other studies have shown that strains of Enterococcus
faecium can survive the British Standard for heat disinfection of bedpans (80"c for 1 minute). The
significance of this finding with reference to the potential for enterococci to survive and disseminate in the
                                         788 790
health-care environment is debatable - . These machines are available and used in many European
countries.

         Surgical instruments and anesthesia equipment are more difficult to clean. They are run in
washer-disinfectors on a longer cycle of approximately 20--30 minutes with a detergent. These machines
                                                  791
also disinfect by hot water at approximately go"c     .

                                                                                                            55
Guideline tor Disinfection and Stetilizntion in llenlt!lcarc Facilities, 2008

             THE REGULATORY FRAMEWORK FOR DISINFECTANTS AND STERILANTS

         Before using the guidance provided in this document, health-care workers should be aware of the
federal laws and regulations that govern the sale, distribution, and use of disinfectants and sterilants. In
particular, health-care workers need to know what requirements pertain to them when they apply these
products. Finally, they should understand the relative roles of EPA, FDA, and CDC so the context for the
guidance provided in this document is clear.

EPA and FDA
         In the United States, chemical germicides formulated as sanitizers, disinfectants, or sterilants are
regulated in interstate commerce by the Antimicrobials Division, Office of Pesticides Program, EPA,
under the authority of the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) of 1947, as
           792
amended • Under FIFRA, any substance or mixture of substances intended to prevent, destroy, repel,
or mitigate any pest (including microorganisms but excluding those in or on living humans or animals)
must be registered before sale or distribution. To obtain a registration, a manufacturer must submit
specific data about the safety and effectiveness of each product. For example, EPA requires
manufacturers of sanitizers, disinfectants, or chemical sterilants to test formulations by using accepted
methods for microbiocidal activity, stability, and toxicity to animals and humans. The manufacturers
submit these data to EPA along with proposed labeling. If EPA concludes the product can be used
without causing "unreasonable adverse effects," then the product and its labeling are registered, and the
manufacturer can sell and distribute the product in the United States.

         FIFRA also requires users of products to follow explicitly the labeling directions on each product.
The following standard statement appears on all labels under the "Directions for Use" heading: "It is a
violation of federal law to use this product in a manner inconsistent with its labeling." This statement
means a health-care worker must follow the safety precautions and use directions on the labeling of each
registered product. F allure to follow the specified use-dilution, contact time, method of application, or any
other condition of use Is considered a misuse of the product and potentially subject to enforcement action
under FIFRA.

         In general, EPA regulates disinfectants and sterilants used on environmental surfaces, and not
those used on critical or semicritical medical devices; the latter are regulated by FDA. In June 1993, FDA
and EPA issued a "Memorandum of Understanding" that divided responsibility for review and surveillance
of chemical germicides between the two agencies. Under the agreement, FDA regulates liquid chemical
sterilants used on critical and semicritical devices, and EPA regulates disinfectants used on noncritical
                                  793
surfaces and gaseous sterilants • In 1996, Congress passed the Food Quality Protection Act (FQPA).
This act amended FIFRA in regard to several types of products regulated by both EPA and FDA. One
provision of FQPA removed regulation of liquid chemical sterilants used on critical and semicritical
                                                                             792 794
medical devices from EPA's jurisdiction, and it now rests solely with FDA ' • EPA continues to
register nonmedical chemical sterilants. FDA and EPA have considered the impact of FQPA, and in
January 2000, FDA published its final guidance document on product submissions and labeling.
Antiseptics are considered antimicrobial drugs used on living tissue and thus are regulated by FDA under
the Food, Drug and Cosmetic Act. FDA regulates liquid chemical sterilants and high-level disinfectants
intended to process critical and semicritical devices. FDA has published recommendations on the types
of test methods that manufacturers should submit to FDA for 51 O(k] clearance for such agents.

CDC
         At CDC, the mission of the Coordinating Center for Infections Diseases is to guide the public on
how to prevent and respond to infectious diseases in both health-care settings and at home. With respect
to disinfectants and sterilants, part of CDC's role is to inform the public (in this case healthcare personnel)
of current scientific evidence pertaining to these products, to comment about their safety and efficacy,
and to recommend which chemicals might be most appropriate or effective for specific microorganisms
and settings.

                                                                                                            56
Cuidoline for Disinfection and Sterilization in llnaiH>rarn Facilitios, 2008

Test Methods
        The methods EPA has used for registration are standardized by the AOAC International;
however, a survey of scientific literature reveals a number of problems with these tests that were reported
                     58 76                      800
during 1987-1990 ' ' 80 ' 428 • 736 • 737 • 79"     that cause them to be neither accurate nor reproducible 416 • 73'-
 As part of their regulatory authorit~, EPA and FDA support development and validation of methods for
                                 801 80
assessing disinfection claims " • For example, EPA has supported the work of Dr. Syed Sattar and
coworkers who have developed a two-tier quantitative carrier test to assess sporicidal, mycobactericidal,
                                                                                            701 803
bactericidal, fungicidal, virucidal, and protozoacidal activity of chemical germicides • • EPA is
accepting label claims against hepatitis B virus (HBV) using a surrogate organism, the duck HBV, to
                               124 80
quantify disinfectant activity • • EPA also is accepting labeling claims against hepatitis C virus using
the bovine viral diarrhea virus as a surrogate.

         For nearly 30 years, EPA also performed intramural preregistration and postregistration efficacy
testing of some chemical disinfectants in its own laboratories. In 1982, this was stopped, reportedly for
budgetary reasons. At that time, manufacturers did not need to have microbiologic activity claims verified
                                                                                                   805
by EPA or an independent testing laboratory when registering a disinfectant or chemical sterilant • This
occurred when the frequency of contaminated germicides and infections secondary to their use had
            404
increased . Investigations demonstrating that interlaboratory reproducibility of test results was poor
                                                     416 737
and manufacturers' label claims were not verifiable •        and symposia sponsored by the American
                          800
Society for Microbiology      heightened awareness of these problems and reconfirmed the need to
improve the AOAC methods and reinstate a microbiologic activity verification program. A General
                                                                                     806
Accounting Office report entitled Disinfectants: EPA Lacks Assurance They Work           seemed to provide
the necessary impetus for EPA to initiate corrective measures, including cooperative agreements to
improve the AOAC methods and independent verification testing for all products labeled as sporicidal and
disinfectants labeled as tuberculocidal. For example, of 26 sterilant products tested by EPA, 15 were
canceled because of product failure. A list of products registered with EPA and labeled for use as
sterilants or tuberculocides or against HIV and/or HBV is available through EPA's website at
http://www.epa.gov/oppad001/chemregindex.htm. Organizations (e.g., Organization for Economic
Cooperation and Development) are working to standardize requirements for germicide testing and
registration.

         Neutralization of Germicides
         One of the difficulties associated with evaluating the bactericidal activity of disinfectants is
prevention of bacteriostasis from disinfectant residues carried over into the subculture media. Likewise,
small amounts of disinfectants on environmental surfaces can make an accurate bacterial count difficult
to get when sampling of the health-care environment as part of an epidemiologic or research
investigation. One wa~ these problems may be overcome is by employing neutralizers that inactivate
residual disinfectants 07"809 • Two commonly used neutralizing media for chemical disinfectants are
Letheen Media and D/E Neutralizing Media. The former contains lecithin to neutralize quaternaries and
polysorbate 80 (Tween 80) to neutralize phenolics, hexachlorophene, formalin, and, with lecithin, ethanol.
The D/E Neutralizing media will neutralize a broad spectrum of antiseptic and disinfectant chemicals,
including quaternary ammonium compounds, phenols, iodine and chlorine compounds, mercurials,
                                     810
formaldehlade, and glutaraldehyde • A review of neutralizers used in germicide testing has been
           08
published •

                                                                                                                   57
Gufdc!ino for Disinfection and Ste-rilization in !-··k:n!tllcaro Facilities, 2008

                                                  STERILIZATION

         Most medical and surgical devices used in healthcare facilities are made of materials that are
heat stable and therefore undergo heat, primarily steam, sterilization. However, since 1950, there has
been an increase in medical devices and instruments made of materials (e.g., plastics) that require low-
temperature sterilization. Ethylene oxide gas has been used since the 1950s for heat- and moisture-
sensitive medical devices. Vvlthin the past 15 years, a number of new, low-temperature sterilization
systems (e.g., hydrogen peroxide gas plasma, peracetic acid immersion, ozone) have been developed
and are being used to sterilize medical devices. This section reviews sterilization technologies used in
healthcare and makes recommendations for their optimum performance in the processing of medical
devices   1, 1a,a11~a2o.

        Sterilization destroys all microorganisms on the surface of an article or in a fluid to prevent
disease transmission associated with the use of that item. While the use of inadequately sterilized critical
items represents a high risk of transmitting pathogens, documented transmission of pathogens
                                                                                 821 822
associated with an inadequately sterilized critical item is exceedingly rare • • This is likely due to the
wide margin of safety associated with the sterilization processes used in healthcare facilities. The
concept of what constitutes "sterile" is measured as a probability of sterility for each item to be sterilized.
This probability is commonly referred to as the sterility assurance level (SAL) of the product and is
defined as the probability of a single viable microorganism occurring on a product after sterilization. SAL
is normally expressed a 1o·". For example, if the probability of a spore surviving were one in one million,
the SAL would be 1         o·'
                        823 824
                           •    • In short, a SAL is an estimate of lethality of the entire sterilization process
and is a conservative calculation. Dual SALs (e.g., 10' 3 SAL for blood culture tubes, drainage bags; 1      o·'
SAL for scalpels, implants) have been used in the United States for many years and the choice of a 1        o·'
SAL was strictly arbitrary and not associated with any adverse outcomes (e.g., patient infections) 823 .

         Medical devices that have contact with sterile body tissues or fluids are considered critical items.
 These items should be sterile when used because any microbial contamination could result in disease
transmission. Such items include surgical instruments, biopsy forceps, and implanted medical devices. If
these items are heat resistant, the recommended sterilization process is steam sterilization, because it
has the largest margin of safety due to its reliability, consistency, and lethality. However, reprocessing
heat- and moisture-sensitive items requires use of a low-temperature sterilization technology (e.g.,
                                                                    825
ethylene oxide, hydrogen peroxide gas plasma, peracetic acid)           • A summary of the advantages and
disadvantages for commonly used sterilization technologies is presented in Table 6.

Steam Sterilization
          Overview. Of all the methods available for sterilization, moist heat in the form of saturated steam
under pressure is the most widely used and the most dependable. Steam sterilization is nontoxic,
               826
inexpensive , rapidly microbicidal, sporicidal, and rapidly heats and penetrates fabrics (Table 6) 827 •
Like all sterilization processes, steam sterilization has some deleterious effects on some materials,
including corrosion and combustion of lubricants associated with dental handpieces 212 ; reduction in ability
                                                   828
to transmit light associated with laryngoscopes ; and increased hardening time (5.6 fold) with plaster-
cast 829.

          The basic principle of steam sterilization, as accomplished in an autoclave, is to expose each
item to direct steam contact at the required temperature and pressure for the specified time. Thus, there
are four parameters of steam sterilization: steam, pressure, temperature, and time. The ideal steam for
                                                                                   813 818
sterilization is dry saturated steam and entrained water (dryness fraction ;::97%) ' • Pressure serves
as a means to obtain the high temperatures necessary to quickly kill microorganisms. Specific
temperatures must be obtained to ensure the microbicidal activity. The two common steam-sterilizing
temperatures are 121"C (250"F) and 132"C (270"F). These temperatures (and other high temperatures)
830
    must be maintained for a minimal time to kill microorganisms. Recognized minimum exposure periods
for sterilization of wrapped healthcare supplies are 30 minutes at 121"C (250"F) in a gravity displacement

                                                                                                              58
Guideline tor Disinloclion and Sterilization in Hefllt!1cme FncilrUos, 200!\

sterilizer or 4 minutes at 132'C (270'C) in a prevacuum sterilizer (Table 7). At constant temperatures,
sterilization times vary depending on the type of item (e.g., metal versus rubber, plastic, items with
lumens), whether the item is wrapped or unwrapped, and the sterilizer type.

          The two basic types of steam sterilizers (autoclaves) are the gravity displacement autoclave and
the high-speed prevacuum sterilizer. In the former, steam is admitted at the top or the sides of the
sterilizing chamber and, because the steam is lighter than air, forces air out the bottom of the chamber
through the drain vent. The gravity displacement autoclaves are primarily used to process laboratory
media, water, pharmaceutical products, regulated medical waste, and nonporous articles whose surfaces
have direct steam contact. For gravity displacement sterilizers the penetration time into porous items is
prolonged because of incomplete air elimination. This point is illustrated with the decontamination of 10
lbs of microbiological waste, which requires at least 45 minutes at 121'C because the entrapped air
                                                                                                831 832
remaining in a load of waste greatly retards steam permeation and heating efficiency ' • The high-
speed prevacuum sterilizers are similar to the gravity displacement sterilizers except they are fitted with a
vacuum pump (or ejector) to ensure air removal from the sterilizing chamber and load before the steam is
admitted. The advantage of using a vacuum pump is that there is nearly instantaneous steam
penetration even into porous loads. The Bowie-Dick test is used to detect air leaks and inadequate air
removal and consists of folded 100% cotton surgical towels that are clean and preconditioned. A
commercially available Bowie-Dick-type test sheet should be placed in the center of the pack. The test
pack should be placed horizontally in the front, bottom section of the sterilizer rack, near the door and
                                                                                         813 819
over the drain, in an otherwise empty chamber and run at 134'C for 3.5 minutes ' . The test is used
each day the vacuum-type steam sterilizer is used, before the first processed load. Air that is not
removed from the chamber will interfere with steam contact. Smaller disposable test packs (or process
challenge devices) have been devised to replace the stack of folded surgical towels for testing the
                                                              833
efficacy of the vacuum system in a prevacuum sterilizer.          These devices are "designed to simulate
                                                                                                    819 834
product to be sterilized and to constitute a defined challenge to the sterilization process" ' • They
                                                                                               835
should be representative of the load and simulate the greatest challenge to the load • Sterilizer vacuum
performance is acceptable if the sheet inside the test pack shows a uniform color change. Entrapped air
will cause a spot to appear on the test sheet, due to the inability of the steam to reach the chemical
indicator. If the sterilizer fails the Bowie-Dick test, do not use the sterilizer until it is inspected by the
                                                                      813 819 836
sterilizer maintenance personnel and passes the Bowie-Dick test ' • •

         Another design in steam sterilization is a steam flush-pressure pulsing process, which removes
air rapidly by repeatedly alternating a steam flush and a pressure pulse above atmospheric pressure. Air
is rapidly removed from the load as with the prevacuum sterilizer, but air leaks do not affect this process
because the steam in the sterilizing chamber is always above atmospheric pressure. Typical sterilization
temperatures and times are 132'C to 135'C with 3 to 4 minutes exposure time for porous loads and
instruments827 ' 837 •

         Like other sterilization systems, the steam cycle is monitored by mechanical, chemical, and
biological monitors. Steam sterilizers usually are monitored using a printout (or graphically) by measuring
temperature, the time at the temperature, and pressure. Typically, chemical indicators are affixed to the
outside and incorporated into the pack to monitor the temperature or time and temperature. The
effectiveness of steam sterilization is monitored with a biological indicator containing spores of
Geobacillus stearothermophi/us (formerly Bacillus stearothermophilus). Positive spore test results are a
                      838                                                                    839
relatively rare event     and can be attributed to operator error, inadequate steam delivery , or
equipment malfunction.
                                                                                               840
          Portable (table-top) steam sterilizers are used in outpatient, dental, and rural clinics . These
sterilizers are designed for small instruments, such as hypodermic syringes and needles and dental
instruments. The ability of the sterilizer to reach physical parameters necessary to achieve sterilization
should be monitored by mechanical, chemical, and biological indicators.

                                                                                                             59
Guideline tor Dlslnfectlon r.1.nd Slori!izat1on in Hoaltr1csro r:·aci!itle$, /~008

         Microbicidal Activity. The oldest and most recognized agent for inactivation of microorganisms
is heat. D-values (time to reduce the surviving population by 90% or 11og 10) allow a direct comparison of
the heat resistance of microorganisms. Because a D-value can be determined at various temperatures, a
subscript is used to designate the exposure temperature (i.e., 0 1210 ). D121 c-values for Geobacillus
stearothermophilus used to monitor the steam sterilization process range from 1 to 2 minutes. Heat-
resistant nonspore-formina bacteria, yeasts, and fungi have such low D121 c values that they cannot be
experimentally measured' 1.

       Mode of Action. Moist heat destroys microorganisms by the irreversible coagulation and
denaturation of enzymes and structural proteins. In support of this fact, it has been found that the
presence of moisture significantly affects the coagulation temperature of proteins and the temperature at
which microorganisms are destroyed.

         Uses. Steam sterilization should be used whenever possible on all critical and semi critical items
that are heat and moisture resistant (e.g., steam sterilizable respiratory therapy and anesthesia
equipment), even when not essential to prevent pathogen transmission. Steam sterilizers also are used
                                                                                         831 832 842
in healthcare facilities to decontaminate microbiological waste and sharps containers • •            but
additional exposure time is required in the gravity displacement sterilizer for these items.

Flash Sterilization
          Overview. "Flash" steam sterilization was originally defined by Underwood and Perkins as
sterilization of an unwrapped object at 132'C for 3 minutes at 27-28 lbs. of pressure in a gravity
displacement sterilizer'". Currently, the time required for flash sterilization depends on the type of
sterilizer and the type of item (i.e., porous vs non-porous items)(see Table 8). Although the wrapped
method of sterilization is preferred for the reasons listed below, correctly performed flash sterilization is
                                                                      844
an effective process for the sterilization of critical medical devices ' 845 • Flash sterilization is a
modification of conventional steam sterilization (either gravity, prevacuum, or steam-flush pressure-pulse)
in which the flashed item Is placed in an open tray or is placed in a specially designed, covered, rigid
container to allow for rapid penetration of steam. Historically, it is not recommended as a routine
sterilization method because of the lack of timely biological indicators to monitor performance, absence of
protective packaging following sterilization, possibility for contamination of processed items during
transportation to the operating rooms, and the sterilization cycle parameters (i.e., time, temperature,
pressure) are minimal. To address some of these concerns, many healthcare facilities have done the
following: placed equipment for flash sterilization in close proximity to operating rooms to facilitate aseptic
delivery to the point of use (usually the sterile field in an ongoing surgical procedure); extended the
                                                                                                         846 847
exposure time to ensure lethality comparable to sterilized wrapped items (e.g., 4 minutes at 132'C) ' ;
                                                                                        847
used biological indicators that provide results in 1 hour for flash-sterilized items'"· ; and used protective
                                              12
packaging that permits steam penetration' • 817"81 '·"'·'". Further, some rigid, reusable sterilization
container systems have been designed and validated by the container manufacturer for use with flash
cycles. When sterile items are open to air, they will eventually become contaminated. Thus, the longer a
sterile item is exposed to air, the greater the number of microorganisms that will settle on it. Sterilization
cycle parameters for flash sterilization are shown in Table 8.

         A few adverse events have been associated with flash sterilization. When evaluating an
increased incidence of neurosurgical infections, the investigators noted that surgical instruments were
flash sterilized between cases and 2 of 3 craniotomy infections involved plate implants that were flash
sterilized 849 . A report of two patients who received burns during surgery from instruments that had been
flash sterilized reinforced the need to develop policies and educate staff to prevent the use of instruments
                                       850
hot enough to cause clinical burns • Staff should use precautions to prevent burns with potentially hot
instruments (e.g., transport tray using heat-protective gloves). Patient burns may be prevented by either
air-cooling the instruments or immersion in sterile liquid (e.g., saline).

         Uses. Flash sterilization is considered acceptable for processing cleaned patient-care items that

                                                                                                             60
Guideline ·for Disinfection and SterHization in Hcalthcaro r-:"ac!!Jties, 200R

cannot be packaged, sterilized, and stored before use. It also is used when there is insufficient time to
sterilize an item by the preferred package method. Flash sterilization should not be used for reasons of
                                                                                               817
convenience, as an alternative to purchasing additional instrument sets, or to save time • Because of
the potential for serious infections, flash sterilization is not recommended for implantable devices (i.e.,
devices placed into a surgically or naturally formed cavity of the human body); however, flash sterilization
may be unavoidable for some devices (e.g., orthopedic screw, plates). If flash sterilization of an
implantable device is unavoidable, recordkeeping (i.e., load identification, patient's name/hospital
identifier, and biological indicator result) is essential for epidemiological tracking (e.g., of surgical site
infection, tracing results of biological indicators to patients who received the item to document sterility),
and for an assessment of the reliability of the sterilization process (e.g., evaluation of biological
monitoring records and sterilization maintenance records noting preventive maintenance and repairs with
dates).

Low-Temperature Sterilization Technologies
         Ethylene oxide (ETO) has been widely used as a low-temperature sterilant since the 1950s. It
has been the most commonly used process for sterilizing temperature- and moisture-sensitive medical
devices and supplies in healthcare institutions in the United States. Two types of ETO sterilizers are
available, mixed gas and 100% ETO. Until1995, ethylene oxide sterilizers combined ETO with a
chloroflourocarbon (CFC) stabilizing agent, most commonly in a ratio of 12% ETO mixed with 88% CFC
(referred to as 12/88 ETO).

          For several reasons, healthcare personnel have been exploring the use of new low-temperature
                              851
sterilization technologies""· • First, CFCs were phased out in December 1995 under provisions of the
                852
Clean Air Act       • CFCs were classified as a Class I substance under the Clean Air Act because of

scientific evidence linking them to destruction of the earth's ozone layer. Second, some states (e.g.,
California, New York, Michigan) require the use of ETO abatement technology to reduce the amount of
ETO being released into ambient air from 90 to 99.9% depending on the state. Third, OSHA regulates
the acceptable vapor levels of ETO (i.e., 1 ppm averaged over 8 hours) due to concerns that ETO
exposure represents an occupational hazard 318 . These constraints have led to the development of
alternative technologies for low-temperature sterilization in the health care setting.

         Alternative technologies to ETO with chlorofluorocarbon that are currently available and cleared
by the FDA for medical equipment include 100% ETO; ETO with a different stabilizing gas, such as
carbon dioxide or hydrochlorofluorocarbons (HCFC); immersion in peracetic acid; hydrogen peroxide gas
plasma; and ozone. Technologies under development for use in healthcare facilities, but not cleared by
the FDA, include vaporized hydro~en reroxide, vapor phase peracetic acid, gaseous chlorine dioxide,
                                   4  75 853
ionizing radiation, or pulsed light '· • • However, there is no guarantee that these new sterilization
technologies will receive FDA clearance for use in healthcare facilities.

          These new technologies should be compared against the characteristics of an ideal low-
                                            851
temperature (<60'C) sterilant (Table 9).         While it is apparent that all technologies will have limitations
(Table 9), understanding the limitations imposed by restrictive device designs (e.g., long, narrow lumens)
                                                                   854
is critical for proper application of new sterilization technology       For example, the development of
increasingly small and complex endoscopes presents a difficult challenge for current sterilization
processes. This occurs because microorganisms must be in direct contact with the sterilant for
inactivation to occur. Several peer-reviewed scientific publications have data demonstrating concerns
about the efficacy of several of the low-temperature sterilization processes (i.e., gas plasma, vaporized
hydrogen peroxide, ETO, peracetic acid), particularly when the test or~anisrns are challenged in the
                                                              469   825 855
presence of serum and salt and a narrow lumen vehicle ' 721 • ' • 8 6 • Factors shown to affect the
efficacy of sterilization are shown in Table 10.

Ethylene Oxide "Gas" Sterilization
       Overview. ETO is a colorless gas that is flammable and explosive. The four essential

                                                                                                               61
Guicle!int:i 'for Disinfection and SteH!izat1on in Hen!thcnre F<:Kilitios) 2008

parameters (operational ranges) are: gas concentration (450 to 1200 mgn); temperature (37 to 63'C);
relative humidity (40 to 80%)(water molecules carry ETO to reactive sites); and exposure ~me (1 to 6
                                                                     857
hours). These influence the effectiveness of ETO sterilization 814 • • 858 • Wthin certain limitations, an
increase in gas concentration and temperature may shorten the time necessary for achieving sterilization.
         The main disadvantages associated with ETO are the lengthy cycle time, the cost, and its
potential hazards to patients and staff; the main advantage is that it can sterilize heat- or moisture-
sensitive medical equipment without deleterious effects on the material used in the medical devices
(Table 6). Acute exposure to ETO may result in irritation (e.g., to skin, eyes, gastrointestinal or
                                                               8 862
respiratory tracts) and central nervous system depression " ' . Chronic inhalation has been linked to
the formation of cataracts, cognitive impairment, neurologic dysfunction, and disabling
polyneuropathies ' ~· "' • Occupational exposure in health care facilities has been linked to
                   860 86 86 866
                         867                                                                       318   870
hematologic changes          and an increased risk of spontaneous abortions and various cancers ' 86.. •
                                                           871
ETO should be considered a known human carcinogen •

         The basic ETO sterilization cycle consists of five stages (i.e., preconditioning and humidification,
gas introduction, exposure, evacuation, and air washes) and takes approximately 2 1/2 hrs excluding
aeration time. Mechanical aeration for 8 to 12 hours at 50 to 60'C allows desorption of the toxic ETO
residual contained in exposed absorbent materials. Most modern ETO sterilizers combine sterilization
and aeration in the same chamber as a continuous process. These ETO models minimize potential ETO
exposure during door opening and load transfer to the aerator. Ambient room aeration also will achieve
desorption of the toxic ETO but requires 7 days at 20'C. There are no federal regulations for ETO
sterilizer emission; however, many states have promulgated emission-control regulations 814 •

         The use of ETO evolved when few alternatives existed for sterilizing heat- and moisture-sensitive
medical devices; however, favorable properties (Table 6) account for its continued widespread use"'.
Two ETO gas mixtures are available to replace ETO-chlorofluorocarbon (CFC) mixtures for large
capacity, tank-supplied sterilizers. The ETO-carbon dioxide (C0 2) mixture consists of 8.5% ETO and
91.5% C0 2 . This mixture is less expensive than ETO-hydrochlorofluorocarbons (HCFC), but a
disadvantage is the need for pressure vessels rated for steam sterilization, because higher pressures
(28-psi gauge) are required. The other mixture, which is a drop-in CFC replacement, is ETO mixed with
HCFC. HCFCs are approximately 50-fold less damaging to the earth's ozone layer than are CFCs. The
EPA will begin regulation of HCFC in the year 2015 and will terminate production in the year 2030. Two
companies provide ETO-HCFC mixtures as drop-in replacement for CFC-12; one mixture consists of
                                                                                               8
8.6% ETO and 91.4% HCFC, and the other mixture is composed of 10% ETO and 90% HCFC "- An
alternative to the pressurized mixed gas ETO systems is 100% ETO. The 100% ETO sterilizers using
unit-dose cartridges eliminate the need for external tanks.

          ETO is absorbed by many materials. For this reason, following sterilization the item must
undergo aeration to remove residual ETO. Guidelines have been promulgated regarding allowable ETO
limits for devices that depend on how the device is used, how often, and how long in order to pose a
                                              814
minimal risk to patients in normal product use •

         ETO toxicity has been established in a variety of animals. Exposure to ETO can cause eye pain,
sore throat, difficulty breathing and blurred vision. Exposure can also cause dizziness, nausea,
                                                              873
headache, convulsions, blisters and vomiting and coughing • In a variety of in vitro and animal studies,
ETO has been demonstrated to be carcinogenic. ETO has been linked to spontaneous abortion, genetic
                                                                                                       873
damage, nerve damage, peripheral paralysis, muscle weakness, and impaired thinking and memory •
Occupational exposure in healthcare facilities has been linked to an increased risk of spontaneous
abortions and various cancers318 • Injuries (e.g., tissue burns) to patients have been associated with ETO
                                                    874
residues in implants used in surgical procedures • Residual ETO in capillary flow dialysis membranes
                                            875
has been shown to be neurotoxic in vitro . OSHA has established a PEL of 1 ppm airborne ETO in the
workplace, expressed as a TWA for an 8-hour work shift in a 40-hour work week. The "action level" for
ETO is 0.5 ppm, expressed as an 8-hour TWA, and the short-term excursion limit is 5 ppm, expressed as

                                                                                                           62
CJuidnline "for Disinfection and   Stf~rili.zation   In Hoa!thcarn Facilities, 2008

                   814
a 15-minute TWA • For details of the requirements in OSHA's ETO standard for occupational
exposures, see Title 29 of the Code of Federal Regulations (CFR) Part 1910.1047873 • Several personnel
monitoring methods (e.g., charcoal tubes and passive sampling devices) are in use 814. OSHA has
established a PEL of 5 ppm for ethylene chlorohydrin (a toxic by-product of ETO) in the workplace 876•
Additional information regarding use of ETO in health care facilities is available from NIOSH.

         Mode of Action. The microbicidal activity of ETO is considered to be the result of alkylation of
protein, DNA, and RNA Alkylation, or the replacement of a hydrogen atom with an alkyl group, within
cells prevents normal cellular metabolism and replication 877•

        Microbicidal Activitv. The excellent microbicidal activity of ETO has been demonstrated in
several studies 469 ' 721 • 722 • 856 ' ~ 78 • 879 and summarized in published reports 877 • ETO inactivates all
microorganisms although bacterial spores (especially B. atrophaeus) are more resistant than other
microorganisms. For this reason B. atrophaeus is the recommended biological indicator.

         Like all sterilization processes, the effectiveness of ETO sterilization can be altered by lumen
length, lumen diameter, inorganic salts, and organic materials469' 721 ' 722 • 855 • 856• 879 • For example, although
ETO is not used commonly for reprocessing endoscopes", several studies have shown failure of ETO in
                                                                                                   879
inactivating contaminating spores in endoscope channels 855or lumen test units 469 ' 721 • and residual
                                                                               456
ETO levels averaging 66.2 ppm even after the standard degassing time • Failure of ETO also has been
observed when dental handpieces were contaminated with Streptococcus mutans and exposed to
ET0 880 • It is recommended that dental handpieces be steam sterilized.

         Uses. ETO is used in healthcare facilities to sterilize critical items (and sometimes semicritical
items) that are moisture or heat sensitive and cannot be sterilized by steam sterilization.

Hydrogen Peroxide Gas Plasma
         Overview. New sterilization technology based on plasma was patented in 1987 and marketed in
the United States in 1993. Gas plasmas have been referred to as the fourth state of matter (i.e., liquids,
solids, gases, and gas plasmas). Gas plasmas are generated in an enclosed chamber under deep
vacuum using radio frequency or microwave energy to excite the gas molecules and produce charged
particles, many of which are in the form of free radicals. A free radical is an atom with an unpaired
electron and is a highly reactive species. The proposed mechanism of action of this device is the
production of free radicals within a plasma field that are capable of interacting with essential cell
components (e.g., enzymes, nucleic acids) and thereby disrupt the metabolism of microorganisms. The
type of seed gas used and the depth of the vacuum are two important variables that can determine the
effectiveness of this process.

         In the late 1980s the first hydrogen peroxide gas plasma system for sterilization of medical and
surgical devices was field-tested. According to the manufacturer, the sterilization chamber is evacuated
and hydrogen peroxide solution is injected from a cassette and is vaporized in the sterilization chamber to
a concentration of 6 mg/1. The hydrogen peroxide vapor diffuses through the chamber (50 minutes),
exposes all surfaces of the load to the sterilant, and initiates the inactivation of microorganisms. An
electrical field created by a radio frequency is applied to the chamber to create a gas plasma.
Microbicidal free radicals (e.g., hydroxyl and hydroperoxyl) are generated in the plasma. The excess gas
is removed and in the final stage (i.e., vent) of the process the sterilization chamber is returned to
atmospheric pressure by introduction of high-efficiency filtered air. The by-products of the cycle (e.g.,
water vapor, oxygen) are nontoxic and eliminate the need for aeration. Thus, the sterilized materials can
be handled safely, either for immediate use or storage. The process operates in the range of 37-44'C
and has a cycle time of 75 minutes. If any moisture is present on the objects the vacuum will not be
achieved and the cycle aborts 856• 881 ' 883 •

         A newer version of the unit improves sterilizer efficacy by using two cycles with a hydrogen

                                                                                                                   63
Guideline for Disinfeclion and St<11'iliza!ion in l·lealthcare l"ncilltios, 2003

peroxide diffusion stage and a plasma stage per sterilization cycle. This revision, which is achieved by a
software modification, reduces total processing time from 73 to 52 minutes. The manufacturer believes
that the enhanced activity obtained with this system is due in part to the pressure changes that occur
during the injection and diffusion phases of the process and to the fact that the process consists of two
                                                                                            856 884 885
equal and consecutive half cycles, each with a separate injection of hydrogen peroxide.        •   •    This
                                400 882
system and a smaller version '          have received FDA 51 O[k] clearance with limited application for
sterilization of medical devices (Table 6). The biological indicator used with this system is Bacillus
atrophaeus spores851 • The newest version of the unit, which employs a new vaporization system that
removes most of the water from the hydrogen peroxide, has a cycle time from 28-38 minutes (see
manufacturer's literature for device dimension restrictions).

        Penetration of hydrogen peroxide vapor into long or narrow lumens has been addressed outside
the United States by the use of a diffusion enhancer. This is a small, breakable glass ampoule of
concentrated hydrogen peroxide (50%) with an elastic connector that is inserted into the device lumen
                                             470 885
and crushed immediately before sterilization • • The diffusion enhancer has been shown to sterilize
bronchoscopes contaminated with Mycobacteria tuberculosis"'. At the present time, the diffusion
enhancer is not FDA cleared.

         Another gas plasma system, which differs from the above in several important ways, including
the use of peracetic acid-acetic acid-hydrogen peroxide vapor, was removed from the marketplace
because of reports of corneal destruction to patients when ophthalmic surgery instruments had been
                              888
processed in the sterilizer"'· • In this investigation, exposure of potentially wet ophthalmologic surgical
instruments with small bores and brass components to the plasma gas led to degradation of the brass to
                 888 889
copper and zinc ' • The experimenters showed that when rabbit eyes were exposed to the rinsates of
the gas plasma-sterilized instruments, corneal decompensation was documented. This toxicity is highly
unlikely with the hydrogen peroxide gas plasma process since a toxic, soluble form of copper would not
form (LA Feldman, written communication, April1998).

        Mode of Action. This process inactivates microorganisms primarily by the combined use of
hydrogen peroxide gas and the generation of free radicals (hydroxyl and hydroproxyl free radicals) during
the plasma phase of the cycle.

           Microbicidal Activity. This process has the ability to inactivate a broad range of
microorganisms, including resistant bacterial spores. Studies have been conducted a@ainst vegetative
                                                                                  469 721 85 881 883 890 893
bacteria (including mycobacteria), yeasts, fungi, viruses, and bacterial spores ' ' • ' • ' • Like
all sterilization processes, the effectiveness can be altered by lumen length, lumen diameter, inorganic
salts, and organic materials469, 721, ass, sse, aso, sst, as3.

         Uses. Materials and devices that cannot tolerate high temperatures and humidity, such as some
plastics, electrical devices, and corrosion-susceptible metal alloys, can be sterilized by hydrogen
peroxide gas plasma. This method has been compatible with most {>95%) medical devices and
                  884 894
materials tested ' ' 895 •

Peracetic Acid Sterilization
         Overview. Peracetic acid is a highly biocidal oxidizer that maintains its efficacy in the presence
                                                                                                         711
of organic soil. Peracetic acid removes surface contaminants (primarily protein) on endoscopic tubing '
717
    • An automated machine using peracetic acid to sterilize medical, surgical, and dental instruments
chemically (e.g., endoscopes, arthroscopes) was introduced in 1988. This microprocessor-controlled,
low-temperature sterilization method is commonly used in the United States 107 . The sterilant, 35%
peracetic acid, and an anticorrosive agent are supplied in a single-dose container. The container is
punctured at the time of use, immediately prior to closing the lid and initiating the cycle. The
concentrated peracetic acid is diluted to 0.2% with filtered water (0.2 ~m) at a temperature of
approximately 50°C. The diluted peracetic acid is circulated within the chamber of the machine and

                                                                                                          64
Guideline for Disinfection 2nd Stenlizntion in llnnltiln'uc FactltMs, 2008

pumped through the channels of the endoscope for 12 minutes, decontaminating exterior surfaces,
lumens, and accessories. Interchangeable trays are available to permit the processing of up to three rigid
endoscopes or one flexible endoscope. Connectors are available for most types of flexible endoscopes
for the irrigation of all channels by directed flow. Rigid endoscopes are placed within a lidded container,
and the sterilant fills the lumens either by immersion in the circulating sterilant or by use of channel
connectors to direct flow into the lumen(s) (see below for the importance of channel connectors). The
peracetic acid is discarded via the sewer and the instrument rinsed four times with filtered water.
                                                                                        896
Concern has been raised that filtered water may be inadequate to maintain sterility • Limited data have
shown that low-level bacterial contamination may follow the use of filtered water in an AER but no data
                                                                 161
has been published on AERs using the peracetic acid system . Clean filtered air is passed through the
chamber of the machine and endoscope channels to remove excess water719 • As with any sterilization
process, the system can only sterilize surfaces that can be contacted by the sterilant. For example,
bronchoscop¥-related infections occurred when bronchoscopes were processed using the wrong
            15 25
connector • • Investigation of these incidents revealed that bronchoscopes were inadequately
reprocessed when inappropriate channel connectors were used and when there were inconsistencies
between the reprocessing instructions provided by the manufacturer of the bronchoscope and the
                                                          155
manufacturer of the automatic endoscope reprocessor • The importance of channel connectors to
                                                               137 856
achieve sterilization was also shown for rigid lumen devices ' .

          The manufacturers suggest the use of biological monitors (G. stearothermophilus spore strips)
both at the time of installation and routinely to ensure effectiveness of the process. The manufacturer's
clip must be used to hold the strip in the designated spot in the machine as a broader clamp will not allow
                                                    897
the sterilant to reach the spores trapped under it • One investigator reported a 3% failure rate when the
appropriate clips were used to hold the spore strip within the machine718 . The use of biological monitors
designed to monitor either steam sterilization or ETO for a liquid chemical sterilizer has been questioned
for several reasons including spore wash-oft from the filter paper strips which may cause less valid
            898 901
monitoring - • The processor is equipped with a conductivity probe that will automatically abort the
cycle if the buffer system is not detected in a fresh container of the peracetic acid solution. A chemical
monitoring strip that detects that the active ingredient is >1500 ppm is available for routine use as an
additional process control.

         Mode of Action. Only limited information is available regarding the mechanism of action of
peracetic acid, but it is thought to function as other oxidizing agents, i.e., it denatures proteins, disrupts
cell wall permeability, and oxidizes sulflhydral and sulfur bonds in proteins, enzymes, and other
                726
metabolites'"· •
         Microbicidal Activity. Peracetic acid will inactivate gram-positive and gram-negative bacteria,
fungi, and yeasts in <5 minutes at <100 ppm. In the presence of organic matter, 200-500 ppm is
required. For viruses, the dosage range is wide (12-2250 ppm), with poliovirus inactivated in yeast extract
in 15 minutes with 1500 to 2250 ppm. Bacterial spores in suspension are inactivated in 15 seconds to 30
                                                 654
minutes with 500 to 10,000 ppm (0.05 to 1%) •

        Simulated-use trials have demonstrated microbicidal activity 111 ' 718-722 and three clinical trials
                                                                                          723 724
have demonstrated both microbial killing and no clinical failures leading to infection"· ' • Alta and co-
workers, who compared the peracetic acid system with ETO, demonstrated the high efficacy of the
system. Only the peracetic acid system was able to completely kill 6-log 10 of Mycobacterium chelonae,
                                                                                                     722
Enterococcus faecalis, and B. atrophaeus spores with both an organic and inorganic challenge • Like
                                                                                                   902
other sterilization processes, the efficacy of the process can be diminished by soil challenges         and test
           856
conditions •

         Uses. This automated machine is used to chemically sterilize medical (e.g., Gl endoscopes) and
surgical (e.g., flexible endoscopes) instruments in the United States. Lumened endoscopes must be
connected to an appropriate channel connector to ensure that the sterilant has direct contact with the
                           856 803
contaminated lumen. 137 • •        Olympus America has not listed this system as a compatible product for

                                                                                                              65
Guideline for Disinfoclion and Sterilization in l·leflltiJCi:irC Fncil;tics, 2008

use In reprocessing Olympus bronchoscopes and gastrointestinal endoscopes (Olympus America,
January 30, 2002, written communication).

Microbicidal Activity of Low-Temperature Sterilization Technologies
          Sterilization processes used in the United States must be cleared by FDA, and they require that
                                                                                    904
sterilizer microbicidal performance be tested under simulated-use conditions • FDA requires that the
                                        6
test article be inoculated with 10 colony-forming units of the most resistant test organism and prepared
with organic and inorganic test loads as would occur after actual use. FDA requires manufacturers to use
organic soil (e.g., 5% fetal calf serum), dried onto the device with the inoculum, to represent soil
remaining on the device following marginal cleaning. However, 5% fetal calf serum as a measure of
marginal cleaning has not been validated by measurements of protein load on devices following use and
the level of protein removal by various cleaning methods. The inocula must be placed in various
locations of the test articles, including those least favorable to penetration and contact with the sterilant
(e.g., lumens). Cleaning before sterilization is not allowed in the demonstration of sterilization efficacy"".
 Several studies have evaluated the relative microbicidal efficacy of these low-temperature sterilization
technologies (Table 11). These studies have either tested the activity of a sterilization process a9ainst
                              892 905 906
sp,ecific microor~anisms ' ' , evaluated the microbicidal activity of a singular technology • • •
                                                                                                         711 19 724
8 5 879 882 884 890 91 907
   •   •   .   •   •   •    or evaluated the comparative effectiveness of several sterilization technologies'"·
426 469 721 722 856 908 909
   •   •   •    •  •    •   • Several test methodologies use stainless steel or porcelain carriers that are
inoculated with a test organism. Commonly used test organisms include vegetative bacteria,
mycobacteria, and spores of Bacillus species. The available data demonstrate that low-temperature
sterilization technologies are able to provide a 6-log 10 reduction of microbes when inoculated onto
carriers in the absence of salt and serum. However, tests can be constructed such that all of the
available sterilization technologies are unable to reliably achieve complete inactivation of a microbial load.
425 426 469 721 856 909
   •   •   •    •   •     For example, almost all of the sterilization processes will fail to reliably inactivate the
microbial load in the presence of salt and serum 469 • 721 • •
                                                             909

         The effect of salts and serums on the sterilization process were studied initially in the 1950s and
1960s424• 910 , These studies showed that a high concentration of crystalline-type materials and a low
                                                                                                       426
protein content provided greater protection to spores than did serum with a high protein content . A
study by Doyle and Ernst demonstrated resistance of spores by crystalline material applied not only to
                                                                             425
low-temperature sterilization technology but also to steam and dry heat • These studies showed that
occlusion of Bacillus atrophaeus spores in calcium carbonate crystals dramatically increased the time
required for inactivation as follows: 10 seconds to 150 minutes for steam (121'C), 3.5 hours to 50 hours
for dry heat (121'C), 30 seconds to >2 weeks for ETO (54'C). Investigators have corroborated and
                                        855 908 909
extended these findings 469 ' 470' 721 • ' ' • While soils containing both organic and inorganic materials
impair microbial killing, soils that contain a hi~h inor~anic salt-to-protein ratio favor crystal formation and
                                                    25 426 81
impair sterilization by occlusion of organisms • • •

          Alfa and colleagues demonstrated a 6-log 10 reduction of the microbial inoculum of porcelain
                                                                                        469
penicylinders using a variety of vegetative and spore-forming organisms (Table 11) • However, if the
bacterial inoculum was in tissue-culture medium supplemented with 10% serum, only the ETO 12/88 and
ETO-HCFC sterilization mixtures could sterilize 95% to 97% of the penicylinder carriers. The plasma and
100% ETO sterilizer demonstrated significantly reduced activity (Table 11 ). For all sterilizers evaluated
using penicylinder carriers (i.e., ETO 12/88, 100% ETO, hydrogen peroxide gas plasma), there was a 3-
to 6-log 10 reduction of inoculated bacteria even in the presence of serum and salt. For each sterilizer
evaluated, the ability to inactivate microorganisms in the presence of salt and serum was reduced even
further when the inoculum was placed in a narrow-lumen test object (3 mm diameter by 125 em long).
Although there was a 2- to 4-log 10 reduction in microbial kill, less than 50% of the lumen test objects were
sterile when processed using any of the sterilization methods evaluated except the peracetic acid
                                721
immersion system (Table 11) • Complete killing (or removal) of 6-log 10 of Enterococcus faecalis,
Mycobacterium chelonei, and Bacillus atrophaeus spores in the presence of salt and serum and lumen
test objects was observed only for the peracetic acid immersion system.

                                                                                                                  66
GuidelinCl for IJisinfcctkm and 0tmilimtion in Healthcwe F'~lcilitics, 20013

                                                             469
          V'vlth respect to the results by Alia and coworkers , Jacobs showed that the use of the tissue
                                                                 426
culture media created a technique-induced sterilization failure . Jacobs et al. showed that
microorganisms mixed with tissue culture media, used as a surrogate body fluid, formed physical crystals
that protected the microorganisms used as a challenge. If the carriers were exposed for 60 sec to
nonflowing water, the salts dissolved and the protective effect disappeared. Since any device would be
exposed to water for a short period of time during the washing procedure, these protective effects would
                                426
have little clinical relevance •

       Narrow lumens provide a challenge to some low-temperature sterilization processes. For
example, Rutala and colleagues showed that, as lumen size decreased, increased failures occurred with
some low-temperature sterilization technologies. However, some low-temperature processes such as
ETO-HCFC and the hydrogen peroxide gas plasma process remained effective even when challenged by
                                                          856
a lumen as small as 1 mm in the absence of salt and serum •

         The importance of allowing the sterilant to come into contact with the inoculated carrier is
demonstrated by comparing the results of two investigators who studied the peracetic acid immersion
system. Alia and coworkers demonstrated excellent activity of the peracetic acid immersion system
against three test organisms using a narrow-lumen device. In these experiments, the lumen test object
was connected to channel irrigators, which ensured that the sterilant had direct contact with the
contaminated carriers"'. This effectiveness was achieved through a combination of organism wash-off
and peracetic acid sterilant killing the test organisms"'. The data reported by Rutala et al. demonstrated
failure of the peracetic acid immersion system to eliminate Geobacil/us stearothermophi/us spores from a
carrier placed in a lumen test object. In these experiments, the lumen test unit was not connected to
channel irrigators. The authors attributed the failure of the peracetic acid immersion system to eliminate
the high levels of spores from the center of the test unit to the inability of the peracetic acid to diffuse into
the center of 40-cm long, 3-mm diameter tubes. This may be caused by an air lock or air bubbles formed
in the lumen, impeding the flow of the sterilant through the long and narrow lumen and limiting complete
access to the Bacillus spores 137 ' 856 • Experiments using a channel connector specifically designed for 1-,
2-, and 3-mm lumen test units with the peracetic acid immersion system were completely effective in
eliminating an inoculum of 108 Geobacillus stearothermophilus spores'. The restricted diffusion
environment that exists in the test conditions would not exist with flexible scopes processed in the
peracetic acid immersion system, because the scopes are connected to channel irrigators to ensure that
the sterilant has direct contact with contaminated surfaces. Alta and associates attributed the efficacy of
the peracetic acid immersion system to the ability of the liquid chemical process to dissolve salts and
                                                                     722
remove protein and bacteria due to the flushing action of the fluid .

Bloburden of Surgical Devices
         In general, used medical devices are contaminated with a relatively low bioburden of
             9 911 912
organisms " • • Nystrom evaluated medical instruments used in general surgical, gynecological,
orthopedic, and ear-nose-throat operations and found that 62% of the instruments were contaminated
         1                                      2                 3
with <10 organisms after use, 82% with <10 , and 91% with <10 • After being washed in an instrument
                                                       1                       2            911
washer, more than 98% of the instruments had <10 organisms, and none >10 organisms • Other
                                               179 912
investigators have published similar findings • • For example, after a standard cleaning procedure,
                                                  1                  2                          2912
72% of 50 surgical instruments contained <10 organisms, 86% <10 , and only 6% had >3 X 10            • In
another study of rigid-lumen medical devices, the bioburden on both the inner and outer surface of the
lumen ranged from 10 1 to 104 organisms per device. After cleaning, 83% of the devices had a bioburden
s10 organisms'". In all of these studies, the contaminating microflora consisted main~ of vegetative
    2
                                                                                 179 911 12
bacteria, usually of low pathogenicity (e.g., coagulase-negative Staphylococcus) • • •

        An evaluation of the microbial load on used critical medical devices such as spinal anesthesia
needles and angiographic catheters and sheaths demonstrated that mesophilic microorganisms were
detected at levels of 101 to 102 in only two of five needles. The bioburden on used angiographic

                                                                                                               67
Guidel111e for Disinfection and SteriliZfltion in Hea!U1cmc Facilities, 2008

                                                 3
catheters and sheath introducers exceeded 10 CFUs on 14% (3 of21) and 21% (6 of28),
            907
respectively •

Effect of Cleaning on Sterilization Efficacy
         The effect of salt and serum on the efficacy of low-temperature sterilization technologies has
raised concern regarding the margin of safety of these technologies. Experiments have shown that salts
have the greatest impact on protecting microorganisms from killing'"· 469• However, other studies have
suggested that these concerns may not be clinically relevant. One study evaluated the relative rate of
removal of inorganic salts, organic soil, and microorganisms from medical devices to better understand
                                       426
the dynamics of the cleaning process • These tests were conducted by inoculating Alia soil (tissue-
                                             469               6
culture media and 10% fetal bovine serum)        containing 10 G. stearothermophilus spores onto the
surface of a stainless-steel scalpel blade. After drying for 30 minutes at 35'C followed by 30 minutes at
room temperature, the samples were placed in water at room temperature. The blades were removed at
specified times, and the concentration of total protein and chloride ion was measured. The results
showed that soaking in deionized water for 60 seconds resulted in a >95% release rate of chloride ion
from NaCI solution in 20 seconds, Alia soil in 30 seconds, and fetal bovine serum in 120 seconds. Thus,
contact with water for short periods, even in the presence of protein, rapidly leads to dissolution of salt
crystals and complete inactivation of spores by a low-temperature sterilization process (Table 10). Based
on these experimental data, cleaning procedures would eliminate the detrimental effect of high salt
content on a low-temperature sterilization process.
                           469
          These articles 426• ' 721 assessing low-temperature sterilization technology reinforce the
importance of meticulous cleaning before sterilization. These data support the critical need for healthcare
facilities to develop rigid protocols for cleaning contaminated objects before sterilization"'. Sterilization of
instruments and medical devices is compromised if the process is not preceded by meticulous cleaning.

         The cleaning of any narrow-lumen medical device used in patient care presents a major
challenge to reprocessing areas. While attention has been focused on flexible endoscopes, cleaning
                                                                                                         913
issues related to other narrow-lumen medical devices such as sphinctertomes have been investigated .
 This study compared manual cleaning with that of automated cleaning with a narrow-lumen cleaner and
found that only retro-flushing with the narrow lumen cleaner provided adequate cleaning of the three
channels. If reprocessing was delayed for more than 24 hours, retro-flush cleaning was no longer
                                                                                        913
effective and ETO sterilization failure was detected when devices were held for 7 days      . In another
study involving simulated-use cleaning of laparoscopic devices, Alia found that minimally the use of retro-
                                                                            914
flushing should be used during cleaning of non-ported laparoscopic devices •

Other Sterilization Methods
          Ionizing Radiation. Sterilization by ionizing radiation, primarily by cobalt 60 gamma rays or
electron accelerators, is a low-temperature sterilization method that has been used for a number of
medical products (e.g., tissue for transplantation, pharmaceuticals, medical devices). There are no FDA-
cleared ionizing radiation sterilization processes for use in healthcare facilities. Because of high
sterilization costs, this method is an unfavorable alternative to ETO and plasma sterilization in healthcare
facilities but is suitable for large-scale sterilization. Some deleterious effects on patient-care equipment
                                                                                 915
associated with gamma radiation include induced oxidation in pol¥ethylene            and delamination and
                                            916                  91 91
cracking in polyethylene knee bearings . Several reviews '              dealing with the sources, effects, and
application of ionizing radiation may be referred to for more detail.

        Dry-Heat Sterilizers. This method should be used only for materials that might be damaged by
moist heat or that are impenetrable to moist heat (e.g., powders, petroleum products, sharp instruments).
The advantages for dry heat include the following: it is nontoxic and does not harm the environment; a
dry heat cabinet is easy to install and has relatively low operating costs; it penetrates materials; and it is
noncorrosive for metal and sharp instruments. The disadvantages for dry heat are the slow rate of heat
penetration and microbial killing makes this a time-consuming method. In addition, the high temperatures

                                                                                                             68
Guideline for D1sinloction and Stn1ilization in Hoalti1cmo Facilities, 2008

                                    919
are not suitable for most materials • The most common time-temperature relationships for sterilization
with hot air sterilizers are 170°C (340°F) for 60 minutes, 160°C (320°F) for 120 minutes, and 150°C
(300°F) for 150 minutes. B. atrophaeus spores should be used to monitor the sterilization process for dry
heat because they are more resistant to dry heat than are G. stearothermophi/us spores. The primary
lethal process is considered to be oxidation of cell constituents.

          There are two types of dry-heat sterilizers: the statio-air type and the forced-air type. The statio-
air type is referred to as the oven-type sterilizer as heating coils in the bottom of the unit cause the hot air
to rise inside the chamber via gravity convection. This type of dry-heat sterilizer is much slower in
heating, requires longer time to reach sterilizing temperature, and is less uniform in temperature control
throughout the chamber than is the forced-air type. The forced-air or mechanical convection sterilizer is
equipped with a motor-driven blower that circulates heated air throughout the chamber at a high velocity,
permitting a more rapid transfer of energy from the air to the instruments'".
          Liquid Chemicals. Several FDA-cleared liquid chemical sterilants include indications for
                                                    69
sterilization of medical devices (Tables 4 and 5) • The indicated contact times range from 3 hours to 12
hours. However, except for a few of the products, the contact time is based only on the conditions to
pass the AOAC Sporicidal Test as a sterilant and not on simulated use testing with devices. These
solutions are commonly used as high-level disinfectants when a shorter processing time is required.
Generally, chemical liquid sterilants cannot be monitored using a biological indicator to verify sterility""·
900

          The survival kinetics for thermal sterilization methods, such as steam and dry heat, have been
studied and characterized extensively, whereas the kinetics for sterilization with liquid sterilants are less
                  921
well understood • The information that is available in the literature suggests that sterilization processes
based on liquid chemical sterilants, in general, may not convey the same sterility assurance level as
                                                            823
sterilization achieved using thermal or physical methods • The data indicate that the survival curves for
liquid chemical sterilants may not exhibit log-linear kinetics and the shape of the survivor curve may vary
depending of the formulation, chemical nature and stability of the liquid chemical sterilant. In addition, the
design of the AOAC Sporicidal Test does not provide quantification of the microbial challenge. Therefore,
sterilization with a liquid chemical sterilant may not convey the same sterility assurance as other
sterilization methods.

         One of the differences between thermal and liquid chemical processes for sterilization of devices
is the accessibility of microorganisms to the sterilant. Heat can penetrate barriers, such as biofilm, tissue,
and blood, to attain organism kill, whereas liquids cannot adequately penetrate these barriers. In
addition, the viscosity of some liquid chemical sterilants impedes their access to organisms in the narrow
                                         922
lumens and mated surfaces of devices • Another limitation to sterilization of devices with liquid
chemical germicides is the post-processing environment of the device. Devices cannot be wrapped or
adequately contained during processing in a liquid chemical sterilant to maintain sterility following
processing and during storage. Furthermore, devices may require rinsing following exposure to the liquid
chemical sterilant with water that typically is not sterile. Therefore, due to the inherent limitations of using
liquid chemical sterilants, their use should be restricted to reprocessing critical devices that are heat-
sensitive and incompatible with other sterilization methods.

        Several published studies compare the sporicidal effect of liquid chemical germicides against
                                    659 660 715
spores of Bacillus and Clostridium"· • • ,

         Performic Acid. Performic acid is a fast-acting sporicide that was incorporated into an
automated endoscope reprocessing system 400 • Systems using performic acid are not currently FDA
cleared.

          Filtration. Although filtration is not a lethality-based process and is not an FDA-cleared
sterilization method, this technology is used to remove bacteria from thermolabile pharmaceutical fluids

                                                                                                              69
Guideline for DisinfeeHon and ,Sterl!iz8tion in Hea!trlcare FHci!itios, 2008

that cannot be purified by any other means. In order to remove bacteria, the membrane pore size (e.g.,
0.22 f!m) must be smaller than the bacteria and uniform throughout"'. Some investigators have
appropriately questioned whether the removal of microorganisms by filtration really is a sterilization
method because of slight bacterial passage through filters, viral passage through filters, and transference
                                                                                                        924
of the sterile filtrate into the final container under aseptic conditions entail a risk of contamination •

          Microwave. Microwaves are used in medicine for disinfection of soft contact lenses, dental
                                                                                           921 931
instruments, dentures, milk, and urinary catheters for intermittent self-catheterization ,. • However,
                                                                                          931
microwaves must only be used with products that are compatible (e.g., do not melt)            . Microwaves are
radio-frequency waves, which are usually used at a frequency of 2450 MHz. The microwaves produce
friction of water molecules in an alternating electrical field. The intermolecular friction derived from the
vibrations generates heat and some authors believe that the effect of microwaves depends on the heat
                                                               932 934
produced while others postulate a nonthermallethal effect - • The initial reports showed microwaves
to be an effective microbicide. The microwaves produced by a "home-type" microwave oven (2.45 GHz)
completely inactivate bacterial cultures, mycobacteria, viruses, and G. stearothermophilus spores within
                                                                     933
60 seconds to 5 minutes depending on the challenge organism ' ,,,.,,_ Another study confirmed these
results but also found that higher power microwaves in the presence of water may be needed for
sterilization'". Complete destruction of Mycobacterium bovis was obtained with 4 minutes of microwave
                                937
exposure (600W, 2450 MHz) . The effectiveness of microwave ovens for different sterilization and
disinfection purposes should be tested and demonstrated as test conditions affect the results (e.g.,
presence of water, microwave power). Sterilization of metal instruments can be accomplished but
requires certain precautions."'. Of concern is that home-type microwave ovens may not have even
distribution of microwave energy over the entire dry device (there may be hot and cold spots on solid
medical devices); hence there may be areas that are not sterilized or disinfected. The use of microwave
ovens to disinfect intermittent-use catheters also has been suggested. Researchers found that test
bacteria (e.g., E. coli, Klebsiella pneumoniae, Candida a/bicans) were eliminated from red rubber
                             931
catheters within 5 minutes       • Microwaves used for sterilization of medical devices have not been FDA
cleared.

        Glass Bead "Sterilizer". Glass bead "sterilization" uses small glass beads (1.2-1.5 mm
diameter) and high temperature (217°C -232°C) for brief exposure times (e.g., 45 seconds) to inactivate
                                                                                                  938 940
microorganisms. These devices have been used for several years in the dental profession - • FDA
believes there is a risk of infection with this device because of potential failure to sterilize dental
instruments and their use should be discontinued until the device has received FDA clearance.

          Vaporized Hydrogen Peroxide (VHP®). Hydrogen peroxide solutions have been used as
chemical sterilants for many years. However, the VHP® was not developed for the sterilization of
medical equipment until the mid-1980s. One method for delivering VHP to the reaction site uses a deep
vacuum to pull liquid hydrogen peroxide (30-35% concentration) from a disposable cartridge through a
heated vaporizer and then, following vaporization, into the sterilization chamber. A second approach to
VHP delivery is the flow-through approach in which the VHP is carried into the sterilization chamber by a
carrier gas such as air using either a slight negative pressure (vacuum) or slight positive pressure.
Applications of this technology include vacuum systems for industrial sterilization of medical devices and
atmospheric systems for decontaminating for large and small areas'". VHP offers several appealing
features that include rapid cycle time (e.g., 30-45 minutes); low temperature; environmentally safe by-
products (H 2 0, oxygen [0 2]); good material compatibility; and ease of operation, installation and
monitoring. VHP has limitations including that cellulose cannot be processed; nylon becomes brittle; and
VHP penetration capabilities are less than those of ETO. VHP has not been cleared by FDA for
sterilization of medical devices in healthcare facilities.

          The feasibility of utilizing vapor-phase hydrogen peroxide as a surface decontaminant and
sterilizer was evaluated in a centrifuge decontamination application. In this study, vapor-phase hydrogen
                                                                941
peroxide was shown to possess significant sporicidal activity       . In preliminary studies, hydrogen

                                                                                                            70
Guide!;ne tor Disinfoclion and Stel'iliziltion in Hoa!ti1cme FilCIIit;es, 20013

peroxide vapor decontamination has been found to be a highly effective method of eradicating MRSA,
Serratia marcescens, Clostridium botulinum spores and Clostridium diffici/e from rooms, furniture,
surfaces and/or equipment; however, further investigation of this method to demonstrate both safety and
effectiveness in reducing infection rates are required 942- 945•

         Ozone. Ozone has been used for years as a drinking water disinfectant. Ozone is produced
when o, is energized and split into two monatomic (0 1) molecules. The monatomic oxygen molecules
then collide with 0 2 molecules to form ozone, which is 0 3• Thus, ozone consists of 0 2 with a loosely
bonded third oxygen atom that is readily available to attach to, and oxidize, other molecules. This
additional oxygen atom makes ozone a powerful oxidant that destroys microorganisms but is highly
unstable (i.e., half-life of 22 minutes at room temperature).

        A new sterilization process, which uses ozone as the sterilant, was cleared by FDA in August
2003 for processing reusable medical devices. The sterilizer creates its own sterilant internally from USP
grade oxygen, steam-quality water and electricity; the sterilant is converted back to oxygen and water
vapor at the end of the cycle by a passing through a catalyst before being exhausted into the room. The
duration of the sterilization cycle is about 4 hand 15m, and it occurs at 30-35'C. Microbial efficacy has
                                                o·'
been demonstrated by achieving a SAL of 1 with a variety of microorganisms to include the most
resistant microorganism, Geobacillus stearothermophi/us.

          The ozone process is compatible with a wide range of commonly used materials including
stainless steel, titanium, anodized aluminum, ceramic, glass, silica, PVC, Teflon, silicone, polypropylene,
polyethylene and acrylic. In addition, rigid lumen devices of the following diameter and length can be
processed: internal diameter (ID): > 2 mm, length,;; 25 em; ID > 3 mm, length,;; 47 em; and ID > 4 mm,
length ,;; 60 em.

         The process should be safe for use by the operator because there is no handling of the sterilant,
no toxic emissions, no residue to aerate, and low operating temperature means there is no danger of an
accidental burn. The cycle is monitored using a self-contained biological indicator and a chemical
indicator. The sterilization chamber is small, about 4 ft 3 (Written communication, S Dufresne, July 2004).

        A gaseous ozone generator was investigated for decontamination of rooms used to house
patients colonized with MRSA. The results demonstrated that the device tested would be inadequate for
                                      946
the decontamination of a hospital room •

          Formaldehyde Steam. Low-temperature steam with formaldehyde is used as a low-temperature
sterilization method in many countries, particularly in Scandinavia, Germany, and the United Kingdom.
The process involves the use of formalin, which is vaporized into a formaldehyde gas that is admitted into
the sterilization chamber. A formaldehyde concentration of 8-16 mg/1 is generated at an operating
temperature of 70-75'C. The sterilization cycle consists of a series of stages that include an initial
vacuum to remove air from the chamber and load, followed by steam admission to the chamber with the
vacuum pump running to purge the chamber of air and to heat the load, followed by a series of pulses of
formaldehyde gas, followed by steam. Formaldehyde is removed from the sterilizer and load by repeated
alternate evacuations and flushing with steam and air. This system has some advantages, e.g., the cycle
time for formaldehyde gas is faster than that for ETO and the cost per cycle is relatively low. However,
ETO is more penetrating and operates at lower temperatures than do steam/formaldehyde sterilizers.
Low-temperature steam formaldehyde sterilization has been found effective against veaetative bacteria,
                                                                                           7 949
mycobacteria, B. atrophaeus and G. stearothermophi/us spores and Candida albicans' ' .

        Formaldeh~de vapor cabinets also may be used in healthcare facilities to sterilize heat-sensitive
                    50
medical equipment • Commonly, there is no circulation of formaldehyde and no temperature and
humidity controls. The release of gas from paraformaldehyde tablets (placed on the lower tray) is slow
                                                                                                  951
and produces a low partial pressure of gas. The microbicidal quality of this procedure is unknown •

                                                                                                          71
Guideline for Disinfeclion and ilterilization in Heillt!1care r·acilillcs, 2008

         Reliable sterilization using formaldehyde is achieved when performed with a high concentration
of gas, at a temperature between 60' and 80'C and with a relative humidity of 75 to 100%.

        Studies indicate that formaldehyde is a mutagen and a potential human carcinogen, and OSHA
regulates formaldehyde. The permissible exposure limit for formaldehyde in work areas is 0. 75 ppm
measured as a 8-hourTWA. The OSHA standard includes a 2 ppm STEL (i.e., maximum exposure
allowed during a 15-minute period). As with the ETO standard, the formaldehyde standard requires that
the employer conduct initial monitoring to identify employees who are exposed to formaldehyde at or
above the action level or STEL. If this exposure level is maintained, employers may discontinue
exposure monitoring until there is a change that could affect exposure levels or an employee reports
                                            269
formaldehyde-related signs and symptoms ' 578• The formaldehyde steam sterilization system has not
been FDA cleared for use in healthcare facilities.

         Gaseous chlorine dioxide. A gaseous chlorine dioxide system for sterilization of healthcare
                                          853   953
products was developed in the late 1980s ' 952 • • Chlorine dioxide is not mutagenic or carcinogenic in
humans. As the chlorine dioxide concentration increases, the time required to achieve sterilization
becomes progressively shorter. For example, only 30 minutes were required at 40 mg/1 to sterilize the
   6                                    954
10 B. atrophaeus spores at 30' to 32'C • Currently, no gaseous chlorine dioxide system is FDA
cleared.
         Vaporized Peracetic Acid. The sporicidal activity of peracetic acid vapor at 20, 40, 60, and 80%
relative humidity and 25'C was determined on Bacillus atrophaeus spores on paper and glass surfaces.
Appreciable activity occurred within 10 minutes of exposure to 1 mg of peracetic acid per liter at 40% or
                        955
higher relative humidity • No vaporized peracetic acid system is FDA cleared.

         Infrared radiation. An infrared radiation prototype sterilizer was investigated and found to
destroy B. atrophaeus spores. Some of the possible advantages of infrared technology include short
cycle time, low energy consumption, no cycle residuals, and no toxicologic or environmental effects. This
may provide an alternative technology for sterilization of selected heat-resistant instruments but there are
                                                          956
no FDA-cleared systems for use in healthcare facilities       •

          The other sterilization technologies mentioned above may be used for sterilization of critical
medical items if cleared by the FDA and ideally, the microbicidal effectiveness of the technology has been
published in the scientific literature. The selection and use of disinfectants, chemical sterilants and
sterilization processes in the healthcare field is dynamic, and products may become available that are not
in existence when this guideline was written. As newer disinfectants and sterilization processes become
available, persons or committees responsible for selecting disinfectants and sterilization processes
should be guided by products cleared by FDA and EPA as well as information in the scientific literature.

Sterilizing Practices
         Ovetview. The delivery of sterile products for use in patient care depends not only on the
effectiveness of the sterilization process but also on the unit design, decontamination, disassembling and
packaging of the device, loading the sterilizer, monitoring, sterilant quality and quantity, and the
appropriateness of the cycle for the load contents, and other aspects of device reprocessing. Healthcare
personnel should perform most cleaning, disinfecting, and sterilizing of patient-care supplies in a central
processing department in order to more easily control quality. The aim of central processing is the
orderly processing of medical and surgical instruments to protect patients from infections while minimizing
risks to staff and preserving the value of the items being reprocessed 957 • Healthcare facilities should
promote the same level of efficiency and safety in the preparation of supplies in other areas (e.g.,
operating room, respiratory therapy) as is practiced in central processing.

        Ensuring consistency of sterilization practices requires a comprehensive program that ensures
operator competence and proper methods of cleaning and wrapping instruments, loading the sterilizer,

                                                                                                          72
Guideline -for Dlslnfectkm and Stet'illzahon in HoaiU1care F·act!ities, 200B

operating the sterilizer, and monitoring of the entire process. Furthermore, care must be consistent from
an infection prevention standpoint in all patient-care settings, such as hospital and outpatient facilities.

         Sterilization Cycle Verification. A sterilization process should be verified before it is put into
use in healthcare settings. All steam, ETO, and other low-temperature sterilizers are tested with
biological and chemical indicators upon installation, when the sterilizer is relocated, redesigned, after
major repair and after a sterilization failure has occurred to ensure they are functioning prior to placing
them into routine use. Three consecutive empty steam cycles are run with a biological and chemical
indicator in an appropriate test package or tray. Each type of steam cycle used for sterilization (e.g.,
vacuum-assisted, gravity) is tested separately. In a prevacuum steam sterilizer three consecutive empty
cycles are also run with a Bowie-Dick test. The sterilizer is not put back into use until all biolo~ical
                                                                                          814 819 95
indicators are negative and chemical indicators show a correct end-point response 811 " • • •

         Biological and chemical indicator testing is also done for ongoing quality assurance testing of
representative samples of actual products being sterilized and product testing when major changes are
made in packaging, wraps, or load configuration. Biological and chemical indicators are placed in
products, which are processed in a full load. When three consecutive cycles show negative biological
indicators and chemical indicators with a correct end point response, you can put the change made into
            811 814 958
routine use - ' • Items processed during the three evaluation cycles should be quarantined until the
test results are negative.
         Physical Facilities. The central processing area(s) ideally should be divided into at least three
areas: decontamination, packaging, and sterilization and storage. Physical barriers should separate the
decontamination area from the other sections to contain contamination on used items. In the
decontamination area reusable contaminated supplies (and possibly disposable items that are reused)
are received, sorted, and decontaminated. The recommended airflow pattern should contain
contaminates within the decontamination area and minimize the flow of contaminates to the clean areas.
The American Institute of Architects 959 recommends negative pressure and no fewer than six air
exchanges per hour in the decontamination area (AAMI recommends 10 air changes per hour) and 10 air
changes per hour with positive pressure in the sterilizer equipment room. The packaging area is for
inspecting, assembling, and packaging clean, but not sterile, material. The sterile storage area should be
a limited access area with a controlled temperature (may be as high as 75'F) and relative humidity (30·
                                                                                                      819
60% in all works areas except sterile storage, where the relative humidity should not exceed 70%) • The
floors and walls should be constructed of materials capable of withstanding chemical agents used for
cleaning or disinfecting. Ceilings and wall surfaces should be constructed of non-shedding materials.
                                                                                             811 819 920 957
Physical arrangements of processing areas are presented schematically in four references ' • • •

         Cleaning. As repeatedly mentioned, items must be cleaned using water with detergents or
                       465    468
enzymatic cleaners ' 466•         before processing. Cleaning reduces the bioburden and removes foreign
material (i.e., organic residue and inor~anic salts) that interferes with the sterilization process by acting as
a barrier to the sterilization agent 179 • 42 • 457 • ' 11 • 912 • Surgical instruments are generally presoaked or
prerinsed to prevent drying of blood and tissue. Precleaning in patient-care areas may be needed on
items that are heavily soiled with feces, sputum, blood, or other material. Items sent to central processing
without removing gross soil may be difficult to clean because of dried secretions and excretions.
Cleaning and decontamination should be done as soon as possible after items have been used.

        Several types of mechanical cleaning machines (e.g., utensil washer-sanitizer, ultrasonic cleaner,
washer-sterilizer, dishwasher, washer-disinfector) may facilitate cleaning and decontamination of most
items. This equipment often is automated and may increase productivity, improve cleaning effectiveness,
and decrease worker exposure to blood and body fluids. Delicate and intricate objects and heat· or
moisture-sensitive articles may require careful cleaning by hand. All used items sent to the central
processing area should be considered contaminated (unless decontaminated in the area of origin),
handled with gloves (forceps or tongs are sometimes needed to avoid exposure to sharps), and
decontaminated by one of the aforementioned methods to render them safer to handle. Items composed

                                                                                                               73
Guicio!ine for Dlsinfcctlon and Stc1·i!izatlon ln Hea!H1care Facl!ltiBS, 2008

of more than one removable part should be disassembled. Care should be taken to ensure that all parts
are kept together, so that reassembly can be accomplished efficiently'".

         Investigators have described the degree of cleanliness by visual and microscopic examination.
One study found 91% of the instruments to be clean visually but, when examined microscopically, 84% of
the instruments had residual debris. Sites that contained residual debris included junctions between
insulating sheaths and activating mechanisms of laparoscopic instruments and articulations and grooves
of forceps. More research is needed to understand the clinical significance of these findings 960 and how
to ensure proper cleaning.

         Personnel working in the decontamination area should wear household-cleaning-type rubber or
plastic gloves when handling or cleaning contaminated instruments and devices. Face masks, eye
protection such as goggles or full-length faceshields, and appropriate gowns should be worn when
exposure to blood and contaminated fluids may occur (e.g., when manually cleaning contaminated
          961
devices) • Contaminated instruments are a source of microorganisms that could inoculate personnel
through nonintact skin on the hands or through contact with the mucous membranes of eyes, nose, or
       214    813
mouth • '"· • Reusable sharps that have been in contact with blood present a special hazard.
Employees must not reach with their gloved hands into trays or containers that hold these sharps to
              214
retrieve them • Rather, employees should use engineering controls (e.g., forceps) to retrieve these
devices.

          Packaging. Once items are cleaned, dried, and inspected, those requiring sterilization must be
wrapped or placed in rigid containers and should be arranged in instrument travs/baskets according to
                                                                           454 811  819 836
the guidelines provided by the AAMI and other professional organizations • •814. • • 962 . These
guidelines state that hinged instruments should be opened; items with removable parts should be
disassembled unless the device manufacturer or researchers provide specific instructions or test data to
              181
the contrary ; complex instruments should be prepared and sterilized according to device
manufacturer's instructions and test data; devices with concave surfaces should be positioned to facilitate
drainage of water; heavy items should be positioned not to damage delicate items; and the weight of the
instrument set should be based on the design and density of the instruments and the distribution of metal
      811 962
mass ' • While there is no longer a specified sterilization weight limit for surgical sets, heavy metal
mass is a cause of wet packs (i.e., moisture inside the case and tray after completion of the sterilization
       963
cycle\ • Other parameters that may influence drying are the density of the wraps and the design of the
set964.

          There are several choices in methods to maintain sterility of surgical instruments, including rigid
containers, peel-open pouches (e.g., self-sealed or heat-sealed plastic and paper pouches), roll stock or
reels (i.e., paper-plastic combinations of tubing designed to allow the user to cut and seal the ends to
form a pouch) 454 and sterilization wraps (woven and nonwoven). Healthcare facilities may use all of
these packaging options. The packaging material must allow penetration of the sterilant, provide
protection against contact contamination during handling, provide an effective barrier to microbial
                                                                                   965
penetration, and maintain the sterility of the processed item after sterilization      • An ideal sterilization
wrap would successfully address barrier effectiveness, penetrability (i.e., allows sterilant to penetrate),
aeration (e.g., allows ETO to dissipate), ease of use, drapeability, flexibility, puncture resistance, tear
strength, toxicity, odor, waste disposal, linting, cost, and transparency"'. Unacceptable packaging for
use with ETO (e.g., foil, polyvinylchloride, and polyvinylidene chlorine [kitchen-type transparent wrap]) 814
or hydrogen peroxide gas plasma (e.g., linens and paper) should not be used to wrap medical items.

        In central processing, double wrapping can be done sequentially or nonsequentially (i.e.,
simultaneous wrapping). Wrapping should be done in such a manner to avoid tenting and gapping. The
sequential wrap uses two sheets of the standard sterilization wrap, one wrapped after the other. This
procedure creates a package within a package. The nonsequential process uses two sheets wrapped at
the same time so that the wrapping needs to be performed only once. This latter method provides

                                                                                                             74
Guiderino 1or DislnfecHon and SleHiizstion in Hea!thcare Fad!ities, 2008

multiple layers of protection of surgical instruments from contamination and saves time since wrapping is
done only once. Multiple layers are still common practice due to the rigors of handling within the facility
                                                                                       966
even though the barrier efficacy of a single sheet of wrap has improved over the years • Written and
illustrated procedures for preparation of items to be packaged should be readily available and used by
                                                         454
personnel when packaging procedures are performed •

         Loading. All items to be sterilized should be arranged so all surfaces will be directly exposed to
the sterilizing agent. Thus, loading procedures must allow for free circulation of steam (or another
sterilant) around each item. Historically, it was recommended that muslin fabric packs should not exceed
the maximal dimensions, weight, and density of 12 inches wide x 12 inches high x 20 inches long, 121bs,
and 7.2 lbs per cubic foot, respectively. Due to the variety of textiles and metal/plastic containers on the
market, the textile and metal/plastic container manufacturer and the sterilizer manufacturers should be
consulted for instructions on pack preparation and density parameters'".

         There are several important basic principles for loading a sterilizer: allow for proper sterilant
circulation; perforated trays should be placed so the tray is parallel to the shelf; nonperforated containers
should be placed on their edge (e.g., basins); small items should be loosely placed in wire baskets; and
                                                                                          454 811 836
peel packs should be placed on edge in perforated or mesh bottom racks or baskets ' • •

          Storage. Studies in the early 1970s suggested that wrapped surgical trays remained sterile for
varying periods depending on the type of material used to wrap the trays. Safe storage times for sterile
packs vary with the porosity of the wrapper and storage conditions (e.g., open versus closed cabinets).
Heat-sealed, plastic peel-down pouches and wrapped packs sealed in 3-mil (3/1 000 inch) polyethylene
oveiWrap have been reported to be sterile for as long as 9 months after sterilization. The 3-mil
polyethylene is applied after sterilization to extend the shelf life for infrequently used items967 • Supplies
wrapped in double-thickness muslin comprising four layers, or equivalent, remain sterile for at least 30
days. Any item that has been sterilized should not be used after the expiration date has been exceeded
or if the sterilized package is wet, torn, or punctured.

         Although some hospitals continue to date every sterilized product and use the time-related shelf-
life practice, many hospitals have switched to an event-related shelf-life practice. This latter practice
recognizes that the product should remain sterile until some event causes the item to become
contaminated (e.g., tear in packaging, packaging becomes wet, seal is broken) 968 • Event-related factors
that contribute to the contamination of a product include bioburden (i.e., the amount of contamination in
the environment), air movement, traffic, location, humidity, insects, vermin, ftooding, storage area space,
                                                                                966 969
open/closed shelving, temperature, and the .p,roperties of the wrap material ' • There are data that
                                               0 972
support the event-related shelf-life practice' " • One study examined the effect of time on the sterile
integrity of paper envelopes, peel pouches, and nylon sleeves. The most important finding was the
absence of a trend toward an increased rate of contamination over time for any pack when placed in
                  971
covered storage • Another evaluated the effectiveness of event-related outdating by microbiologically
                                                                                              972
testing sterilized items. During the 2-year study period, all of the items tested were sterile • Thus,
contamination of a sterile item is event-related and the probability of contamination increases with
                      973
increased handling •

          Following the sterilization process, medical and surgical devices must be handled using aseptic
technique in order to prevent contamination. Sterile supplies should be stored far enough from the ftoor
(8 to 10 inches), the ceiling (5 inches unless near a sprinkler head [18 inches from sprinkler head]), and
the outside walls (2 inches) to allow for adequate air circulation, ease of cleaning, and compliance with
local fire codes (e.g., supplies must be at least 18 inches from sprinkler heads). Medical and surgical
supplies should not be stored under sinks or in other locations where they can become wet. Sterile items
that become wet are considered contaminated because moisture brings with it microorganisms from the
air and surfaces. Closed or covered cabinets are ideal but open shelving may be used for storage. Any
package that has fallen or been dropped on the ftoor must be inspected for damage to the packaging and

                                                                                                             75
Guidc:!lnc for D!sinteclion and S!eri!i;::aHon   1'n Heo!tilcare F24 hours. A rapid-readout biological indicator that detects the presence of
enzymes of G. stearothermophilus by reading a ftuorescent product produced by the enzymatic
breakdown of a nonfluorescent substrate has been marketed for the more than 10 years. Studies
demonstrate that the sensitivity of rapid-readout tests for steam sterilization (1 hour for 132°C gravity
sterilizers, 3 hrs for 121°C gravity and 132•c vacuum sterilizers) parallels that of the conventional
                                                     976 977
sterilization-specific biological indicators"'· " 7 • •      and the fluorescent rapid readout results reliably
                                               978
predict 24- and 48-hour and 7-day growth           The rapid-readout biological indicator is a dual indicator
system as it also detects acid metabolites produced during growth of the G. stearothermophilus spores.
This system is different from the indicator system consisting of an enzyme system of bacterial origin
without spores. Independent comparative data using suboptimal sterilization cycles (e.g., reduced time or
                                                                                       979
temperature) with the enzyme-based indicator system have not been published •

          A new rapid-readout ETO biological indicator has been designed for rapid and reliable monitoring
of ETO sterilization processes. The indicator has been cleared by the FDA for use in the United
        400
States • The rapid-readout ETO biological indicator detects the presence of B. atrophaeus by detecting
a fluorescent signal indicating the activity of an enzyme present within the B. atrophaeus organism, beta-
glucosidase. The fluorescence indicates the presence of an active spore-associated enzyme and a
sterilization process failure. This indicator also detects acid metabolites produced during growth of the B.
atrophaeus spore. Per manufacturer's data, the enzyme always was detected whenever viable spores
were present. This was expected because the enzyme is relatively ETO resistant and is inactivated at a
slightly longer exposure time than the spore. The rapid-readout ETO biological indicator can be used to
monitor 100% ETO, and ETO-HCFC mixture sterilization cycles. It has not been tested in ETO-CO,
mixture sterilization cycles.

          The standard biological indicator used for monitoring full-cycle steam sterilizers does not provide
reliable monitoring flash sterilizers'". Biological indicators specifically designed for monitoring flash
                                                                                         847 981
sterilization are now available, and studies comparing them have been published"'· ' .
                                                                    982
          Since sterilization failure can occur (about 1% for steam) , a procedure to follow in the event of
positive spore tests with steam sterilization has been provided by CDC and the Association of
peri Operative Registered Nurses (AORN). The 1981 CDC recommendation is that "objects, other than
implantable objects, do not need to be recalled because of a single positive spore test unless the steam
sterilizer or the sterilization procedure is defective." The rationale for this recommendation is that single
positive spore tests in sterilizers occur sporadically. They may occur for reasons such as slight variation
in the resistance of the spores 983 , improper use of the sterilizer, and laboratory contamination during
culture (uncommon with self-contained spore tests). If the mechanical (e.g., time, temperature, pressure
in the steam sterilizer) and chemical (internal and/or external) indicators suggest that the sterilizer was
functioning properly, a single positive spore test probably does not indicate sterilizer malfunction but the
                                               983
spore test should be repeated immediately • If the spore tests remain positive, use of the sterilizer
                                             1
should be discontinued until it Is serviced . Similarly, AORN states that a single positive spore test does
not necessarily indicate a sterilizer failure. If the test is positive, the sterilizer should immediately be
rechallenged for proper use and function. Items, other than implantable ones, do not necessarily need to
be recalled unless a sterilizer malfunction is found. If a sterilizer malfunction is discovered, the items
must be considered nonsterile, and the items from the suspect load(s) should be recalled, insofar as

                                                                                                            77
Guido!ine for Dislhfectk>n and StGHI!zation in Hen!theare Fad!itios, 2008

                             984
possible, and reprocessed • A suggested protocol for management of positive biological indicators is
                    839                                                                  813
shown in Table 12 • A more conservative approach also has been recommended                   in which any
positive spore test is assumed to represent sterilizer malfunction and requires that all materials
processed in that sterilizer, dating from the sterilization cycle having the last negative biologic indicator to
the next cycle showing satisfactory biologic indicator challenge results, must be considered nonsterile
and retrieved, if possible, and reprocessed. This more conservative approach should be used for
sterilization methods other than steam (e.g., ETO, hydrogen peroxide gas plasma). However, no action is
                                                                                     98
necessary if there is strong evidence for the biological indicator being defective      or the growth medium
contained a Bacl7/us contaminant'"         .

         If patient-care items were used before retrieval, the infection control professional should assess
the risk of infection in collaboration with central processing, surgical services, and risk management staff.
 The factors that should be considered include the chemical indicator result (e.g., nonreactive chemical
indicator may indicate temperature not achieved); the results of other biological indicators that followed
the positive biological indicator (e.g., positive on Tuesday, negative on Wednesday); the parameters of
the sterilizer associated with the positive biological indicator (e.g., reduced time at correct temperature);
the time-temperature chart (or printout); and the microbial load associated with decontaminated surgical
instruments (e.g., 85% of decontaminated surgical instruments have less than 100 CFU). The margin of
safety in steam sterilization is sufficiently large that there is minimal infection risk associated with items in
a load that show spore growth, especially if the item was properly cleaned and the temperature was
achieved (e.g., as shown by acceptable chemical indicator or temperature chart). There are no published
studies that document disease transmission via a nonretrieved surgical instrument following a sterilization
cycle with a positive biological indicator.

          False-positive biological indicators may occur from improper testing or faulty indicators. The
latter may occur from improper storage, processing, product contamination, material failure, or variation in
resistance of spores. Gram stain and subculture of a positive biological indicator may determine if a
                                                      986
contaminant has created a false-positive result"'· . However, in one incident, the broth used as growth
                                                                                             985
medium contained a contaminant, B. coagulans, which resulted in broth turbidity at 55°C • Testing of
                                                                                                     839
paired biological indicators from different manufacturers can assist in assessing a product defect .
False-positive biological indicators due to extrinsic contamination when using self-contained biological
indicators should be uncommon. A biological indicator should not be considered a false-positive indicator
until a thorough analysis of the entire sterilization process shows this to be likely.

          The size and composition of the biological indicator test pack should be standardized to create a
significant challenge to air removal and sterilant penetration and to obtain interpretable results. There is
                                                                                 813 987
a standard 16-towel pack recommended by AAMI for steam sterilization • 81 '·             consisting of 16 clean,
preconditioned, reusable huck or absorbent surgical towels each of which is approximately 16 inches by
26 inches. Each towel is folded lengthwise into thirds and then folded widthwise in the middle. One or
more biological indicators are placed between the eight and ninth towels in the approximate geometric
center of the pack. When the towels are folded and placed one on top of another, to form a stack
(approximately 6 inch height) it should wei~h approximately 3 pounds and should have a density of
                                                3
approximately 11.3 pounds per cubic foot' . This test pack has not gained universal use as a standard
pack that simulates the actual in-use conditions of steam sterilizers. Commercially available disposable
test packs that have been shown to be equivalent to the AAMI16 towel test pack also may be used. The
test pack should be placed flat in an otherwise fully loaded sterilizer chamber, in the area least favorable
to sterilization (i.e., the area representing the greatest challenge to the biological indicator). This area is
                                                                             813
normally in the front, bottom section of the sterilizer, near the drain' 11 • . A control biological indicator
from the lot used for testing should be left unexposed to the sterilant, and then incubated to verify the
presterilization viability of the test spores and proper incubation. The most conservative approach would
be to use a control for each run; however, less frequent use may be adequate (e.g., weekly). There also
is a routine test pack for ETO where a biological indicator is placed in a plastic syringe with plunger, then
placed in the folds of a clean surgical towel, and wrapped. Alternatively, commercially available disposal

                                                                                                              78
Guideline tor Disinlection Hnd Sterilization in Healti'iccme F acil;tlns, 2008

test packs that have been shown to be e~uivalent to the AAMI test pack may be used. The test pack is
                                             4
placed in the center of the sterilizer load' • Sterilization records (mechanical, chemical, and biological)
should be retained for a time period in compliance with standards (e.g., Joint Commission for the
Accreditation of Healthcare Facilities requests 3 years) and state and federal regulations.

          In Europe, biological monitors are not used routinely to monitor the sterilization process. Instead,
release of sterilizer items is based on monitoring the physical conditions of the sterilization process that is
termed "parametric release." Parametric release requires that there is a defined quality system in place
at the facility performing the sterilization and that the sterilization process be validated for the items being
sterilized. At present in Europe, parametric release is accepted for steam, dry heat, and ionizing radiation
processes, as the physical conditions are understood and can be monitored directly'". For example, with
steam sterilizers the load could be monitored with probes that would yield data on temperature, time, and
humidity at representative locations in the chamber and compared to the specifications developed during
the validation process.

         Periodic infection control rounds to areas using sterilizers to standardize the sterilizer's use may
identify correctable variances in operator competence; documentation of sterilization records, including
chemical and biological indicator test results; sterilizer maintenance and wrapping; and load numbering of
packs. These rounds also may identify improvement activities to ensure that operators are adhering to
established standards'".

                                                                                                              79
Guideline for Disinfection and SterHizatl011 in He1 0 mL) of blood or OPIM, or involves a culture spill in the
       laboratory, use a 1:1 0 dilution for the first application of hypochlorite solution before cleaning in
       order to reduce the risk of infection during the cleaning process in the event of a sharp injury.
       Follow this decontamination process with a terminal disinfection, using a 1:100 dilution of sodium
                                         63 215 557
       hypochlorite. Category /B, /C. • '
    o. If the spill contains large amounts of blood or body fluids, clean the visible matter with disposable
       absorbent material, and discard the contaminated materials in appropriate, labeled containment.
                               44 214
         Category II, /C.        •
                                                                                            44 214
    p.   Use protective gloves and other PPE appropriate for this task. Category II, /C.      •

                                                                                                              85
Guideline for Disinfrc)Ction and Stofilization in IIDBithcme rcncilities, 2008

     q.   In units with high rates of endemic Clostridium difficile infection or in an outbreak setting, use
          dilute solutions of 5.25%-6.15% sodium hypochlorite (e.g., 1:10 dilution of household bleach) for
          routine environmental disinfection. Currently,. no products are EPA-registered specifically for
          inactivating C. difficile spores. Category 11. 57· 259
     r.   If chlorine solution is not prepared fresh daily, it can be stored at room temperature for up to 30
          days in a capped, opaque plastic bottle with a 50% reduction in chlorine concentration after 30
          days of storage (e.g., 1000 ppm chlorine [arp,roximately a 1:50 dilution] at day 0 decreases to
          500 ppm chlorine by day 30). Category /B. 7• 1014
     s.   An EPA-registered sodium hypochlorite product is preferred, but if such products are not
          available, generic versions of sodium hypochlorite solutions (e.g., household chlorine bleach) can
          be used. Category 11. 44

6.        Disinfectant Fogging
                                                                                                                                   23
          a. Do not perform disinfectant fogging for routine purposes in patient-care areas. Category II.                               •
                228

7.        High-Level Disinfection of Endoscopes
     a.   To detect damaged endoscopes, test each flexible endoscope for leaks as part of each
          reprocessing cycie. Remove from clinical use any instrument that fails the leak test, and repair
                                        113 115 116
          this instrument. Category II.    •   •
     b.   Immediately after use, meticulously clean the endoscope with an enzymatic cleaner that is
          compatible with the endoscope. Cleanina is necessary before both automated and manual
          disinfection. Category lA.              a3, 1o1, 1o4-1os, 113'; 11s, 11s, 124, 12a, 4ss, 4Bs, 4ss, 471, 101s

     c.      Disconnect and disassemble endoscopic components (e.g., suction valves) as completely as
          possible and completely immerse all components in the enzymatic cleaner. Steam sterilize these
                                                           115 116 139 4 5 466
          components if they are heat stable. Category /B.    •   •   • ~ -
     d.   Flush and brush all accessible channels to remove all organic (e.g., blood, tissue) and other
          residue. Clean the external surfaces and accessories of the devices by using a soft cloth or
                                                                                                     6  108
          soonae or brushes. Continue brushing until no debris appears on the brush. Category /A • 17 · '
          1{3, 111r. 116, 137' 145, 147, 725, 856, 903

     e.   Use cleaning brushes appropriate for the size of the endoscope channel or port (e.g., bristles
          should contact surfaces). Cleaning items (e.g., brushes, cloth) should be disposable or, if they
          are not disposable, they should be thorou~hly cleaned and either high-level disinfected or
                                                         5
          sterilized after each use. Category 11. 113 • 1 • 11 6 , 1°16
     f.   Discard enzymatic cleaners (or detergents) after each use because they are not microbicidal and,
                                                                        38 113 115 116 466
          therefore, will not retard microbial growth. Category /8. • • • •
     g.   Process endoscopes (e.g., arthroscopes, cystoscope, laparoscopes) that pass through normally
          sterile tissues using a sterilization procedure before each use; if this is not feasible, provide at
          least high-level disinfection. High-level disinfection of arthroscopes, laparoscop,es, and
                                                                                        1 17 31 32 5 89 90 113 554
          cytoscopes should be followed by a sterile water rinse. Category /B. • • • • • • • •
     h.   Phase out endoscopes that are critical items (e.g., arthroscopes, laparoscopes) but cannot be
          steam sterilized. Replace these endoscopes with steam sterilizable instruments when feasible.
          Category II.
     i.   Mechanically clean reusable accessories inserted into endoscopes (e.g., biopsy forceps or other
          cutting instruments) that break the mucosal barrier (e.g., ultrasonically, clean biopsy forceps) and
          then sterilize these items between each patient. Category /A. 1• 6 • 8 • 17 • 08 • 113• 115 - 1i 6,l 38 • 145 • 147,153 • m
     j.   Use ultrasonic cleaning of reusable endoscopic accessories to remove soil and organic material
          from hard-to-clean areas. Category 11. ~ •
                                                   11  145 148

     k.   Process endoscopes and accessories that contact mucous membranes as semicritical items, and
                                                                                               1 6 8 17 108 113 115 116 129
          use at least hiah-level disinfection after use on each patient. Category /A. • • • • • • • • •
          138, 145~148, 152-154,278

     I.   Use an FDA-cleared sterilant or high-level disinfectant for sterilization or high-level disinfection
          (Table 1). Category/A. 1,6-8,17,85,108,113,115,116,147
     m. After cleaning, use formulations containing glutaraldehyde, glutaraldehyde with phenol/phenate,

                                                                                                                                  86
Guideline for Disinlcor:lion and Stelilizallon in HciJit11cam F'1Cilitles, 20013

         ortho-phthalaldehyde, hydrogen peroxide, and both hydrogen peroxide and peracetic acid to
         achieve high-level disinfection followed by rinsinq and drying (see Table 1 for recommended
         concentrations). Category lB. 1, o.8,17, "· "· 108,113,145-148
    n.   Ex1end exposure times beyond the minimum effective time for disinfecting semi critical patient-
         care equipment cautiously and conservatively because extended exposure to a high-level
         disinfectant is more likely to damage delicate and intricate instruments such as ftexible
         endoscopes. The exposure times vary among the Food and Drug Administration (FDA)-cleared
                                                               17 69 73 76 78 83
         high-level disinfectants (Table 2). Category /B. • • • • •
    o.   Federal regulations are to follow the FDA-cleared label claim for high-level disinfectants. The
         FDA-cleared labels for high-level disinfection with >2% glutaraldehyde at 25°C range from 20-90
         minutes, depending upon the product based on three tier testing which includes AOAC sporicidal
         tests, simulated use testing with mycobacterial and in-use testing. Category /C.
    p.   Several scientific studies and professional organizations support the efficacy of >2%
         glutaraldehyde for 20 minutes at 2o•c; that efficacy assumes adequate cleaning prior to
         disinfection, whereas the FDA-cleared label claim incorporates an added margin of safety to
         accommodate possible lapses in cleaning practices. Facilities that have chosen to apply the 20
         minute duration at 2o•c have done so based on the lA recommendation in the July 2003 SHEA
         position paper, "Multi-society Guideline for Reprocessing Flexible Gastrointestinal Endoscopes 12 '
         !7, \9, 26, 27, 49, 55, 57, 58, 60, 73, 76, 79-81, 83·85, 93, 94, 104-106, 110, Ill, 115-121, 124, 125,233, 235,236,243,265, 266,609

    q.   When using FDA-cleared high-level disinfectants, use manufacturers' recommended exposure
         conditions. Certain products may require a shorter exposure time (e.g., 0.55% ortho-
         phthalaldehyde for 12 minutes at 20°C, 7.35% hydrogen peroxide plus 0.23% peracetic acid for
         15 minutes at 20'C) than glutaraldehyde at room temperature because of their rapid inactivation
         of mycobacteria or reduced exposure time because of increased mycobactericidal activity at
                                                                                              83 100 689 693
         elevated temperature (e.g., 2.5% glutaraldehyde at 5 minutes at 35°C). Category /B. • • • •
         694, 700

    r.   Select a disinfectant or chemical sterilant that is compatible with the device that is being
         reprocessed. Avoid using reprocessing chemicals on an endoscope if the endoscope
         manufacturer warns against using these chemicals because of functional damage (with or without
                                           69 113 116
         cosmetic damage). Category /B. · •
    s.   Completely immerse the endoscope in the high-level disinfectant, and ensure all channels are
                                                                                                    108 11 116
         perfused. As soon as is feasible, phase out nonimmersible endoscopes. Category /B.            · "'    '
         '37, 725, 856, 882

    t.   After high-level disinfection, rinse endoscopes and flush channels with sterile water, filtered
         water, or tapwater to prevent adverse effects on patients associated with disinfectant retained in
         the endoscope (e.g., disinfectant induced colitis). Follow this water rinse with a rinse with 70%-
         90% ethyl or isopropyl alcohol. Category /B. 11,31-35,38,39,108, 113, 115, 116, 134,145-148, 620·622, 624·63o, 1011
    u.   After flushing all channels with alcohol, purge the channels using forced air to reduce the
         likelihood of contamination of the endoscope by waterborne pathogens and to facilitate drying.
         Category lB. 39,113,115, 116,145, w
                                                                                                                              17 108 113 115 116 145 815
    v. Hang endoscopes in a vertical position to facilitate drying. Category 11. • • • • • •
    w. Store endoscopes in a manner that will protect them from damage or contamination. Category II.
         17, 108, 113, 115, 116, 145

    x.   Sterilize or high-level disinfect both the water bottle used to provide intraprocedural flush solution
         and its connecting tube at least once daily. After sterilizin~ or high-level disinfecting the water
                                                         10 31 35 113 116 1 17
         bottle, fill it with sterile water. Category /B. • • • • •
    y.   Maintain a log for each procedure and record the following: patient's name and medical record
         number (if available), procedure, date, endoscopist, system used to reprocess the endoscope (if
         more than one system could be used in the rewocessinp, area), and serial number or other
                                                              08 113 115 16
         identifier of the endoscope used. Category 11.         •   •   •
    z.   Design facilities where endoscopes are used and disinfected to provide a safe environment for
         healthcare workers and patients. Use air-exchange equipment (e.g., the ventilation system, out-
         exhaust ducts) to minimize exposure of all persons to potentially toxic vapors (e.g.,

                                                                                                                                                           87
Guideline for Disinfoclion and Sterilization in Heolthcme Facilities, 2008

           glutaraldehyde vapor). Do not exceed the allowable limits of the vapor concentration of the
           chemical sterilant or high-level disinfectant (e.g., those of ACGIH and OSHA). Category 18, /C.
           116,145,318,322,577,652

     aa. Routinely test the liquid sterilantlhigh-level disinfectant to ensure minimal effective concentration
         of the active ingredient. Check the solution each day of use (or more frequently) using the
         appropriate chemical indicator (e.g., glutaraldehyde chemical indicator to test minimal effective
         concentration of glutaraldehyde) and document the results of this testing. Discard the solution if
         the chemical indicator shows the concentration is less than the minimum effective concentration.
         Do not use the liquid sterilantlhigh-level disinfectant beyond the reuse-life recommended by the
                                                                                    76 108 11 116 608 609
         manufacturer (e.g., 14 days for ortho-phthalaldehyde). Category fA. • • 113 • s, • •
     bb. Provide personnel assigned to reprocess endoscopes with device-specific reprocessing
         instructions to ensure proper cleaning and high-level disinfection or sterilization. Require
         competency testing on a regular basis (e.g., beginnin~ of employment, annually) of all personnel
         who reprocess endoscopes. Category /A. 6-8,108,113; 11 , 116, 14s, 148,1ss
     cc. Educate all personnel who use chemicals about the possible biologic, chemical, and
                                                                                                           116
         environmental hazards of performing procedures that require disinfectants. Category 18, /C.           '
           997,998,1018,1019

     dd. Make PPE(e.g., gloves, gowns, eyewear, face mask or shields, respiratory protection devices)
         available and use these items appropriately to protect workers from ex~osure to both chemicals
         and microorganisms (e.g., HBV). Category IB, /C. 11S,116, 214,961,997,998,1 20,1021
     ee. If using an automated endoscope reprocessor (AER), place the endoscope in the reprocessor
         and attach all channel connectors according to the AER manufacturer's instructions to ensure
                                                                                                          7 8
         exposure of all internal surfaces to the high-level disinfectant/chemical sterilant. Category /B. · '
           115,116, 155,725,903

     ff.  If using an AER, ensure the endoscope can be effectively reprocessed in the AER. Also, ensure
          any required manual cleaning/disinfecting steps are performed (e.g., elevator wire channel of
                                                                                               7 8 11 116 1 72
          duodenoscopes might not be effectively disinfected by most AERs). Category lB. • • s. • ss. s
     gg. Review the FDA advisories and the scientific literature for reports of deficiencies that can lead to
          infection because design flaws and improper operation and practices have compromised the
                                                98 13 134   72
          effectiveness of AERs. Category 11. 1· • '· • iss. s
     hh. Develop protocols to ensure that users can readily identify an endoscope that has been properly
          processed and is ready for patient use. Category II.
     ii. Do not use the carrying case designed to transport clean and reprocessed endoscopes outside
          of the healthcare environment to store an endoscope or to transport the instrument within the
          healthcare environment. Category II.
     Jj. No recommendation is made about routinely performing microbiologic testing of either
                                                                                          116 164
          endoscopes or rinse water for quality assurance purposes. Unresolved Issue.        •
      kk. If environmental microbiologic testing is conducted, use standard microbiologic techniques.
          Category II. 23, 116,1S7,161, 167
     II. If a cluster of endoscopy-related infections occurs, investigate potential routes of transmission
                                                                                   8 1022
         (e.g., person-to-person, common source) and reservoirs. Category /A. •
     mm.          Report outbreaks of endoscope-related infections to persons responsible for institutional
                                                                               113 116 1023
         infection control and risk management and to FDA. Category /B.'· 7 • • '           Notify the local
         and the state health departments, CDC, and the manufacturer(s). Category II.
     nn. No recommendation is made regarding the reprocessing of an endoscope again immediately
         before use if that endoscope has been processed alter use according to the recommendations in
                                           157
         this guideline. Unresolved issue.
     oo. Compare the reprocessing instructions provided by both the endoscope's and the AER's
                                                                                                     116 1 5
         manufacturer's instructions and resolve any conflicting recommendations. Category /B.          · s

8.         Management of Equipment and Surfaces in Dentistry
     a.    Dental instruments that penetrate soft tissue or bone (e.g., extraction forceps, scalpel blades,
           bone chisels, periodontal scalers, and surgical burs) are classified as critical and should be

                                                                                                               88
Guideline for Disinfection and Sterilization in Healthcam rcacilittes, 2008

           sterilized after each use or discarded. In addition, after each use, sterilize dental instruments that
           are not intended to penetrate oral soft tissue or bone (e.g., amalgam condensers, air-water
           syringes) but that might contact oral tissues and are heat-tolerant, although classified as
           semi critical. Clean and, at a minimum, high-level disinfect heat-sensitive semi critical items.
           Category lA.        43,209211

      b.   Noncritical clinical contact surfaces, such as uncovered operatory surfaces (e.g., countertops,
           switches, light handles), should be barrier-protected or disinfected between patients with an
           intermediate-disinfectant (i.e., EPA-registered hospital disinfectant with a tuberculocidal claim) or
           low-level disinfectant (i.e., EPA-registered hospital disinfectant with HIV and HBV claim).
           Category 18 _43,209211
      c.   Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched
           frequently with gloved hands during the delivery of patient care, that are likely to become
           contaminated with blood or body substances, or that are difficult to clean. Change these
           coverings when they are visibly soiled, when they become damaged, and on a routine basis (e.g.,
           between patients). Disinfect protected surfaces at the end of the day or if visibly soiled. Category
          II. 43, 21o
9.        Processing Patient-Care Equipment Contaminated with 8/oodborne Pathogens (HBV,
Hepatitis C Virus, HIV), Antibiotic-Resistant Bacteria (e.g., Vancomycin-Resistant Enterococci,
Methicillin-Resistant Staphylococcus aureus, Mutt/drug Resistant Tuberculosis), or Emerging
Pathogens (e.g., Cryptosporidium, Helicobacter pylori, Escherichia coli 0157:H7, Clostridium
diffici/e, Mycobacterium tuberculosis, Severe Acute Respiratory Syndrome Coronavirus), or
Bioterrorist Agents
      a.   Use standard sterilization and disinfection procedures for patient-care equipment (as
           recommended in this guideline), because these procedures are adequate to sterilize or disinfect
           instruments or devices contaminated with blood or other body ftuids from persons infected with
           bloodborne pathogens or emerging pathogens, with the exception of prions. No changes in these
           procedures for cleaning, disinfecting, or sterilizing are necessarv for removing bloodborne and
           emeraing oathoaens other than orions. Category lA. 22, 53, so.sz, 73,79-81, 1os, 11a-121, 12s, 12s, 221,224-234, zJs,
           244, 265:' 266, :!71-273, ~79, 282, 283, 354-357, 666

10.        Disinfection Strategies for Other Semicritica/ Devices
      a.   Even if probe covers have been used, clean and high-level disinfect other semi critical devices
           such as rectal probes, vaginal probes, and cryosurgical probes with a product that is not toxic to
           staff, patients, probes, and retrieved germ cells (if applicable). Use a high-level disinfectant at the
                                                                                                                68
           FDA-cleared exposure time. (See Recommendations 7o and 11e for exceptions.) Category 18. ' •
           17,69

      b.   When probe covers are available, use a probe cover or condom to reduce the level of microbial
           contamination. Category If. 197-201 Do not use a lower category of disinfection or cease to follow
           the appropriate disinfectant recommendations when using probe covers because these sheaths
                                                  197 201
           and condoms can fail. Category 18 -
      c.   After high-level disinfection, rinse all items. Use sterile water, filtered water or tapwater followed
           by an alcohol rinse for semicritical equipment that will have contact with mucous membranes of
                                                                                           10 31 35 1017
           the upper respiratory tract (e.g., nose, pharynx, esophagus). Category 11. • ' •
      d.   There is no recommendation to use sterile or filtered water rather than tapwater for rinsing
           semicritical equipment that contact the mucous membranes of the rectum (e.g., rectal probes,
                                                                                 11
           anoscope) or vagina (e.g., vaginal probes). Unresolved issue.
      e.   Wipe clean tonometer tips and then disinfect them by immersing for 5-10 minutes in either 5000
           ppm chlorine or 70% ethyl alcohol. None of these listed disinfectant products are FDA-cleared
                                                    49 95 185 188 293
           high-level disinfectants. Category 11. • • • •

11.        Disinfection by Healthcare Personnel in Ambulatory Care and Home Care
      a.   Follow the same classification scheme described above (i.e., that critical devices require
           sterilization, semicritical devices require high-level disinfection, and noncritical equipment

                                                                                                                             89
Guidelrne for Disinfection and Sterilization in Hcaltilcare Fncilrtres, 2008

           requires low-level disinfection) in the ambulatory-care (outpatient medical/surgical facilities)
           setting because risk for infection in this setting is similar to that in the hospital setting (see Table
           1). Category /B. ~ 8 • 17 • 330
      b.   When performing care in the home, clean and disinfect reusable objects that touch mucous
           membranes (e.g., tracheostomy tubes) by immersing these objects in a 1:50 dilution of 5.25%-
           6.15% sodium hypochlorite (household bleach) (3 minutes), 70% isopropyl alcohol (5 minutes), or
           3% hydrogen peroxide (30 minutes) because the home environment is, in most instances, safer
           than either hospital or ambulatory care settings because person-to-person transmission is less
           likely. Category II. 327' 32 ~ 330' 331
      c.   Clean noncritical items that would not be shared between patients (e.g., crutches, blood pressure
                                                                                                                  53
           cuffs) in the home setting with a detergent or commercial household disinfectant. Category II. '
           330

12.        Microbial Contamination of Disinfectants
      a.   Institute the following control measures to reduce the occurrence of contaminated disinfectants:
           1) prepare the disinfectant correctly to achieve the manufacturer's recommended use-dilution;
           and 2) prevent common sources of extrinsic contamination of germicides (e.g., container
           contamination or surface contamination of the healthcare environment where the germicide are
           prepared and/or used). Category /B. 404 • 406• 1024

13.        Flash Sterilization
                                                                                                                849
      a.   Do not flash sterilize implanted surgical devices unless doing so is unavoidable. Category /B.             '
           850

      b.   Do not use flash sterilization for convenience, as an alternative to purchasing additional
           instrument sets, or to save tirne. Category 11. 817 • 962
      c.   When using flash sterilization, make sure the following parameters are met: 1) clean the item
           before placing it in the sterilizing container (that are FDA cleared for use with flash sterilization) or
           tray; 2) prevent exogenous contamination of the item during transport from the sterilizer to the
           patient; and 3) monitor sterilizer function with mechanical, chemical, and biologic monitors.
           Category lB.    812, 819, 846, 847. 962

      d. Do not use packaging materials and containers in flash sterilization cycles unless the sterilizer
                                                                                              812 819 1025
           and the packaging material/container are designed for this use. Category /B. ' •
      e.   When necessary, use flash sterilization for patient-care items that will be used immediately (e.g.,
                                                                                             845
           to reprocess an inadvertently dropped instrument). Category /B. 812 • 817 • 819 •
      f.   When necessary, use flash sterilization for processing patient-care items that cannot be
           packaged, sterilized, and stored before use. Category /B. 812 • 819

14.        Methods of Sterilization
      a. Steam is the preferred method for sterilizing critical medical and surgical instruments that are not
                                                                                425 426 827 841   1027
         damaged by heat, steam, pressure, or moisture. Category /A. 181 • 271 • • • • • 1026 •
      b. Cool steam- or heat-sterilized items before they are handled or used in the operative setting.
                           850
           Category lB.
      c. Follow the sterilization times, temperatures, and other operating parameters (e.g., gas
           concentration, humidity) recommended by the manufacturers of the instruments, the sterilizer,
           and the container or wrap used, and that are consistent with guidelines published by government
                                                                                                 1026 1028
           agencies and professional organizations. Category /B. 811 . 814 • 819• 825• 827• 841 • •
      d.   Use low-temperature sterilization technologies (e.g., EtO, hydrogen peroxide gas plasma) for
           reprocessing critical patient-care equipment that is heat or moisture sensitive. Category /A 469 • 721 •
           82~, 856,858,878,879,881,882,890,891, 1027

      e.   Completely aerate surgical and medical items that have been sterilized in the EtO sterilizer (e.g.,
           polyvinylchloride tubing requires 12 hours at 50"C, 8 hours at 60"C) before using these items in
           patient care. Category /B. 814
      f.   Sterilization using the peracetic acid immersion system can be used to sterilize heat-sensitive

                                                                                                                 90
Guideline Tor !Jisinfeclion and Stel'i!izaHon in ~··!ea!thcarc Facilities) 2008

           immersible medical and surgical items. Category /8. 90• 717' 719• 721 •724
      g.   Critical items that have been sterilized by the peracetic acid immersion process must be used
           immediately (i.e., items are not complete!¥ protected from contamination, making long-term
                                                  817 82
           storage unacceptable). Category II.       •
      h.   Dry-heat sterilization (e.g., 340°F for 60 minutes) can be used to sterilize items (e.g., powders,
                                                                   815 827
           oils) that can sustain high temperatures. Category 18.       •
      i.   Comply with the sterilizer manufacturer's instructions reqardinq the sterilizer cycle parameters
           (e.g., time, temperature, concentration). Category 18. 15 ,;; 725 • 81 ~ 814 · 819
      j.   Because narrow-lumen devices provide a challenge to all low-temperature sterilization
           technologies and direct contact is necessary for the sterilant to be effective, ensure that the
           sterilant has direct contact with contaminated surfaces (e.Q., scopes processed in peracetic acid
                                                                    137 725 825 856 890 891 1029
           must be connected to channel irrigators). Category 18.         •     · · • • •

15.        Packaging
      a. Ensure that packaging materials are compatible with the sterilization process and have received
           FDA 51 O[k] clearance. Category 18. 811 · 81 4, 819 • 966
      b.   Ensure that packaging is sufficiently strong to resist punctures and tears to provide a barrier to
                                                             454 811 81 819 966
           microorganisms and moisture. Category /8.              •  • '·  •

16.        Monitoring of Sterilizers
      a. Use mechanical, chemical, and bioloqic monitors to ensure the effectiveness of the sterilization
           process. Category lB. a11-s1s, a1s, a4a, a4f. s1s-s17
      b.   Monitor each load with mechanical (e.g., time, temperature, pressure) and chemical (internal and
           external) indicators. If the internal chemical indicator is visible, an external indicator is not
           needed. Category II. a11-a1s, 819, a4a, 847, 975-977, sao
      c. Do not use processed items if the mechanical (e.g., time, temperature, pressure) or chemical
                                                                                                          819
           (internal and/or external) indicators suggest inadequate processing. Category 18 811 ' 814 • ,
      d.   Use biologic indicators to monitor the effectiveness of sterilizers at least weekly with an FDA-
           cleared commercial preparation of spores (e.g., Geobacillus stearothennophi/us for steam)
                                                                                                           813 815
           intended specifically for the type and cycle parameters of the sterilizer. Category 18. 1• 811 • ' •
           819,846,647,976,977

      e.   After a single positive biologic indicator used with a method other than steam sterilization, treat
           as nonsterile all items that have been processed in that sterilizer, dating from the sterilization
           cycle having the last negative biologic indicator to the next cycle showing satisfactory biologic
           indicator results, These nonsterile items should be retrieved if possible and reprocessed.
           Category 1/, 1
      f.   After a positive biologic indicator with steam sterilization, objects other than implantable objects
           do not need to be recalled because of a single positive spore test unless the sterilizer or the
           sterilization procedure is defective as determined by maintenance personnel or inappropriate
           cycle settings. If additional spore tests remain positive, consider the items nonsterile and recall
           and reprocess the items from the implicated load(s). Category 1/. 1
      g.   Use biologic indicators for every load containing implantable items and quarantine items,
                                                                                        811 814 819
           whenever possible, until the biologic indicator is negative. Category 18. . •

17.        Load Configuration.
      a.   Place items correctly and loosely into the basket, shelf, or cart of the sterilizer so as not to
                                                                 445 454 811 813 819 836
           impede the penetration of the sterilant. Category 18.    •   •   •   •   •

18.        Storage of Sterile Items
      a.   Ensure the sterile storage area is a well-ventilated area that provides protection a~ainst dust,
                                                                                     454 819 836 69
           moisture, insects, and temperature and humidity extremes. Category 11.       •   •   •
                                                                                                           454
      b.   Store sterile items so the packaging is not compromised (e.g., punctured, bent). Category II.       •
           816,819,968,969,1030

                                                                                                                     91
Guideline tor Disinfection and ,(3teri!izahon ln HeniHlt;.aro Ff1Cilities) 2008

      c.   Label sterilized items with a load number that indicates the sterilizer used, the cycle or load
                                                                                                   811 812 814 816
           number, the date of sterilization, and, if applicable, the expiration date. Category lB. • • • •
           819

      d. The shelf life of a packaged sterile item depends on the quality of the wrapper, the storage
         conditions, the conditions during transport, the amount of handling, and other events (moisture)
         that compromise the integrity of the package. If event-related storage of sterile items is used,
         then packaged sterile items can be used indefinitely unless the packaging is compromised (see f
         and g below). Category /B. 816,819,836,968,973,1030, 1031
      e. Evaluate packages before use for loss of integrity (e. g., torn, wet, punctured). The pack can be
                                                                                         968
         used unless the integrity of the packaging is compromised. Category 11. 819 •
      f. If the integrity of the packaging is compromised (e.g., torn, wet, or punctured), repack and
         reprocess the pack before use. Category 11. 819 • 1032
      g. If time-related storage of sterile items is used, label the pack at the time of sterilization with an
                                                                                           968
         expiration date. Once this date expires, reprocess the pack. Category 11. 819 •

19.      Quality Control
      a. Provide comprehensive and intensive training for all staff assigned to reprocess semi critical and
         critical medical/surgical instruments to ensure they understand the importance of reprocessing
         these instruments. To achieve and maintain competency, train each member of the staff that
         reprocesses semicritical and/or critical instruments as follows: 1) provide hands-on training
         according to the institutional policy for reprocessing critical and semi critical devices; 2) supervise
         all work until competency is documented for each reprocessing task; 3) conduct competency
         testing at beginning of employment and regularly thereafter (e.g., annually); and 4) review the
         written reprocessing instructions regularly to ensure ther, compl¥ with the scientific literature and
         the manufacturers' instructions. Category lB. 6-8 • 108 • 114 • 29 • 155 • 72 • 813 • 819
      b. Compare the reprocessing instructions (e.g., for the appropriate use of endoscope connectors,
         the capping/noncapping of specific lumens) provided by the instrument manufacturer and the
         sterilizer manufacturer and resolve any confticting recommendations by communicating with both
         manufacturers. Category lB. 155' 725
      c. Conduct infection control rounds periodically (e.g., annually) in high-risk reprocessing areas (e.g.,
         the Gastroenterology Clinic, Central Processing); ensure reprocessing instructions are current
         and accurate and are correctly implemented. Document all deviations from policy. All
                                                                                                        6 8 129
         stakeholders should identify what corrective actions will be implemented. Category /B. - ·
      d. Include the following in a quality control program for sterilized items: a sterilizer maintenance
         contract with records of service; a system of process monitoring; air-removal testing for
         prevacuum steam sterilizers; visual inspection of packaging materials; and traceability of load
         contents. Category II 811 ' 814 ' 819 •
      e. For each sterilization cycle, record the type of sterilizer and cycle used; the load identification
         number; the load contents; the exposure parameters (e.g., time and temperature); the operator's
         name or initials; and the results of mechanical, chemical, and biological monitoring. Category II
           811-814, 819

      f. Retain sterilization records (mechanical, chemical, and biological) for a time period that complies
         with standards (e.g., 3 years), statutes of limitations, and state and federal regulations. Category
         II, /C. 1o33
      g. Prepare and package items to be sterilized so that sterility can be achieved and maintained to the
         point of use. Consult the Association for the Advancement of Medical Instrumentation or the
         manufacturers of surgical instruments, sterilizers, and container systems for guidelines for the
         density of wrapped packages. Category 11. 811 - 814• 819
      h. Periodically review policies and procedures for sterilization. Category II. 1033
      i. Perform preventive maintenance on sterilizers by qualified personnel who are guided by the
         manufacturer's instruction. Category 11. 811 -814 • 819

                                                                                                                92
Guideline for Disinfection and Sterilization in Hoalti1cmc Facilttios, /.008

20.        Reuse of Single-Use Medical Devices
      a.   Adhere to the FDA enforcement document for single-use devices reprocessed by hospitals. FDA
           considers the hospital that reprocesses a single-use device as the manufacturer of the device
           and regulates the hospital using the same standards by which it regulates the original equipment
                                          995
           manufacturer. Category 1/, /C.

                                                                                                         93
Guideline for Olslnfection and SteH!lzatlon in Hea!thcare Facilities, 2008

                                      PERFORMANCE INDICATORS

    1.   Monitor adherence to high-level disinfection and/or sterilization guidelines for endoscopes on a
         regular basis. This monitoring should indude ensuring the proper training of persons performing
         reprocessing and their adherence to all endoscope reprocessing steps, as demonstrated by
         competency testing at commencement of employment and annually.
    2.   Develop a mechanism for the occupational health service to report all adverse health events
         potentially resulting from exposure to disinfectants and sterilants; review such exposures; and
         implement engineering, work practice, and PPE to prevent future exposures.
    3.   Monitor possible sterilization failures that resulted in instrument recall. Assess whether additional
         training of personnel or equipment maintenance is required.

                                                                                                            94
Guideline for Disinfection and .Stcri!L::atlon in Ho8!thc1m)
                                                                                                      9
                                                                                                                      > 1 m}
                                                                                                                             9

Smooth, hard                      A          MR                              D                    K                      K
       14
Surface •                         8          MR                              E                      L'                    L
                                  c          MR                              F                      M                     M
                                  D          10 h at20-25'C                  H                      N                     N
                                  F          6h                              I'                                           0
                                  G          12 m at 50-56'C                  J
                                  H          3-Bh

Rubber tubing and                 A          MR                              D
         34
catheters •                       8          MR                              E
                                  c          MR                              F
                                  D          10 h at 20-25'C                 H
                                  F          6h                              I'
                                  G          12 m at 50-56'C                  J
                                  H          3-Bh

Polyethylene tubing               A          MR                              D
and catheters3.4. 7               8          MR                              E
                                  c          MR                              F
                                  D          10 h at 20-25'C                 H
                                  F          6h                              I'
                                  G          12 m at 50-56'C                  J
                                  H          3-Bh

                      4
Lensed instruments                A          MR                              D
                                  8          MR                              E
                                  c          MR                              F
                                  D          10 hat 20-25'C                  H
                                  F          6h                               J
                                  G          12 m at 50-56'C
                                  H          3-Bh

Thermometers (oral                                                                                                        K'
            6
and rectal)
                   4
Hinged instruments                A          MR                              D
                                  8          MR                              E
                                  c          MR                              F
                                  D          1o h at 20-25'C                 H
                                  F          6h                              I'
                                  G          12 m at 5Q-56°C                 J
                                  H          3-Bh

Modified from Rutala and Simmons. 15 • 17 • 18• 421 The selection and use of disinfectants in the health care field is dynamic, and
products may become available that are not in existence when this guideline was written. As newer disinfectants become
available, persons or committees responsible for selecting disinfectants and sterilization processes should be guided by
products cleared by the FDA and the EPA as well as information in the scientific literature.

                                                                                                                                104
Guid650-675 active free chlorine;
        (will corrode metal instruments)
K,      Ethyl or isopropyl alcohol (70-90%)
L,      Sodium hypochlorite (5.25-6.15% household bleach diluted 1:500 provides >1 00 ppm available chlorine)
M,      Phenolic germicidal detergent solution (follow product label for use-dilution)
N,      Iodophor germicidal detergent solution (follow product label for use-dilution)
0,      Quaternary ammonium germicidal detergent solution (follow product label for use-dilution)
MR,     Manufacturer's recommendations
NA, Not applicable

     See text for discussion of hydrotherapy.
     The longer the exposure to a disinfectant, the more likely it is that all microorganisms will be eliminated. Follow the
     FDA-cleared high-level disinfection claim. Ten-minute exposure is not adequate to disinfect many objects, especially
     those that are difficult to clean because they have narrow channels or other areas that can harbor organic material and
     bacteria. Twenty-minute exposure at 20°C is the minimum time needed to reliably kill M. tuberculosis and
     nontuberculous mycobacteria with a 2% glutaraldehyde. Some high-level disinfectants have a reduced exposure time
     (e.g., ortho-phthalaldehyde at 12 minutes at 20°C) because of their rapid activity against mycobacteria or reduced
     exposure time due to increased mycobactericidal activity at elevated temperature (e.g., 2.5% glutaraldehyde at 5
     minutes at 35°C, 0.55% OPA at 5 min at 25°C in automated endoscope reprocessor).
'    Tubing must be completely filled for highMievel disinfection and liquid chemical sterilization; care must be taken to avoid
     entrapment of air bubbles during immersion.
     Material compatibility should be investigated when appropriate.
6
     A concentration of 1000 ppm available chlorine should be considered where cultures or concentrated preparations of
     microorganisms have spilled (5.25% to 6.15% household bleach diluted 1:50 provides > 1 000 ppm available chlorine).
     This solution may corrode some surfaces.
6
     Pasteurization (washer-disinfector) of respiratory therapy or anesthesia equipment is a recognized alternative to high-
     level disinfection. Some data challenge the efficacy of some pasteurization units.
     Thermostability should be investigated when appropriate.
     Do not mix rectal and oral thermometers at any stage of handling or processing.
     By law, all applicable label instructions on EPA-registered products must be followed. If the user selects exposure
     conditions that differ from those on the EPA-registered products label, the user assumes liability from any injuries
     resulting from off-label use and is potentially subject to enforcement action under FIFRA.

                                                                                                                             105
Cuidef!no ·for D!s\nfect!on and Sterilization in !. ·!ea!thcarr~ Faci!lh;s, 2008

Table 2. Properties of an Ideal disinfectant

Broad spectrum: should have a wide antimicrobial spectrum
Fast acting: should produce a rapid kill
Not affected by environmental factors: should be active in the
   presence of organic matter (e.g., blood, sputum, feces) and
   compatible with soaps, detergents, and other chemicals
   encountered in use
Nontoxic: should not be harmful to the user or patient
Surface compatibility: should not corrode instruments and
   metallic surfaces and should not cause the deterioration of
   doth, rubber, plastics, and other materials
Residual effect on treated surfaces: should leave an
antimicrobial film on the treated surface
Easy to use with clear label directions
Odorless: should have a pleasant odor or no odor to facilitate its
   routine use
Economical: should not be prohibitively high in cost
Solubility: should be soluble in water
Stability: should be stable in concentrate and use-dilution
Cleaner: should have good cleaning properties
Environmentally friendly: should not damage the environment on
disposal
Modified from Molinari

                                                                                   106
Guideline for Oislnlection and Sterilization In Hea!Hicare Faci!itles, 2008

Table 3. Epidemiologic evidence associated with the use of surface disinfectants or detergents
on noncritical environmental surfaces.
Justification for Use of Disinfectants for Noncritical Environmental Surfaces
Surfaces may contribute to transmission of epidemiologically important microbes (e.g., vancomycin-
   resistant Enterococci, methicillin-resistantS. aureus, viruses)
Disinfectants are needed for surfaces contaminated by blood and other potentially infective material
Disinfectants are more effective than detergents in reducing microbial load on floors
Detergents become contaminated and result in seeding the patient's environment with bacteria
Disinfection of noncritical equipment and surfaces is recommended for patients on isolation precautions
   by the Centers for Disease Control and Prevention.
Advantage of using a single product for decontamination of noncritical surfaces, both floors and
equipment
Some newer disinfectants have persistent antimicrobial activity
Justification for Using a Detergent on Noncritical Environmental Surfaces
Noncritical surfaces contribute minimally to endemic healthcare-associated infections
No difference in healthcare-associated infection rates when floors are cleaned with detergent versus
disinfectant
No environmental impact (aquatic or terrestrial) issues with disposal
No occupational health exposure issues
Lower costs
Use of antiseptics/disinfectants selects for antibiotic-resistant bacteria (?)
More aesthetically pleasing floor
Modified from Rutala    .

                                                                                                     107
Guideline for Disinfection and Stei'ilization in Healthcmo F5 ~m in size is expelled, resulting in
the potential exposure of susceptible persons within 3 feet of the source person.' Examples of
pathogens spread in this manner are influenza virus, rhinoviruses, adenoviruses, and respiratory
syncytial virus (RSV). Because these agents primarily are transmitted directly and because the droplets
tend to fall out of the air quickly, measures to control air flow in a health-care facility (e.g., use of
negative pressure rooms) generally are not indicated for preventing the spread of diseases caused by
these agents. Strategies to control the spread of these diseases are outlined in another guideline 3

The spread of airborne infectious diseases via droplet nuclei is a form of indirect transmission. 34
Droplet nuclei are the residuals of droplets that, when suspended in air, subsequently dry and produce
                                                                                                                                    7

particles ranging in size from 1-5 11m. TI1ese patticles can a) contain potentially viable microorganisms,
b) be protected by a coat of (hy secretions, c) remain suspended indefinitely in air, and d) be transported
over long distances. Tite microorganisms in droplet nuclei persist in favorable conditions (e.g., a dty,
cool atmosphere with little or no direct exposure to sunlight or other sources of radiation). Pathogenic
microorganisms that can be spread via droplet nuclei include lY~rcobacterium tuberculosis, VZV.
measles vims (i.e .. mbeola), and smallpox vims (i.e., vmiola major). 6 Several environmental pathogens
have life-cycle forms that are similar in size to droplet nuclei and may exhibit similar behavior in the
air. The spores ot'Aspergillusjinnigatns have a diameter of2-3.5 !1111, with a settling velocity estimated
at 0.03 em/second (or about !meter/hour) in still air. With this enhanced buoyancy, the spores. which
resist desiccation, can remain airbome indefinitely in air cunents and travel far from their source. 35

2. Airborne Infectious Diseases in Health-Care Facilities
a. Aspergillosis ami Of/1er Fungal Diseases
Aspergillosis is caused by molds belonging to the genus Aspergillus. Aspergillus spp. are prototype
health-care-acquired pathogens associated with dusty or moist environmental conditions. Clinical and
epidemiologic aspects of aspergillosis (Table 1) are discussed extensively in another guideline!

Table 1. Clinical and epidemiologic chnracteristics of nspergillosis
                                                                                                                   Refert>nres
                               Aspergillusfumigaws (90o/c-95% ofAspergillus infections among
     Causative agent<;         hematopoietic .stem cell tran'>plnnt (HSCT) patients; A.jlnvus, A. nigel', A.          36-43
                                      A. nidulans
                               te/Te11S,

  l\Iode.s of transmission
                               All·bome trnnsmis<:>lou of fu>l~~al_;fores; direct inhalntion; direct inoculation        37
                               from environmental s.omces rare
Acti\'itle.c; nssodnted with   Con<;tmction. rc:novotion. r~modeling:, repairs. building demolition; rare
                                                                                                                      44-51
            infection          eJlisodes associated with fomites
                               A!'ute inWJsb•e: pnt>umonin: ulcerative tracheobronchitis; osteomyelitis:
                               abscesses (aspergiltomas) of the lungs. brain, liver, spleen, and kidneys:
                               tlu·ombosis of deep blood vessels: necrotizing: skin uh;:ers; et}dophthalmitis;
 Clinlcnl !i~·udrome_s !lnd
                               and sinusitis                                                                       44.45,52-58
         disen:Ses
                               Chronic fm•asiw: chronic pneumot1itis
                               H.Jpersl'JISI~I'; allergic bronchopulmonmy aspergiUosis
                               Ct1ta11eous: · orimarV c,kin and burn-wound infections
                               H('matopoietic stem cell tl'tmsp)ant patients (HSCT):
                               inununocompromised patients (i.e., tho>e with tmderlying disease), pntients
  Patient populations at       undergoing chemothet-apy, organ h'attsplnnt redpients~ pretenn neonates 1
                               hemodialysis patients. p11ticnts wilh identifiable immune ·system deficiencies
                                                                                                                    36, 59-78
       greatest risk
                               who receive c!lre in general inten'.>ive care units (ICUs). nnd cystic fibrosis
                               natienis fmav be colonized occasionnllv become iufe~ted)
l'aetor:s nffediug scvN·ity    111e inunune '!.tatus of the patient and the dumtion of severe neutropenia
                                                                                                                      79,80
       nud outt:Otut''i
                               Rare nnd spomdi~, but increasing as proportion of itmmmocompronllfied
       0CC\ll'l'eUCt'          patients increases; 5% ofHSCT patients infected, <5% of solid orgnn                 36,37,81-88
                               trnnsolaut recioients infected
                               Rate can be as high as 100% if severe neutropenia persists; 13%-80%
      Mortality rate                                                                                               58, 83, 89, 90
                               mo11a1itv amon2leukeruia Datients

Aspergillus spp. are ubiquitous, aerobic fungi that occur in soil, water, and decaying ve§etation; the
organism also survives well in air. dust. and moisture present in health-care facilities."- 3 The presence
of aspergilli in the health-care facility environment is a substantial extrinsic risk factor for opportunistic
invasive aspergillosis (invasive aspergillosis being the most serious tonn of the disease) 69· 9 Site
renovation and constmction can disturb Awm:gil/us-contaminated dust and produce bursts of airbome
8

fungal spores. Increased levels of atmospheric dust and fungal spores have been associated with
clusters of health-care-acquired infections in immunocompromised patients. 17• 20• 44• 47• 49• 50• ,,_98
Absorbent building materials (e.g., wallboard) serve as an ideal substrate for the proliferation of this
organism if they become and remain wet, thereby increasing the numbers of fungal spores in the area.
Patient-care items, devices, and equipment can become contaminated with Aspergillus spp. spores and
serve as sources of infection if stored in such areas. 57

Most cases of aspergillosis are caused by Aspergillus fitmigatus, a thermotolerant/thermophilic fungus
capable of growing over a temperature range from 53.6°F-127.4°F ( I2°C-53°C); optimal growth occurs
at approximately 104°F (40°C), a temperature inhibitory to most other saprophytic fungi. 99 It can use
cellulose OJ' sugars as carbon sources; because its respiratory process requires an ample supply of
carbon, decomposing organic matter is an ideal substrate.

Other oppmtunistic fungi that have been occasionally linked with health-care-associated infections are
members of the order Mucorales (e.g., Rhizopus spp.) and miscellaneous moniliaceous molds (e.g.,
Fusarium spp. and Penicillium spp.) (Table 2). Many of these fungi can proliferate in moist
environments (e.g., water-damaged wood and building materials). Some fungi (e.g., Fusarium spp. and
Pseudoal/escheria spp.) also can be airborne pathogens. 100 As with aspergillosis, a major risk factor for
disease caused by any of these pathogens is the host's severe immunosuppression fi·mn either
                                                  101
underlying disease or immunosuppressive therapy. • 102

Table 2. Environmental fungal pathogens: entry into and contamination of the health-
care facility

         Implicated environmental vehicle                         References

Aspergillus spp.
         Improper!): functioning ventilation systems              20, 46, 47, 97, 98, 103, 104
         Air filters ,+                                           17, 18, 105-107
         Air filter frames                                        17, 18
         Window air conditioners                                  96
         Backflow of contaminated air                             107
         Air exhaust contamination+                               104
         False ceilings                                           48, 57, 97, 108
         Fibrous insulation and perforated metal ceilings         66
         Acoustic ceiling tiles, plasterboard                     18, 109
         Fireproofing material                                    48,49
         Damp wood building materials                             49
         Opening doors to constmction site                        110
         Construction                                             69
         Open windows                                             20, 108, Ill
         Disposal conduit door                                    68
         Hospital vacuum cleaner                                  68
         Elevator                                                 112
         Atmboards                                                57
         Walls                                                    113
         Unit kitchen                                             114
         Food                                                     21
         Ornamental plants                                        21
Mucorales I Rhizopus spp.
        Air filter                                                20, 115
        False ceilings                                            97
        Heliport                                                  115
Scedospol'ium spp.
        Construction                                              116
                                                                                                                                                    9

(Table 2. continued)

           Implicated environmental vehicles                                                References

Penicillium spp.
           Rotting cabinet wood, pipe leak                                                  21
           Ventilation duct fiberglass insulation                                           112
           Air filters                                                                      105
           Topical anesthetic                                                               117
Acremonium spp.
           Air filters                                                                       105
Cladosporium spp.
           Air filters                                                                       105
Sporothrix
            Constmction (pseudoepidemic)                                                     118

*. Pigeons, their droppings and roosts are associated with spread of Aspergtllus, C/Jptococcus, and Histoplasma spp. There have been at
    least three outbreaks linked to contamination of the filtering systems from bird droppings 98 • 103 • 104 Pigeon mites may gain access into a
     health-care facility through the ventilation system. 119
+. The American Institute of Architects (AlA) standards stipulate that for new or renovated construction a) exhaust outlets are to be placed
     >25 feet from air intake systems, b) the bottom of outdoor air intakes for HVAC systems should be 6 feet above ground or 3 feet nbove
    roof level, and c) exhaust outlets from contaminated areas are situated above the roof level and arranged to minimize the recirculation of
    exhausted air back into the building. 120

Infections due Cryptococcus neoformans, Histoplasma capsulatum, or Coccidioides immitis can occur
in health-care settings if nearby ground is disturbed and a malfunction of the facility's air-intake
components allows these pathogens to enter the ventilation system. C. neoformans is a yeast usually 4-
8 flm in size. However, viable particles of <2 flm diameter (and thus pennissive to alveolar deposition)
                                                                                             103
have been found in soil contaminated with bird droppings, particularly from pigeons."'· • 104• 121 H
capsulatum, with the infectious microconidia ranging in size ft·om 2-5 ftm, is endemic in the soil of the
central river valleys of the United States. Substantial numbers of these infectious particles have been
associated with chicken coops and the roosts of blackbirds."'· 103 ' 104• 122 Several outbreaks of
histoplasmosis have been associated with disruption of the environment; construction activities in an
endemic area may be a potential risk factor for health-care--acquired airborne infection. 123 • 124 C.
immitis, with arthrospores of3-5 flm diameter, has similar potential, especially in the endemic
southwestern United States and during seasons of drought followed by heavy rainfall. After the 1994
earthquake centered near Northridge, California, the incidence of coccidioidomycosis in the surrounding
area exceeded the historical norm. 125

Emerging evidence suggests that Pneumocystis carinii, now classified as a fungus, may be spread via
airborne, person-to-person transmission. 126 Controlled studies in animals first demonstrated thatP.
carinii could be spread through the air. 127 More recent studies in health-care settings have detected
nucleic acids of P. carinii in air samples from areas frequented or occupied by P. carinii-infected
patients but not in control areas that are not occupied by these patients."'· 129 Clusters of cases have
been identified among immunocompromised patients who had contact with a source patient and with
each other. Recent studies have examined the presence of P. carinii DNA in oropharyngeal washings
and the nares of infected patients, their direct contacts, and persons with no direct contact. 130 • 131
Molecular analysis of the DNA by polymerase chain reaction (PCR) provides evidence for airborne
transmission of P. cm·inii from infected patients to direct contacts, but immunocompetent contacts tend
to become transiently colonized rather than infected. 131 The role of colonized persons in the spread of
P. carinii pneumonia (PCP) remains to be determined. At present, specific modifications to ventilation
systems to control spread of PCP in a health-care facility are not indicated. Current recommendations
10

outline isolation procedures to minimize or eliminate contact of inununocompromised patients not on
PCP prophylaxis with PCP-infected patients.'· m

b. Tuberculosis ami Otiler Bacterial Diseases
The bacterium most commonly associated with airbome transmission is Mycobacterium tuberculosis. A
comprehensive review of the microbiology and epidemioloiF of M. tuberculosis and guidelines for
tuberculosis (TB) infection controllwve been published.'· 1l · 134 A Slll1llllalY of the clinical and
epidemiologic information from these materials is provided in this guideline (Table 3).

Table 3. Clinical and epidemiologic characteristics oftuberculosis (TB)*
          Cau~atiY{' ngeuts                     l\(l'<'Obncterlum tubnculosis, M bovis, M afiicanlutl
         Mode of transmission                   Airborne trnnstni!>sion via droplet nuclei 1-5 ~1m in dinmeter
                                                • Disease of the hmgs, airways, or lmynx: presence of coug-h or other forceful
                                                       expiratory measures
    PMient fnrtors nssodntt>d with               •   Pr~sence of "cid-fasi bnciUi (AFB) in the sputum
     infeftivity nud transmission                •  FRihu·e of the patient to cover the mouth and nose when coughing or .sneezing
                                                 •  Presence of cavitntion on chest radiogl'aph
                                                 •  Inappropriate or shortened duration of chemothempy
                                                 •  Exposures in rehtively small, enclosed spa~s
                                                 •  Inadeqtmte ventilation resulting in insufficient removal of droplet nuclei
       Activiti(l's nssorinte-d with             •  Cough~produdng procedures done in areas without proper enviromnental controls
                 infections                      •  Recirculation of nir containing infectious droplet JlU()lei
                                                 •  Fnilure to me respirat01y protection whell managing open lesions for pntients with
                                                       suspected extrapulmonary TB 135
                                                 Pulmoual'y TB; extrapulmonaty TB can ail'ect any organ system or tissue; lnryngcal
 Clinknl syndromes and dis<>ns<'                 TB is highly contagious
                                                 * lllUnlUlOCOlllpromised peJ:>OilS (c.g., fliV.infected persons)
                                                  • Medically underset'~o'ed persons. urbnn poor. homele'>s persons, elderly persons.
                                                      migrant fnrm workers. close contacls of known patients
     Populnfions 11t grente-st ri.sk             • Substance abusers, pre'>ent and fonner prison Uuuates
                                                 • Foreign~bol'll persons from areas with high prevaleu~e ofTB
                                                 .. Health-care worker-S
                                                 • Concentration of droplet nuclei in air, duration of exposure
    Factors affecting sevel'ity And              • Age nt infection
              outcomt's                          • Inmmnosuppression due to therapy Ol' disease, underlying cht·onic medical
                                                       conditions, histoty of malia:nnncies or lesions or the luno.s
               OccmTem·e                         Worldwide; incidence in the United States is 5.6 cases/100,000 population (200 1)'" 9
                 Mortality                       930 denths in the United States (1999)""
                                                                                                                                         -
                                                 Treatment of latent infection includes isoniazid (INH) or rifampin (IUF).''
                                                 Directly obsetTed therapy (DOT) for active cases as indicated: INH, RIF,
 ChetuOJH'ophyhtxis I tr<'-atment                pymzin~mide (PZA), ethmnbutol (EMB), streptomydn (SM.f- in various combinations
                                                 detennined by prev;llent level<; of specific resistance,'1·1J'I. 13 -!3!) Consult therapy
                                                                                                 139
                                               I Rttidelines for specific treatment indications,
•   Matenal m this table 1s C                 Mucorales (Rhizopus spp.) 91• 115         tuberculosis+                          VmiceHn-zoster vims 162•166
fnclllfios
Atypical,                       Acrem_onitml    ·"f£·
                                                 1
                                                   "'"· ~v"               Acinqtobacter w~- IQI                  Smallpox vims (variola)§ 111ll' Ill'>'
ocrnstonnlreports               Fusarmm "'PP·                             Bacillus spp.~ 1 '"07                  Influenza vimses 181 • 162
                                Pseudoal/escheria bo}'dii100              Brucella spp.** 20S-2tt                RespirfttOJy syncytinl vin1s 183
                                Scedosporimn spp. 116                     Staphvlococcus aureus 148• 156         Adenovimses 134
                                Sporothrix cyanesceJJS~ 118               GrouP A Sh·eptococcus 151              Nonvalk-li.ke \'i.ttts185
Airbol'ne in nature;            Coccidioides inunitisw                    Coxiella bumetii (Q fever)             Hautavimses
flirboruP                       OJpfococctts spp. m                                                              Lns!.a viruo; ~ 05
transmi~sion       in           Histoplasma capsulatum 114                                                       Marburg virus 20 ~
lt0nlth rare st>ttings                                                                                           Ebola vints 205
                                                                                                                 Crimean-Congo virm.205
not desrl'ibE'd
Under invE'stigatiou            Pmmmocystis cminii
• Tius hst excludes nucroorgamsms transmuted from aerosols dern ed front \\ater .
+ Refer to the text for references for these di!iesion iucre;~ses with patients who are effechve. disseruinntors
    present in facilitie.<> with low rel60%, in addition to being perceived as
uncomfortable, promote fungal growth. 243 Humidity levels can be manipulated by either of two
mechanisms. 244 In a water-wash unit, water is sprayed and drops are taken up by the filtered air;
additional heating or cooling of this air sets the humidity levels. The second mechanism is by means of
water vapor created from steam and added to filtered air in humidifYing boxes. Reservoir-type
humidifiers are not allowed in health-care facilities as per AlA guidelines and many state codes. 120
Cool-mist humidifiers should be avoided, because they can disseminate aerosols containing allergens
and microorganisms. 245 Additionally, the small, personal-use ve1~ions of this equipment can be
difficult to clean.
18

     iii. Ventilation
The control of air pollutants (e.g., microorganisms, dust, chemicals, and smoke) at the source is the most
effective way to maintain clean air. The second most effective means of controlling indoor air pollution
is through ventilation. Ventilation rates are voluntaty unless a state or local government specifies a
standard in health-care licensing or health department requirements. These standards typically apply to
only the design of a facility, rather than its operation. 220' 246 Health-care facilities without specific
ventilation standards should follow the AlA guideline specific to the year in which the building was
built or the ANSIIASHRAE Standard 62, Ventilation for Acceptable Indoor Air Quality. 120• 214· 241

Ventilation guidelines are defined in terms of air volume per minute per occupant and are based on the
assumption that occupants and their activities are responsible for most of the contaminants in the
conditioned space. 215 Most ventilation rates for health-care facilities are expressed as room ACH. Peak
efficiency for particle removal in the air space occurs between 12 ACH-15 ACH. 35• 247 •248 Ventilation
rates vaty among the different patient-care areas of a health-care facility (Appendix B). 120
                                                           120
                                                                      °
Health-care facilities generally use recirculated air. 35 ' ' 241 · 249· 25 Fans create sufficient positive
pressure to force air through the bt1ilding duct work and adequate negative pressure to evacuate air fi·om
the conditioned space into the return duct work and/or exhaust, thereby completing the circuit in a
sealed system (Figure 1). However, because gaseous contaminants tend to accumulate as the air
recirculates, a percentage of the recirculated air is exhausted to the outside and replaced by fresh
outdoor air. In hospitals, the delivety of filtered air to an occupied space is an engineered system design
issue, the full discussion of which is beyond the scope of this document.

Hospitals with areas not served by central HVAC systems often use through-the-wall or fan coil air
conditioning units as the sole source of room ventilation. AlA guidelines for newly installed systems
stipulate that through-the-wall fan-coil units be equipped with permanent (i.e., cleanable) or replaceable
filters with a minimum efficiency of 68% weight arrestance. 120 These units may be used only as
recirculating units; all outdoor air requirements must be met by a separate central air handling system
with proper filtration, with a minimum of two outside air changes in general patient rooms (D. Erickson,
ASHE, 2000). 120 If a patient room is equipped with an individual through-the-wall fan coil unit, the
room should not be used as either All or as PE. 120 These requirements, although directed to new
HVAC installations also are appropriate for existing settings. Non-central air-handling systems are
prone to problems associated with excess condensation accumulating in drip pans and improper filter
maintenance; health-care facilities should clean or replace the filters in these units on a regular basis
while the patient is out of the room.

Laminar airflow ventilation systems are designed to move air in a single pass, usually through a bank of
HEPA filters either along a wall or in the ceiling, in a one-way direction through a clean zone with
parallel streamlines. Laminar airflow can be directed vertically or horizontally; the unidirectional
system optimizes airflow and minimizes air turbulence. 63 • 241 Delive1y of air at a rate ofO.S meters per
second (90 ±20ft/min) helps to minimize oppmiunities for microorganism proliferation. 63 • 251 · 252
Laminar airflow systems have been used in PE to help reduce the risk for health-care--associated
airborne infections (e.g., aspergillosis) in high-risk patients. 63 ' "· 253 · 254 However, data that demonstrate
a survival benefit for patients in PE with laminar airflow are lacking. Given the high cost of installation
and apparent lack of benefit, the value oflaminar airflow in this setting is questionable?-" Few data
suppoli the use oflaminar airflow systems elsewhere in a hospital. 255

    iv. Pressurization
Positive and negative pressures refer to a pressure differential between two adjacent air spaces (e.g.,
rooms and hallways). Air flows away from areas or rooms with positive pressure (pressurized), while
                                                                                                                                              19

air flows into areas with negative pressure (depressurized). Ali rooms are set at negative pressure to
prevent airbome microorganisms in the room from entering hallways and corridors. PE rooms housing
severely neutropenic patients are set at positive pressure to keep airbome pathogens in adjacent spaces
or corridors from coming into and contaminating the airspace occupied by such high-risk patients. Self-
closing doors are mandatory for both of these areas to help maintain the con·ect pressure differential 4 · 6·
120
     Older health-care tacilities may have variable pressure rooms (i.e .. rooms in which the ventilation
can be manually switched between positive and negative pressure). These rooms are no longer
pennitted in the constmction of new facilities or in renovated areas of the tacility, 110 and their use in
existing facilities has been discomaged because of difficulties in assuring the proper pressure
differential, especially for the negative pressure setting, and because of the potential for enor associated
with switching the pressure differentials for the room Continuecl use of existing vmiable pressure
rooms depends on a partnership between engineering and infection control. Both positive- and
negative-pressure rooms should be maintained according to specific engineering specifications (Table
6).

Table 6. Engineered specifications for positive- nnd negative pressure rooms*
                                                 PositiV(I-}>l'f:\SSUl'(> nrens (e.g.,               Negative pre-sslll'(> l:ll'PilS (e.g.,
                                                prot{'rti\'e NlViromnf.'nts [PE])                  nirborne infe-ction isolation [All])
       Pt·essm·p diffe-r(>ntinls                   > +2.5 Pa§ (0.01'' water gauge)                      > ~2.5 Pn (0.01" watt:1· 2auge)
    Air changes f>H hour (ACH)                                  >12                               >12 (for renovation or new comhllCtion)
                                                Supply: 99.97%@ 0.3 ~1m DO-p4J                           Supply: 90'V<> (dtlsf spot test)
        Filtration efficiency
                                                     Return: none requited**                         Reh.m1: 99.97% tffi 0.3 ~un DOFf; t
      Room nil'flow dh'E'rtion                        Out to the n£lj11cent area                              In lo the room
      Clean-to-dil'ty airflow in              Away from the patient (higlNisk patient,              Towards the patient (airbome disease
                 room                               immunosuppressed pntieni)                                     patient)
     Ideo! pressure differential                            >+8 Pa                                             > ~ 2.5 Pa
* Mntenolul dus 1able WU.'> compded from references 3 5 and 120. Table l'ldapted from and used ·w1th penmssJOll of the pubhsber of reference
      35 (Lippincott Williams and Wilkins)-
§ Pais the abbreviation for Pascal, a metric unit ofmeas:urement for pressure ba-"Sed on air velocity; 250 Pa equals 1.0 inch water- gauge.
~ DOP is the nbbtt'vintiou for dloctylphth<~lnte pnttides o£0.3 11111 diameter.
** If the patient requires both PE and Ali, ret\lm air should be HEPA-filtered or otherwise exhausted to the outside,
t HEPA filtration of exhaust air from All rooms shmdd uot be required, providing that the exhaust is properly located to prevent re-entry into
    the building.

Health-care professionals (e.g., infection control, hospital epidemiologists) must pe1fonn a risk
assessment to determine the appropriate number of Ail rooms (negative pressme) and/or PE rooms
(positive pressme) to serve the patient population. The AlA guidelines require a ce11ainnumber of Ail
rooms as a minimum, and it is important to refer to tile edition under which the building was built for
appropriate guidance. 120

In large heallh-care facilities with central HVAC systems, sealed windows help to ensure the efficient
operation of the system, especially with respect to creating and maintaining pressure differentials.
Sealing the windows in PE areas helps minimize the risk of airbome contamination from the outside.
One outbreak of aspergillosis among innnmtosuppressed patients in a hospital was attributed in part to
an open window in the 1mit during a time when both comlmction and a fire happened nearby; sealing
the window prevented further ently of ftmgal spores into the lUlit from the outside air. 111 Additionally.
all emergency exits (e.g .. fire escapes and emergency doors) in PE wards should be kept closed (except
during emergencies) and equipped with almms.

e. llifecllon Control Impact of HVA C S)'Siem Malnlellance a11d Repair
A failure or malfunction of any component of the HVAC system may subject patients and staff to
cliscomfort and exposure to airbome contaminants. Only limited infonnation is available fi·om fonual
20

studies on the infection-control implications of a complete air-handling system failure or shutdown for
maintenance. Most experience has been derived from infectious disease outbreaks and adverse
outcomes among high-risk patients when HVAC systems are poorly maintained. (See Table 7 for
potential ventilation hazards, consequences, and correction measures.)

AlA guidelines prohibit U.S. hospitals and surgical centers from shutting down their HVAC systems for
purposes other than required maintenance, filter changes, and construction.'" Airflow can be reduced;
however, sufficient supply, return, and exhaust rnust be provided to maintain required pressure
relationships when the space is not occupied. Maintaining these relationships can be accomplished with
special drives on the air-handling units (i.e., a variable air ventilation [VAV] system).

Microorganisms proliferate in environments wherever air, dust, and water are present, and air-handling
systems can be ideal environments for microbial growth." Properly engineered HVAC systems require
routine maintenance and monitoring to provide acceptable indoor air quality efficiently and to minimize
conditions that favor the proliferation of health-care-associated pathogens.35 • 249 Performance
monitoring of the system includes determining pressure differentials across filters, regular inspection of
system filters, DOP testing ofHEPA filters, testing of low- or medium efficiency filters, and manometer
tests for positive- and negative-pressure areas in accordance with nationally recognized standards,
guidelines, and manufacturers' recommendations. The use of hand-held, calibrated equipment that can
provide a numerical reading on a daily basis is preferred for engineering purposes (A.Streifel,
University of Minnesota, 2000). 256 Several methods that provide a visual, qualitative measure of
pressure differentials (i.e., airflow direction) include smoke-tube tests or placing flutter strips, ping-pong
balls, or tissue in the air stream.

Preventive filter and duct maintenance (e.g., cleaning ductwork vents, replacing filters as needed, and
properly disposing spent filters into plastic bags immediately upon removal) is important to prevent
potential exposures of patients and staff dming HVAC system shut-down. The frequency of filter
inspection and the parameters of this inspection are established by each facility to meet their unique
needs. Ductwork in older health-care facilities may have insulation on the interior surfaces that can trap
contaminants. This insulation material tends to break down over time to be discharged from the HVAC
system. Additionally, a malfunction of the air-intake system can overburden the filtering system and
permit aerosolization of fungal pathogens. Keeping the intakes free from bird droppings, especially
those from pigeons, helps to minimize the concentration of fungal spores entering from the outside."

Accumulation of dust and moisture within HVAC systems increases the risk for spread of health-care-
associated environmental fungi and bacteria. Clusters of infections caused by Aspergillus spp., P.
aeruginosa, S. aureus, and Acinetobacter spp. have been linked to poorly maintained and/or
malfunctioning air conditioning systems."·"'·"'·'" Efforts to limit excess humidity and moisture in
the infrastructure and on air-stream smfaces in the HVAC system can minimize the proliferation and
                                                                                  262
dispersion of fungal spores and waterborne bacteria throughout indoor air. 25s                               Possible solutions
Water-damaged building materials (18.      Water leaks can soak wood, wall board,        1. Replace water-damaged materials.
266)                                       iu!>ulation. wall coYering:s. cdling tiles,   2. IncorporAte fuugistntic compounds
                                           and carpeting, All of these materials              into building materials in areas at
                                           can provide microbial habitat when wet             risk for moisture probkms.
                                           This is especially tme fo1· fungi growing     3. Test for nll moisture and d1y in le'>s
                                           on gypsum board,                                    than 72 homs, Replace if the
                                                                                               material cannot dry within 72
                                                                                               hours.
Filter bypns;e; (17)                       Rig.orou<; air filtrntion requires air flow   l.   Use pressm·e gauges lo ellsure that
                                           resistance. Air stream will elude                   filters are perfonning nt proper
                                           filtrntion if opening~ are pre~ent because          statk pressure.
                                           of tilter damage or poor fit.                 2.   Make ease of installation and
                                                                                               maintenance critetia fol' filter
                                                                                               .selection.
                                                                                         3.   Properly train maintenance persotmel
                                                                                               in HV AC concems,
                                                                                         4.   Design system with titters down-
                                                                                               stream from fans.
                                                                                         5.   Avoid water on fihers or insnlntion.
Improper t~n setting (267)                 AU: must be delivered at design voume         1. Routindy mo11itor air flow nnd
                                           to mnintain pressure billnnces. Air flow          pressure b-alances tlll'ougboul
                                           in special veut rooms reverses.                   ct1tical parts of HVAC system.
                                                                                         2. Minimize or avoid using rooms that
                                                                                             switch between positive and
                                                                                             nert,ative presstue.
Ductwork disconnections (268)              Dislodged or lenky supply duct mns can        1. Design a ductwork system thai is
                                           spill into and leaky retnms may draw              easy to access, maintain, and repair.
                                           from hidden area<,. PJ·e:.surc bnlance        2. Train mainlenance per<>onnel to
                                           \Vill be interrupted, and infectiml<>             regtllatly monitor air flow volumes
                                           mnterial may be disturbed and entmined            and pressm·e balances throughout
                                           into hospitnl air supply.                         the sy!.tem.
                                                                                         3. Te'>t critknl areas for appropriate
                                                                                             air flow
Air flow impedance (213)                   Debris, '>tmctural failure, or improperly     1. Design and budget for a duct ~ystem
                                           adjusted dampers can block duct work              that is ea"'y to inspect, maintain, and
                                           and prevent designed air fl.O\v,                  repair.
                                                                                         2. AleJi contmctor<> to liSe caution when
                                                                                             working around HVAC' systems
                                                                                             during the construction phase.
                                                                                         3. Regularly dean ex.hnust gt"illes.
                                                                                         4. Provide monitoring for special
                                                                                             ventilation nreas.
Open windows (96, 247)                     Open windows can alter fan-induced            I. Use sealed windows.
                                           pressure balance and allow dirty~to~          2. Design HV AC systems to deliver
                                           clean air flow.                                   sufftcient m1tdoor dilution
                                                                                             ventilation.
                                                                                         3. Eusm·e that OSHA indoor air qunlity
                                                                                             stundnt'ds are met.
Dirty window flir conditioners (96, 269)   Di.ti, moisture. and bit'd droppings can      I. Eliminate such devices it1 plans fo!'
                                           contaminate window air conditioners,              new consimction.
                                           \vhich <:an then introduce infectious         2. Where they must be used, make sure
                                           matedal into hospital moms.                       that they are routinely <:leaned nnd
                                                                                             inspected.
                                                                                                                                     23

               Pl'oblem§                                        Cou$equenc"'s                            Po$sible solutions
Inadequate filtration (270)                       Infectious partides may pass through         l. Specify appwprhttc filters dtuing
                                                  filters into vulnernble p*'ltieut areas.         new constmction design pho<>e.
                                                                                               2. Make S.lll't" that HVAC fans are sized
                                                                                                   t<:> overcome pressure demands of
                                                                                                    filter system.
                                                                                               3. Inspect :md test filters for proper
                                                                                                   installation.
Mniutenflnce dismption'> (271)                    F,·m shut~offs 1 dislodged filter cake       1. Budget for a rigorous tnnintenance
                                                  material contaminates do\nlslream air            schedule when designing a fadlity.
                                                  supply and drain pnns. This may              2. Design system for easy mive condensate,              the final filters.
                                                  tUld drip pnns with stagnant water may       2. Identify 11 means to remove w11ter
                                                  result from this problem.                        from the system.
                                                                                               3. Monitor humidity; all dltct take~offs:
                                                                                                   should be dowmtream of the
                                                                                                   lnunidifiers. so thai moishll'e is
                                                                                                   ah!';orbed completely.
                                                                                               4. Use steam humidifiers in the HVAC
                                                                                                   system.

Duct contmnination (18, 272)                      Debris is released during maintenance        1. Provide point~of~use filtration in the
                                                  or cleaning.                                     critical at'eas.
                                                                                               2. Design nir~lmndling i:oystems with
                                                                                                   insulation of the exterior of the
                                                                                                   ducts.
                                                                                               3. Do not use fibrous smmd atteunators.
                                                                                               4. Decontaminate or encap-:.ulate
                                                                                                   contaminfliion.

• Rep-outed wnh peruuss10n of the pubhsher of reference 35 (Ltppmcott W.Utams iUld Wtlkim) .
§ Numbers in pMenlheses are reffieJtce citalion.o;.

Constmction, renovation. repair, and demolition activities in health-care facilities require substantial
planning and coordination to minimize the risk for airbome infection both dming projects and after their
completion. Several organizations and experts have endorsed a nmlti-disciplinary team approach (Box
4) to coordinate the various stages of constmction activities (e.~.. project inception, project
implementation. final walk-through. and completion)l 20• 249 •250 · 73- 276 Environmental services,
employee health, engineering. and infection conn·olmust be represented in constmction planning and
design meetings should be convened with architects and design engineers. The number of members and
disciplines represented is a function of the complexity of a project. Smaller, less complex projects and
maintenance may require a minimal number of members beyond the core representation fi·om
engineering, infection control, environmental services, and the directors of the specialized departments.
24

Box 4. Suggested members and functions of a multi-disciplinary coordination team for
construction, renovation, repair, and demolition projects

          Members

           Infection-control personnel, including hospital epidemiologists
           Laboratory personnel
           Facility administrators or their designated representatives, facility managers
           Director of engineering
           Risk-management personnel
           Directors of specialized programs (e.g., transplantation, oncology and ICU* programs)
           Employee safety personnel, industrial hygienists, and regulatory affairs personnel
           Environmental services personnel
           Information systems personnel
           Construction administrators or their designated representatives
           Architects, design engineers, project managers, and contractors

           Functions and responsibilities

          Coordinate members' input in developing a comprehensive project management plan.
          Conduct a risk assessment of the project to determine potential hazards to susceptible patients.
          Prevent unnecessary exposures of patients, visitors, and staff to infectious agents.
          Oversee all infection-control aspects of construction activities.
          Establish site-specific infection-control protocols for specialized areas.
          Provide education about the infection-control impact of construction to staff and construction
            workers.
          Ensure compliance with technical standards, contract provisions, and regulations.
          Establish a mechanism to address and correct problems quickly.
          Develop contingency plans for emergency response to power failures, water supply disruptions,
             and fires.
           Provide a water-damage management plan (including drying protocols) for handling water
            intrusion from floods, leaks, and condensation.
          Develop a plan for structural maintenance.

* JCU is intensive care unit

Education of maintenance and construction workers, health-care staff caring for high-risk patients, and
persons responsible for controlling indoor air quality heightens awareness that minimizing dust and
moisture intrusion from construction sites into high-risk patient-care areas helps to maintain a safe
environment. 120• 250• 271 • 27 >-278 Visual and printed educational materials should be provided in the
language spoken by the workers. Staff and construction workers also need to be aware of the potentially
catastrophic consequences of dust and moisture intrusion when an HVAC system or water system fails
during construction or repair; action plans to deal quickly with these emergencies should be developed
in advance and kept on file. Incorporation of specific standards into construction contracts may help to
prevent depattures from recommended practices as projects progress. Establishing specific lines of
communication is impo1tant to address problems (e.g., dust control, indoor air quality, noise levels, and
vibrations), resolve complaints, and keep projects moving toward completion. Health-care facility staff
should develop a mechanism to monitor worker adherence to infection-control guidelines on a daily
basis in and around the constmction site for the duration of the project.
                                                                                                                                             25

b. Preliminary Considerations
The three major topics to consider before initiating any construction or repair activity are as follows: a)
design and function of the new structure or area, b) assessment of environmental risks for airborne
disease and opportunities for prevention, and c) measures to contain dust and moisture during
construction or repairs. A checklist of design and function considerations can help to ensure that a
planned structure or area can be easily serviced and maintained for environmental infection control (Box
5) . 17· 250· 273 ' 275-277 spect'fiteat'tons ~10r th e cons tructton,
                                                                  . renovat'ton, remo de1'mg, an d mamtenance
                                                                                                     .        of
health-care facilities are outlined in the AlA document, Guidelines for Design and Construction of
Hospitals and Health Care Faci/ities. 120• 275

Box 5. Construction design and function considerations for environmental infection
control

           Location of sinks and dispensers for band washing products and hand hygiene products
           Types offaucets (e.g., aerated vs. non-aerated)
           Air~handling systems engineered for optimal performance, easy maintenance, and repair
           ACH and pressure differentials to accommodate special patient-care areas
           Location of fixed sharps containers
           Types of surface finishes (e.g., porous vs. non-porous)
           Well-caulked walls with minimal seams
           Location of adequate storage and supply areas
           Appropriate location of medicine preparations areas (e.g.,z::3 ft. from a sink)
           Appropriate location and type of ice machines (e.g., preferably ice dispensers rather than ice bins)
           Appropriate materials for sinks and wall coverings
           Appropriate traffic flow (e.g., no "dirty" movement through "clean" areas)
           Isolation rooms with anterooms as appropriate
           Appropriate flooring (e.g., seamless floors in dialysis units)
           Sensible use carpeting (e.g., avoiding use of carpeting in special care areas or areas likely to become
              wet)*
           Convenient location of soiled utility areas
           Properly engineered areas for linen services and solid waste management
           Location of main generator to minimize the risk of system failure from flooding or other emergency
           Installation guidelines for sheetrock

* Use of carpet cleaning methods (e,g., "bonneting") that disperse microorganisms into the air may increase the risk of airborne infection
among at-risk patients, especially if they are in the vicinity of the cleaning activity. 111

Proactive strategies can help prevent environmentally mediated airborne infections in health-care
facilities during demolition, construction, and renovation. The potential presence of dust and moisture
and their contribution to health-care-associated infections must be critically evaluated early in the
planning of any demolition, construction, renovation, and repairs. 120• 250 • 251 • 273 ' 274• 276--279 Consideration
must extend beyond dust generated by majo1· projects to include dust that can become airborne if
disturbed during routine maintenance and minor renovation activities (e.g., exposure of ceiling spaces
for inspection; installation of conduits, cable, or sprinkler systems; rewiring; and structural repairs or
replacement). 273 • 276' 277 Other projects that can compromise indoor air quality include construction and
repair jobs that inadvertently allow substantial amounts of raw, unfiltered outdoor air to enter the facility
(e.g., repair of elevators and elevator shafts) and activities that dampen any structure, area, or item made
of porous materials or characterized by cracks and crevices (e.g., sink cabinets in need of repair, carpets,
                                                                                                  273
ceilings, floors, walls, vinyl wall coverings, upholstery, drapes, and countertops). 18' • 277 Molds grow
                                                                        21 120 250 266 270 272 280
and proliferate on these surfaces when they become and remain wet • • • • • •                            Scrubbable
26

materials are preferred for use in patient-care areas.

Containment measures for dust and/or moisture control are dictated by the location of the construction
site. Outdoor demolition and construction require actions to keep dust and moisture out of the facility
(e.g., sealing windows and vents and keeping doors closed or sealed). Containment of dust and
moisture generated from construction inside a facility requires batTier structures (either pre-fabricated ot·
constructed of more durable materials as needed) and engineering controls to clean the air in and around
the construction or repair site.

c. Infection-Control Risk Assessment
 An infection-control risk assessment (ICRA) conducted before initiating repairs, demolition,
construction, or renovation activities can identifY potential exposures of susceptible patients to dust and
moisture and determine the need for dust and moisture containment measures. This assessment centers
on the type and extent of the construction or repairs in the work area but may also need to include
adjacent patient-care areas, supply storage, and areas on levels above and below the proposed project.
An example of designing an !CRA as a matrix, the policy for petforming an ICRA and implementing its
results, and a sample permit form that streamlines the communication process are available. 281
Knowledge of the air flow patterns and pressure differentials helps minimize or eliminate the
.tnadvertent d'tsperston
                      . ofd ust that cou ld contammate
                                                   .     . space, patient-care
                                                        an·          .         .ttems, an d surtaces.
                                                                                               '      57 282 283
                                                                                                        ' ·
A recent aspergillosis outbreak among oncology patients was attributed to depressurization of the
building housing the HSCT unit while construction was underway in an adjacent building. Pressure
readings in the affected building (including 12 of25 HSCT-patient rooms) ranged from 0.1 Pa-5.8 Pa.
Unfiltered outdoor air flowed into the building through doors and windows, exposing patients in the
HSCT unit to fungal spores. 283 During long-term projects, providing temporaty essential services (e.g.,
toilet facilities) and conveniences (e.g., vending machines) to construction workers within the site will
help to minimize traffic in and out of the area. The type of barrier systems necessaty for the scope of
the project must be defined."· 120' 250• 279' 284

Depending on the location and extent of the construction, patients may need to be relocated to other
areas in the facility not affected by construction dust. 51· 285 Such relocation might be especially prudent
when construction takes place within units housing immunocompromised patients (e.g., severely
neutropenic patients and patients on corticosteroid therapy). Advance assessment of high-risk locations
and planning for the possible transport of patients to other depattments can minimize delays and waiting
time in hallways. 51 Although hospitals have provided immunocompromised patients with some fonn of
respiratory protection for use outside their rooms, the issue is complex and remains unresolved until
more research can be done. Previous guidance on this issue has been inconsistent.' Protective
respirators (i.e., N95) were well tolerated by patients when used to prevent fmther cases of construction-
related aspergillosis in a recent outbreak. 283 The routine use of the N95 respirator by patients, however,
has not been evaluated for preventing exposure to fungal spores during periods of non-construction.
Although health-care workers who would be using the N95 respirator for personal respiratmy protect
must be fit-tested, there is no indication that either patients or visitors should undergo fit-testing.
                                                                                               3   20    286
Surveillance activities should augment preventive strategies during construction projects. • 4 • • 110• • 287
By determining baseline levels of health-care--acquired airborne and waterborne infections, infection-
control staff can monitor changes in infection rates and patterns during and immediately after
construction, renovations, or repairs. 3

d. Air Sampling
Air sampling in health-care facilities may be conducted both during periods of construction and on a
periodic basis to determine indoor air quality, efficacy of dust-control measures, or air-handling system
performance via parametric monitoring. Parametric monitoring consists of measuring the physical
                                                                                                        27

performance of the HVAC system in accordance with the system manufacturer's specifications. A
periodic assessment of the system (e.g., air flow direction and pressure, ACH, and filter efficiency) can
give assurance of proper ventilation, especiaJly for special care areas and operating rooms. 288

Air sampling is used to detect aerosols (i.e., particles or microorganisms). Particulate sampling (i.e.,
total numbers and size range of particulates) is a practical method for evaluating the infection-control
performance of the HVAC system, with an emphasis on filter efficiency in removing respirable particles
(<5 flm in diameter) or larger patticles from the air. Particle size is reported in terms of the mass
median aerodynamic diameter (MMAD), whereas count median aerodynamic diameter (CMAD) is
useful with respect to particle concentrations.

Patticle counts in a given air space within the health-care facility should be evaluated against counts
obtained in a comparison area. Particle counts indoors are commonly compared with the particulate
levels of the outdoor air. This approach determines the "rank order" air quality from "dirty" (i.e., the
outdoor air) to "clean" (i.e., air filtered through high-efficiency filters [90%-95% filtration]) to
"cleanest" (i.e., HEPA-filtered air). 288 Comparisons fi·om one indoor area to another may also provide
useful information about the magnitude of an indoor air-quality problem. Making rank-order
comparisons between clean, highly-filtered areas and dirty areas and/or outdoors is one way to interpret
sampling results in the absence of air quality and action level standards."· 289

In addition to verifYing filter performance, particle counts can help determine if barriers and effotts to
control dust dispersion from construction are effective. This type of monitoring is helpful when
performed at various times and barrier perimeter locations during the project. Gaps or breaks in the
barriers' joints or seals can then be identified and repaired. The American Conference of Governmental
Industrial Hygienists (ACGJH) has set a threshold limit value-time weighted average (TLV®-TWA) of
I 0 mg/m3 for nuisance dust that contains no asbestos and ction in 11 manner thnt mn~' dislodge dust
           D('molition, l'E'pnir, ot· construction of E'leYntor shafts
           Repairing water dnmnge

• Material for thi~ box was compiled from references 120,250,273,276, and 277.

Dust and moisture abatement and control rely primarily on the impenneable bmTier containment
approach; as constmction continues, numerous opportunities can lead to dispersion of dust to other areas
of the health-care facility. Infection-control measures that augment the use of ban1er containment
should be undertaken (Table 9).

Dust-control measures for clinical laboratories are an essential part of the infection-control strategy
during hospital constmction or renovation. Use of plastic or solid barriers may be needed if the ICRA
detennines that air flow from constmction areas may introduce airbome contaminants into the
laboratory space. In one facility, pseudofungemia clusters attdbuted to Aspergillus spp. and Penicillium
spp. were linked to improper air flow patterns and coustmction projects adjacent to the laboratmy;
intmsion of dust and spores into a biological safety cabinet from constmction activity inunediately next
to the cabinet resulted in a cluster of cultt1res contaminated with Aspergillus niger. 310• 311 Repottedly,
no banier containment was used and the HEPA llltration system was overloaded with dust. In addition.
an outbreak ofpseudobacteremia caused by Bacillus spp. occuned in another hospital during
constmction above a storage area for blood culttrre bottles.'07 Airbome spread of Bacillus spp. spores
resulted in contamination of the bottles' plastic lids. which were not disinfected or handled with proper
aseptic technique prior to collection of blood samples.

Table 9. Infection-wntrolmeasures for internal construction and repair projects*+
     Infeetiou~control      measure                                        Stous for hnul•m•ntntion
Prepare for the project.                       l. Use n lllulti~disciplinnty team approach to incotvomte infection control into the
                                                   project.
                                               2. Conduct the risk assessment nnd a prelimi.nnry wnlkwthrough with pt'oject
                                                   mruu12.crs and staff.
Educate staff and construction workers.        1. Educate staff and constmction workers about the imp011ance of adheting to
                                                   infection·control meas11re:. during the project.
                                               2. Provide educational matel'ials in the language of the workers.
                                               3. Indude hmguage in the construction contract requiring constmction workers and
                                                   subcontnlctors to pmiiciT>ate in infection·control training,
Issue hazard nnd wanting notices.              !. Post signs to identify constmction areas and potential hazards.
                                               2. Mark delo\Jrs reQuirintt pedestrians to inmid the work area.
Relocnte high~risk pntients as ni.!edepiratory equipment (e.g.. a high·
                                                    efficiencv mask) when outside their PE rooms.
Establi<>h altemative traffic pnttems for      1. Determiue npproprintoe altcruate routes from the risk assessment
staff. patients, visitors, !lnd cohstruction   2. Designate an~as (e.g .• hallways, elevators, and entranceslex.its) for construction~
workers.                                            worker U'i>e,
                                               .l. Do not transport patient"> on the <;nme elevator with cono;,tntction materials and
                                                   debrk
                                                                                                                               33

     Infection-control measure                                      Steps for implementation
Erect appropriate barrier containment.   I. Use prefabricated plastic units or plastic sheeting for shmt-tetm projects that
                                             will generate minimal dust.
                                         2. Use durable rigid bmTiers for ongoing, Jong-tenn projects.
Establish proper ventilation.            I. Shut off return air vents in the construction zone, if possible, and seal around
                                             grilles.
                                         2. Exhaust air and dust to the outside, if possible.
                                         3. If recirculated air from the construction zone is unavoidable, use a pre--filter and
                                             a HEPA filter before the air returns to the HV AC system.
                                         4. When vibration-related work is being done that may dislodge dust in the
                                             ventilation system or when modifications are made to ductwork serving
                                             occupied spaces, install filters on the supply air grilles temporarily.
                                         5. Set pressure differentials so that the contained work area is under negative
                                             pressure.
                                         6. Use air flow monitoring devices to verify the direction of the air pattern.
                                         7. Exhaust air and dust to the outside, if possible.
                                         8. Monitor temperature, air changes per hour (ACH), and humidity levels
                                             (humidity levels should be <65%).
                                         9. Use pmiable, industrial grade HEPA filters in the adjacent area and/or the
                                             conshuction zone for additional ACH.
                                         10. Keep windows closed, if possible.
Control solid debris.                    I. When replacing filters, place the old filter in a bag prior to transport and dispose
                                             as a routine solid waste.
                                         2. Clean the constluction zone daily or more often as needed.
                                         3. Designate a removal route for small quantities of solid debris.
                                         4. Mist debris and cover disposal carts before transport (i.e., leaving the
                                             constmction zone).
                                         5. Designate an elevator for construction crew use.
                                         6. Use window chutes and negative pressure equipment for removal oflarger
                                             pieces of debris while maintaining pressure differentials in the constmction
                                             zone.
                                         7. Schedule debris removal to periods when patient exposures to dust is minimal.
Control water damage.                    1. Make provisions for dry storage of building materials.
                                         2. Do not install wet, porous building materials (i.e., sheet rock).
                                         3. Replace water-damaged porous building materials if they cannot be completely
                                              dried out within 72 hours.

Control dust in air and on surfaces.     1. Monitor the construction area daily for compliance with the infectionRcontrol
                                             plan.
                                         2. Protective outer clothing for construction workers should be removed before
                                             entering clean areas.
                                         3. Use mats with tacky surfaces within the constmction zone at the entry; cover
                                             sufficient area so that both feet make contact with the mat while walking
                                             through the entry.
                                         4. Construct an anteroom as needed where coveralls can be donned and removed.
                                         5. Clean the consbuction zone and all areas used by construction workers with a
                                             wet mop.
                                         6. If the area is carpeted, vacuum daily with a HEPA-filtered-equipped vacuum.
                                         7. Provide temporary essential services (e.g., toilets) and worker conveniences
                                             (e.g, vending machines) in the constmction zone as appropriate.
                                         8. DampRwipe tools if removed from the construction zone or left in the area.
                                         9. Ensure that construction barriers remain well sealed; use particle sampling as
                                             needed.
                                         10. Ensure that the clinical laboratory is fi·ee from dust contamination.
34

                                                                   water system to
                                                2. Tem1innlly dean the constmction zone before the constmction bnniers are
                                                    removed.
                                                3. Check for visible mold and mildew and eliminat<: (i.e., decontaminate and
                                                    remove), if present.
                                                4. Verify appropriate ventilation parameters for the new area as needed.
                                                5. Do not accept ventilation ddiciendes. e-specially in special care 1ueas.
                                                6. Clerm or repl!lce HVAC filters ming proper dust~contaimneni procedures.
                                                7. Remove the banlers and denn the area of any dust generated during tills work.
                                                8. Ensun~ that the de•.dgnated air balances in the operntiug rooms (OR) nnd
                                                    protective environments (PE) nre achieved bef125-cfm supply ver<:.us exhaust:
     • sealed room, approximately 0.5-sq. ft. Ieokag:e:
     • denn to dirty air flow;
     • monitoring:
     • .2;.12 air changes per hour (ACH); and
     • retum air if rdiltcrcd.
1j This diagram is a generk illus.trotion of ail' tlow inn typknl ins.tallation. Altemative air tlow mTangements nl'e recognized.
     Adapted nud used with pennission from A Streifel and the publisher of reference 328 (Penton Media, Inc.)

The use of surface fungicide treatments is becoming more common. especially lor building materials."9
Copper-based compOlmds have demonstrated ami-fungal activity and are often applied to wood or paint.
Copper-8-quinolinolate was used on enviromnental s1ufaces contaminilted with Aspergillus spp. to
control one reported outbreak of aspergillosis. 310 The compound was also incorporated into the
fireprootlng material of a newly constmcted hospital to help decrease the enviromuental spore
burden. 316

b. Alrbome lllfectlon1so/atlon (All)
Acute-care inpatient facilities need at least one room equipped to house patients with airbome infectious
disease. Evety health-care facility. including ambu!Moty and long-tenn care facilities, should undettake
an IC:RA to identify the need for Ail areas. Once the need is established. the appropriate ventilation
equipment can be identitled. Air handling systems for this pmpose need not be restricted to central
systems. Guidelines lor the prevention of health-care-acquired TB have been published in response to
multiple rep01ts of health-care-associated transmission of mnlti-d111g resistant strains. 4· 330 In reports
documenting health-care-acquired TB. investi~ators have noted a failure to comply fttlly with
preventionmeasmes in established guidelines. 31 • 345 Titese gaps highlight the impmtance of prompt
recognition of the disease. isolation of patients, proper treatment, and engineeting controls. All rooms
36

are also appropriate for the care and management of smallpox patients.• Environmental infection
control with respect to smallpox is currently being revisited (see Appendix E).

Salient feah1res ofengineeting controls for Ali areas include a) use of negative pressure rooms with
close monitoring of air flow direction using manometers or temporary or installed visual indicators [e.g ..
smoke tubes and flutter strips] placed in the room with the door closed; b) minimum 6 ACH for existing
facilities, 2:;12 ACH for areas under renovntion or for new const111ction; and c) air from negative
pressure rooms and treatment rooms exhausted directly to the outside if possible.'· 110·'" As with PE,
airflow rates need to be determined to ensure the proper numbers of ACH. 320• 321 AU rooms can be
const111cted either with (Figure 3) or without (Figure 4) an anteroom. When the recirculation of air from
All rooms is unavoidable, HEPA filters should be installed in the exhaust duct leading from the room to
the general ventilation system. In addition to UVGI tixtJu·es in the room, UVGI can be e!aced in the
ducts as an adjunct measure to HEPA tiltration, but it can not replace the HEPA tilter.4·      A UVGI
fixh1re placed in the upper room, coupled with a minimum of 6 ACH. also provides adequate air
cleaning.248

Figure 3. Example of negative-pressure room control for airborne infection isolation
(Ail)*+§,

        Monitor

                                                       !                                                         Bathroom

                                                                                                                  [S;J
                                                                                                                     ll
       Corridor
                                                                                   --
*" Stacked black boxes repr?sent patient's bed. Long open box with cross.hatch represents <:.Up}Jly air. Open boxes with single,
    ding.ona1 slashes represent ai1· exhaust regisiers. An·ows indicate din:ction of air flow.
+ Posi:.ible uses include treatmeut or procedm·e rooms, bronchoscopy rooms, and autopsy.
§ Negative-pressllre room engineering features inclnde
     • negative pressure (greatet' exhaust than supply oir vohune);
     • pressure difthential of 2.5 Pa (0.0 l-in. water galtge);
     • flh· flow volume diffenmtial > 125-cfm exhau<:.t versus supply:
     • sealo:d room, approximately 0.5~sq, ft. leakage;
     • dean to dirty air flow;
     • monitoring;
     • ~12 air changes per hour (ACH) n~w or renovation, 6 ACH existing: and
     • ex.hnust to outside or HEPA·filtered if recil'culated.
~This diagram is a generic illustration of air flow in a typical imtallation. Altemative air flow an.·augements are recognized.
     Adapted and used with pennis<>ion from A. Streitd and the publisher of reference 328 (Penton Media, Inc.)

One of the components of airbome infection isolation is respiratoty protection for health-care workers
and visitors when entering AII rooms.'· 6• 347 Reconunendations of the type of respiratory protection are
dependent on the patient's airbome infection (indicating the need for Ali) and the risk of infection to
                                                                                                                               37

persons entering the Ali room. A more in-depth discussion of respiratOJy protection in this instance is
presented in the crment isolation guideline;' a revision of tllis guideline is in development Cough-
inducing procedures (e.g., endotracheal intubation and suctioning of known or suspected TB patients,
diagnostic sputum induction, aerosol treatments, and bronchoscopy) require similar precautions."&-350

Additional engineering measures are necessmy for the management of patients requiring PE (i.e ..
allogeneic HSCT patients) who concurrently have airbome infection. For this type of patient treatment,
an anteroom (Figure 4) is required in new constmction and renovation as per AlA guidelines. 120

Figure 4. Example or airborne infection isolation (All) room with anteroom and neutral
nnteroom * + §
                                      Anteroom

                           IS] lXI

                                                                                                    --
                                                                                                                        Bathroom

                                  t       ~                                                                               LSJ
       All only
                                                                                                                           tt
             Conidor
                                                                      •
                               Neutral Anteroom
                                                                 . Momor                       I                I
                            lXI
                                                                                                   ~~ ~~                Bathroom

                                  ~
    All and imm uno-
    com prom is ed                                                         u~                                             1r
            Corri dor
                                                                   // LSJ            Ill                                  /
                              /
                                      Anteroom     "'        i   Monnor                        I             ""'
                                                                                                               I
                           lSI
                                                                                                   ~~~~~                Bathroom

                                  t
    All and lmm uno~
    compromls ed

                                                                  ·LSJ
                                                                           ~u                                            1r
             Com'dor

                  ""--        /                   ·,              /                  Ill                                 /
                                                                                                             ""'
"' The top diagram indicates air flow pattcm<.. when patient with only airboml! infectious disease occupies room, Middle and
    bottom dingrmns indic.1te recommended nit· flow pattems when room is occupied by inummocomprom.hed patient with
    airborne infectious diseaso;. Stacko;d black boxes represent patient beds. Long open boxes with cross-hatches reprc">-ent
    supply air. Open boxes with single. diagonal slashes l'l!present air exhamt registers. Arrows indicate directions of air flow.
+ Ali isolation room with anteroom engineering fenhll'¢'> include
     • pressure differential of 2.5 Pa (0.01-in. water gauge) measmed at il1e door betweetl patient room nnd anteroom~
     • air flow volume differential >125-cUn. depending: on anteroom air flow direction (pressurized versus depressurized):
38

     • sealed room with approximately 0.5-sq. ft. leakage;
     • clean to dirty air flow
     • monitoring;
    • ,:::12 air changes per hour (ACH) new or renovation, 6 ACH existing; and
    • anteroom air flow patterns. The small • in panels I and 2 indicate the anteroom is pressurized (supply versus exhaust),
          while the small • in panel 3 indicates the anteroom is depressurized (exhaust versus supply).
§ Used with pcnnission of A. Streifel, University of Minnesota

The pressure differential of an anteroom can be positive ot· negative relative to the patient in the room. 120
An anteroom can act as an airlock (Figure 4). Jfthe anteroom is positive relative to the air space in the
patient's room, staff members do not have to mask prior to entry into the anteroom if air is directly
exhausted to the outside and a minimum of I 0 ACH (Figure 4, top diagram). 120 When an anteroom is
negative relative to both the AJT room and the corridor, health-care workers must mask prior to entering
the anteroom (Figure 4, bottom diagram). If an ATT room with an anteroom is not available, use of a
portable, industrial-grade HEPA filter unit may help to increase the number of ACHs while facilitating
the removal of fungal spores; however, a fresh air source must be present to achieve the proper air
exchange rate. Incoming ambient air should receive HEPA filtration.

c. Operating Rooms
Operating room air may contain microorganisms, dust, aerosol, lint, skin squamous epithelial cells, and
respiratory droplets. The microbial level in operating room air is directly proportional to the number of
people moving in the room. 351 One study documented lower infection rates with coagulase-negative
staphylococci among patients when operating room traffic during the surgical procedure was limited 352
Therefore, effotts should be made to minimize personnel traffic during operations. Outbreaks of SSJs
caused by group A beta-hemolytic streptococci have been traced to airborne transmission from
colonized operating-room personnel to patients. 15 o- 154 Several potential health-care-associated
pathogens (e.g., Staphylococcus aureus and Staphylococcus epidermidis) and dmg-resistant organisms
have also been recovered from areas adjacent to the surgical field,' 53 but the extent to which the
presence of bacteria near the surgical field influences the development of postoperative SS!s is not
         354
clear.

Proper ventilation, humidity (<68%), and temperature control in the operating room is important for the
comfort of surgical personnel and patients, but also in preventing environmental conditions that
encourage growth and transmission ofmicroorganisms. 355 Operating rooms should be maintained at
positive pressure with respect to corridors and adjacent areas. 356 Operating rooms typically do not have
a variable air handling system. Variable air handling systems are permitted for use in operating rooms
only if they continue to provide a positive pressure with respect to the cot1'idors and adjacent areas and
the proper ACHs are maintained when the room is occupied. Conventional operating-room ventilation
systems produce a minimum of about 15 ACH of filtered air for thermal control, three (20%) of which
must be fresh air. 120' 357' 358 Air should be introduced at the ceiling and exhausted near the floor."'· 359

Laminar airflow and UVGJ have been suggested as adjunct measures to reduce SSI risk for certain
operations. Laminar airflow is designed to move particle-free air over the aseptic operating field at a
uniform velocity (0.3-0.5 m/sec), sweeping away particles in its path. This air flow can be directed
vettically or horizontally, and recirculated air is passed through a HEPA filter. 36o-363 Neither laminar
airflow nor UV light, however, has been conclusively shown to decrease overall SSI risk. 356 • 364-370

Elective surgery on infectious TB patients should be postponed until such patients have received
adequate drug therapy. The use of general anesthesia in TB patients poses infection-control challenges
because intubation can induce coughing, and the anesthesia breathing circuit apparatus potentially can
become contaminated. 371 Although operating room suites at 15 ACH exceed the air exchanges required
                                                                                                                                                39

for TB isolation, the positive air flow relative to the corridor could result in health-care-associated
transmission ofTB to operating-room personnel. If feasible, intubation and extubation of the TB
surgical patient should be perfonuecl in AIL AlA currently does not recommend changing pressure
from positive to negative or setting it to neutral: most facilities lack the capability to do so. 20 When
emergency sm·gery is indicated for a suspecteJ'Y is indiellted for n patient with nftiVE' TB, scht>dule the TB patient a~ the last
    surgical cnse to provide- mnxhnum time for ndt'qnatP ACH.
2. Operating r·oom pN·souue-1 should use NIOSH-nppt·-ovf'd N95 l'('Spirnfot·s without E'Xltnlntiou vnlves.'H 7
3. K('t>p thE' OJH'rnting room door closed Rft('l' the (Hltie-nt is iutubntE'd, and nHow ndE"quntt" time for
    sufficient ACH to remove 99% of nit·borne particles (Appeudl< B, Tnble B.l.):
          n) after tbe patient h intubated aucl partkularly if intubation produces eoughing;
          b) U the- door to thE' opN'nfing !)Uit<" mn!!:t bE' open£>d, ruul intubation inducE's coughing in th£>
               pnti{'nt; ol·
          c) after the pntient is utubnted nnd suctioned {unlt>ss n dosed suctioniug system is JH'esPntJ.
4. Extubate tlu• pnti('nt in th<' opHating room or nllolv the patit>ut to recovN' in Ail l'ather than iu the
    regular opNl ncovpry fa dUties.
5. TE'tn}lOI'RlJ llS(' of n portable, industrinl grndl' HEPA filter may E':Xpedite removal of airborne
    contnmhmnts (fl'E'SlHtir E'Xcbnng(' requirements for pi'OPN' YE'ntilation must still bE' met).+
6. BI'NHbing circuit filtN~ with 0.1-0.2 Jim pore siz(' can be US('d ns au :Hljunct inf(letion-control
       measure.373' 374

* Mutcriul in this table was compiled from refe-rMlces 4, 347, nnd 372-374.
+ T11e placement of portable HEPA filtrr unit<; In the opemling room musl be carefully evaluated for potential dismptions in nonmd uir flow.
      The porti\ble unit should be turned off while the surgical procedure is 11nderway and turned on following extubation. Portable HEPA filter
      units previously placed in coustruction nrNIS may be n<;ed in subsequent patient cru-e, provided that ,,u internal ,md external surfaces ru-e
      deaued and tl1e filttr's performance i<> verified w.ith appropriate pll!ticle testing and 1s changed, if needed.

Table 10. Summary of ventilation specifications in selected nreas ofhealtb-cnre facilities*
                                                                              Criticnl nu·e               Isolation               Opel'tlting
    Specifications            All room+                 PE l'OOIU
                                                                                   room§                 itllt(';l'OOW               I'ootn
                                                                            Po::.ilive, neglltiyc,        Po<>itive or
     Air prc<:>Surt:~           Negative                 Positive                                                                   Positive
                                                                                  o1· neutl'al             ne2:ative
                             2:6 ACH (for
                            existing rooms);
Room air changes             2:12 ACH (for              2:12 AC'H                 2:6 ACH                 Z;lO ACH                 Z;l5ACH
                          renovation ol' new
                             constn1ction)
       Senled**                    Yes                     Yes                       No                      Yes                      Yes
                            90% (dust·spot
    Filtration supply       ASHRAE 52.1                 99.97%++                    2:,90%                  ~90°/o                    90%
                               1992)
     Recirculation                No~§                     Yes                       Yes                      No                      Yes
•   Matenal m tlus table J.<> comptled from references 35 and 120.
+ Includes bronchoscopy suite'>.
 § Positive pressure and HEPA filten may be preferred in some room.~ in intensive cure units (lCUs) caring for large uurubern of
      inmnUiocompromised palients.
'i! Clean-to-dirty: negative to an infectious patient. positive away from nn iuununocompromised p<\tient.
 ** Minimized infiltration for ventilation control; pertains to windows, doSt"d doors, and stll·face joints.
H Fungal spore fdter at 1>oint of use (HEPA at 99.97% of0.3 ~un pa11icles).
40

§§ Recirculated air may be used if the exhaust air is first processed through a HEPA filter.
'if~   Table used with permission of the publisher of reference 35 (Lippincott Williams and Wilkins).

6. Other Aerosol Hazards in Health-Care Facilities
In addition to infectious bioaerosols, several crucial non-infectious, indoor air-quality issues must be
addressed byhealth-care facilities. The presence of sensitizing and allergenic agents and irritants in the
workplace (e.g., ethylene oxide, glutaraldehyde, formaldehyde, hexachlorophene, and latex allergens"')
is increasing. Asthma and dermatologic and systemic reactions often result with exposure to these
chemicals. Anesthetic gases and aerosolized medications (e.g., ribavirin, pentamidine, and
aminoglycosides) represent some of the emerging potentially hazardous exposures to health-care
workers. Containment of the aerosol at the source is the first level of engineering control, but personal
protective equipment (e.g., masks, respirators, and glove liners) that distances the worker from the
hazard also may be needed.

Laser plumes and surgical smoke represent another potential risk for health-care workers. 37G-378 Lasers
transfer electromagnetic energy into tissues, resulting in the release of a heated plume that includes
patticles, gases, tissue debris, and offensive smells. One concern is that aerosolized infectious material
in the laser plume might reach the nasal mucosa of surgeons and adjacent personnel. Although some
viruses (i.e., varicella-zoster virus, pseudorabies virus, and herpes simplex virus) do not aerosolize
efficiently ,379• 380 other viruses and bacteria (e.g., human papilloma virus [HPV], HIV, coagulase-
negative Staphylococcus, Corynebacterium spp., and Neisseria spp.) have been detected in laser
plumes. 381 - 387 The presence of an infectious agent in a laser plume may not, however, be sufficient to
cause disease from airborne exposure, especially if the normal mode of transmission for the agent is not
airborne. No evidence indicated that HIV or hepatitis B virus (HBV) has been transmitted via
aerosolization and inhalation. 388

Although continuing studies are needed to fully evaluate the risk of laser plumes to surgical personnel,
the prevention measures in these other guidelines should be followed: a) NIOSH recommendations,'"
b) the Recommended Practices for Laser Safety in Practice Settings developed by the Association of
peri Operative Registered Nurses [AORN],389 c) the assessments ofECR1, 390-392 and d) the ANSI
standard. 393 These guidelines recommend the use of a) respirators (N95 or NIOO) or full face shields
and masks, 260 b) central wall-suction units with in-line filters to collect particulate matter from minimal
plumes, and c) dedicated mechanical smoke exhaust systems with a high-efficiency filter to remove
large amounts of laser plume. Although transmission ofTB has occurred as a result of abscess
management practices that lacked airborne particulate control measures and respiratoty protection, use
of a smoke evacuator or needle aspirator and a high degree of clinical awareness can help protect health-
care workers when excising and draining an extrapulmonaty TB abscess. 137

D. Water
1. Modes of Transmission of Waterborne Diseases
Moist environments and aqueous solutions in health-care settings have the potential to serve as
reservoirs for waterborne microorganisms. Under favorable environmental circumstances (e.g., warm
temperature and the presence of a source of nutrition), many bacterial and some protozoal
microorganisms can either proliferate in active growth or remain for long periods in highly stable,
environmentally resistant (yet infectious) forms. Modes of transmission for waterborne infections
                                                                                                                        41

include a) direct contact [e.g., that required for hydrotherapy]; b) ingestion of water [e.g .. through
consuming contaminated ice]; c) indirect-contact transmission [e.g .. from an improperly reprocessed
medical device]; 6 d) inhalation ofaerosob dispersed from water sources;' and e) aspiration of
contaminated water. The tirst three modes of transmission are conuuonly associated with infections
caused by gram-negative bacteria and nonmberculous mycobacteria (NTM). Aerosols generated from
water sources contaminated with Legionella spp. often se1ve as the vehicle for introducing legionellae to
the respiratory tract. 394

2. Waterborne Infectious Diseases in Health-Cat·e Facilities
a. Leglone/losls
Legionellosis is a collective tenu describing infection produced by Legion ella spp., whereas
Legionnaires disease is a multi-system illness with pneumonia. 395 The clinical and epidemiologic
aspects of these diseases(Table ll) are discussed extensively in another gnideline 3 Although
Legionnaires disease is a respirat01y infection, infection-control measures intended to prevent health-
care-associated cases center on the quality of water-the principal resetvoir for Legione/la spp.

Table 11. Clinical and epidemiologic characteristics of legionellosis/Legionnnires disease
                                                                                                    Rt>f('l'(lll("(IS
                              I.egionefla pneumopltila (90% of inf<:ctious); L. micdadei, L.
     Causative ngent          bozemanii, L. dumoffii,. L longbeachii. (14 additional species          395-399
                              can cau!>e infection in hmnnns)
  Mod(' of tr~msmission       Aspiration of watel'. direct inhalation or water aerosols           3,394-398,400
                              Ex.pos\lre to environmental sourcec,. of Legionella spp. (i.e.,
   So nrc<' of t>xposure      wnter or water aerosols)
                                                                                                  31,33.401-414
                              Two distinct illnesses: a) Po11tiac fevet' [a mils]; and b) progressive pneumonia that mny be
                                                                                                 3,397-399,415-422
         dis<"nses            accornprmied by cardinc. renal. and gastrointcstinnl
                              involvemenl
                              Inummosuppress.ed patients (e.g,. transplant patients, cancer
                              potienls, and patients receiving cotiicosteroid thempy);
 Populntious Rt greatl'st                                                                        395-397, 423-433
                              immm1ocompromised patients (e.g., surgical patients,
            l'isk             patients \Vith undel'lying clu·onic lung disease, and dialysis
                              patients); elderly persons; and patients who smoke
                              Proportion of conmmnity-ncqnired pnemnonia cm1sed by
                              Legionella spp. nmges fi·om 1'%-5%. ; estimated annual
                              incidence among the geneml population is 8,000--18,000
       OecunenrE>                                                                                396. 397, 434-444
                              cases in the United States; the incidence of health-care-
                              associated pnemnonio (0%,-14%) may be tmderestimated if
                              appropriate laboratoty diagnostic methods are \lnavailable.
                              1-.·fortnlity dl;clined nuukedly during 1980 1993, from34% to
                              12% for nil cnse'!.: the mot1nlity rate is higher among p~:rsons
                              with henlth~care-nssociated pneumonia compm·ed with the
      Mortality mt•                                                                                395-397, 445
                              rate among conununitywacq\lired pn~:umonia patients (14%
                              for health-care-associated pneumonia versus: 10% for
                              conmmuity~acquired pnetunonia f1998 dntal),

Legionel/a spp. are conm10nly found in vmious natural and man-made aquatic envirOJunents'146 ' 447 and
can enter health-care facility water systems in low or undetectable munbers.448 · 449 Cooling towers.
evaporative condensers, heated potable water distribution sr,stems, and locally-produced distilled water
can provide environments for multiplication oflegionellae. sferenC('S
                                 Septicemia. pneumonin (pm1icularly ventilfltor-ns.sociated),
                                 du'Onic respiratory infections among: cystic fibrosi<; patients.
  Cliuklll syndromes nnd         urinaty Inlet infections, skin aud soft-tissue iufectiom (e.g., thsue
                                                                                                                466-503
          diseRS<'S              necrosis nud hemorrhnge), bum-wound infections, folliculitis,
                                 endocarditis, central nervous sy<,.tem infections (e.g., meningitis
                                 and abscess), eve infections. and bone and joint infet;tions
                                 Direct contact \Yith water, aerowls: aspiration of wafer· and
  Modes of fl•:msmission         inhalation of water nerosols.; and indirect transfer from moist              28.502-506
                                 environmental surfaces vin ha11ds ofhenhh-cnre worb~rs
                                 Potable (tap) water, distilled \Vatel', antiseptic solution'>
 Environmeutnl sotu'('(IS of     contmninated with tap water, ~inks., hydrotherapy Jlools.
                                                                                                            28, 29, 466. 468,
 pseudomounds in bt>alth-        whirlpooh. and whirlpool spns, water baths, lithotripsy therapy
                                                                                                                507-520
       cnre settings             tanks. dinlysh water, eyewash stations. flower vase<:>, and
                                 endoscones with residual moisn.u·e in the channels
 E1nironmeutal ~'out·ces of      F<>mites (e.g:.. drug injection equipment stored in contnminMed
   pseudomounds in tlu.•         wnter)                                                                         494.495
       connnunity
                                 Intensive care nnit (JCU) pntien!s (including: neonatnllCU),
                                 transplant patients (organ and hetnf\topoietic stem cell),                 28,466.467,472,
Populations flt grent!'st risk   neutropenic patients., bnrn therapy and hydrothernpy patients,            477,493,506-508.
                                 pulient<;, with malig:noncies, cy<;lic fibrosis patients, patients with   5ll, 512.521-526
                                 undedvint< medical conditions. and dialvsiS ontients
                                                                                                                                                   43

Table 13. Other gram-negative bacteria associated with water and moist environments

Implicated contaminated environmental vehicle                                                References

Burkholderia cepacia
        Distilled watel'                                                                     527
        Contaminated solutions and disinfectants                                             528,529
        Dialysis machines                                                                    527
        Nebulizers                                                                           530-532
        Water baths                                                                          533
        IntrinsicallyMcontaminated mouthwash*                                                534
        Ventilator temperature probes                                                        535
Stenotrophomonas maltophlia, Sphingomonas spp.
        Distilled water                                                                      536, 537
        Contaminated solutions and disinfectants                                             529
        Dialysis machines                                                                    527
           Nebulizers                                                                        530-532
           Water                                                                             538
        Ventilator temperature probes                                                        539
Ralstonia pickettii
        Fentanyl solutions                                                                   540
        Chlorhexidine                                                                        541
           Distilled water                                                                   541
         Contaminated respiratory therapy solution                                           541,542
Sen·atla marcescens
         Potable water                                                                       543
         Contaminated antiseptics (i.e., benzalkonium chloride                               544-546
             and chlorhexidine)
         Contaminated disinfectants (i.e., quaternary ammonhun                               547,548
             compounds and glutaraldehyde)
Acinetobacter spp.
        Medical equipment that collects moisture (e.g., mechanical                           54'1-556
             ventilators, cool mist humidifiers, vaporizers, and mist
             tents)
        Room humidifiers                                                                     553,555
        Environmental surfaces                                                               557-564
Enterobacter spp.
        Humidifier water                                                                     565
        Intravenous fluids                                                                   566-578
        Unsterilized cotton swabs                                                            573
        Venti laton>                                                                         565, 569
        Rubber piping on a suctioning machine                                                565,569
        Blood gas analyzers                                                                  570

* This report describes intrinsic contamination (i.e., occurring during manufacture) prior to use by the healtlrcare facility staff.   All other
    entries reflect extrinsic sources of contamination.

Two additional gram-negative bacterial pathogens that can proliferate in moist environments are
Acinetobacter spp. and Enterobacter spp. 571 • 572 Members of both genera are responsible for health-
care-associated episodes of colonization, bloodstream infections, pneumonia, and urinary tract
                                                                                                     566
infections among medically compromised patients, especially those in JCUs and burn therapy units. •
572 583
   -     Infections caused by Acinetobacter spp. represent a significant clinical problem. Average
infection rates are higher from July through October compared with rates from November through
June. 584 Mortality rates associated with Acinetobacter bacteremia are 17%-52%, and rates as high as
71% have been reported for pneumonia caused by infection with either Acinetobacter spp. or
44

                       576
Pseudomonas spp. 574-     Multi-drug resistance, especially in third generation cephalosporins for
Enterobacter spp., contributes to increased morbidity and mortality. 569• 572

Patients and health-care workers contribute significantly to the environmental contamination of surfaces
and equipment with Acinetobacter spp. and Enterobacter spp., especially in intensive care areas,
because of the nature of the medical equipment (e.g., ventilators) and the moisture associated with this
    .
eqUipment.  "'' '" ' sn' sss H an d carnage
                                       .    an d h and trans1er
                                                            c are common 1y assoctate
                                                                                 . d wtt. h h eatI h-care-
associated transmission of these organisms and for S. marcescens. 586 Enterobacter spp. are primarily
spread in this manner among patients by the hands of health-care workers. 567' 587 Acinetobacter spp.
have been isolated from the hands of 4o/.-33% of health-care workers in some studies,"'-590 and
transfer of an epidemic strain of Acinetobacter from patients' skin to health-care workers' hands has
been demonstrated experimentally."' Acinetobacter infections and outbreaks have also been attributed
to medical equipment and materials (e.g., ventilators, cool mist humidifiers, vaporizers, and mist tents)
that may have contact with water of uncertain quality (e.g., rinsing a ventilator circuit in tap water). 54"-
556 Strict adherence to hand hygiene helps prevent the spread of both Acinetobacter spp. and
Enterobacter spp. 577 • 592

Acinetobacter spp. have also been detected on dry environmental surfaces (e.g., bed rails, counters,
sinks, bed cupboards, bedding, floors, telephones, and medical charts) in the vicinity of colonized or
infected patients; such contamination is especially problematic for surfaces that are frequently
touched. 557- 564 In two studies, the survival periods of Acinetobacter baumannii and Acinetobacter
                                                                                    593
calcoaceticus on dry surfaces approximated that for S. aureus (e.g., 26-27 days). ' 594 Because
Acinetobacter spp. may come from numerous sources at any given time, laboratory investigation of
health-care--associated Acinetobacter infections should involve techniques to determine biotype,
anti biotype, plasmid profile, and genomic fingerprinting (i.e., macrorestriction analysis) to accurately
identify sources and modes of transmission of the organism(s). 595

c. Infections and Pseudo-Infections Due to Nontuberculous Mycobacteria
NTM are acid-fast bacilli (AFB) commonly found in potable water. NTM include both saprophytic and
opportunistic organisms. Many NTM are of low pathogenicity, and some measure of host impairment is
necessary to enhance clinical disease.'" The four most common forms of human disease associated
with NTM are a) pulmonary disease in adults; b) cervical lymph node disease in children; c) skin, soft
 .
ttssue,           . c t'IOns; an d d) d'tssemma
        an d bone tntec                      . t ed d'tsease m
                                                             . tmmunocompromtse
                                                               .                        . ts. 596· 597
                                                                                . d patten
Person-to-person acquisition ofNTM infection, especially among immunocompetent persons, does not
appear to occur, and close contacts of patients are not readily infected, despite the high numbers of
organisms harbored by such patients. 596• 59..600 NTM are spread via all modes of transmission
associated with water. In addition to health-care--associated outbreaks of clinical disease, NTM can
colonize patients in health-care facilities through consumption of contaminated water or ice or through
inhalation of aerosols. 601 - 605 Colonization following NTM exposure, particularly of the respiratory
tract, occurs when a patient's local defense mechanisms are impaired; ovett clinical disease does not
develop. 606 Patients may have positive sputum cultures in the absence of clinical disease.

Using tap water during patient procedures and specimen collection and in the final steps of instrument
reprocessing can result in pseudo-outbreaks ofNTM contamination 607- 609 NTM pseudo-outbreaks of
Mycobacterium chelonae, M gordonae, and M xenopi have been associated with both bronchoscopy
and gastrointestinal endoscopy when a) tap water is used to provide irrigation to the site or to rinse off
the viewing tip in situ or b) the instmments are inappropriately reprocessed with tap water in the final
steps.GI0---612
                                                                                                      45

Table 14. Nontuberculous mycobacteria-environmental vehicles

Vehicles associated with infections or colonizations                  References

Mycobacterium abscessus
        Inadequately sterilized medical instmments                    613
Mycobacterium avium complex (MAC)
        Potable water                                                 614-616
Mycobacterium chelonae
        Dialysis, reprocessed dialyzers                               31,32
        Inadequately-sterilized medical instruments, jet injectors    617,618
        Contaminated solutions                                        619, 620
        Hydrotherapy tanks                                            621
Mycobacterium fortuitum
        Aerosols ti·om showers or other water sources                 605, 606
        lee                                                           602
        Inadequately sterilized medical instmments                    603
        Hydrotherapy tanks                                            622
Mycobactel'ium marinum
        Hydrotherapy tanks                                            623
Mycobacterium ulceJ'Uits
        Potable water                                                 624

Vehicles associated with pseudo-outbreaks                             References

Mycobactel'ium chelonae
        Potable water used during bronchoscopy and instrument         610
            reprocessing
MycobacteJ·ium foJ·tuitum
        lee                                                           607
Mycobactel'ium gordonae
        Deionized water                                               611
        Ice                                                           603
        Laboratory solution (intrinsically contaminated)              625
        Potable water ingestion prior to sputum specimen collection   626
Mycobacterium kansasii
        Potable water                                                 627
Mycobactel'ium terrae
        Potable water                                                 608
Mycobacterium xenopi
        Potable water                                                 609,612,627

NTM can be isolated from both natural and man-made environments. Numerous studies have identified
                                                                                          615 616 624 627
various NTM in municipal water systems and in hospital water systems and storage tanks. • • • -
632 Some NTM species (e.g., Mycobacterium xenopi) can survive in water at ll3°F (45°C), and can be
isolated from hot water taps, which can pose a problem for hospitals that lower the temperature of their
hot water systems. 627 Other NTM (e.g., Mycobacterium kansasii, M gordonae, M fortuitum, and M
chelonae) cannot tolerate high temperatures and are associated more often with cold water lines and
taps.'29

NTM have a high resistance to chlorine; they can tolerate free chlorine concentrations of0.05-0.2 mg/L
(0.05-0.2 ppm) found at the tap. 598• 633• 634 They are 20-100 times more resistant to chlorine compared
with coliforms; slow-growing strains ofNTM (e.g., Mycobacterium avium and M kanasii) appear to be
46

more resistant to chorine inactivation compared to fast-growing NTM. 635 Slow-growing NTM species
have also demonstrated some resistance to formaldehyde and glutaraldehyde, which has posed problems
for reuse ofhemodialyzers. 31 The ability ofNTM to form biofilms at fluid-surface interfaces (e.g.,
interior surfaces of water pipes) contributes to the organisms' resistance to chemical inactivation and
provides a microenvironment for growth and proliferation. 636 • 637

d. Ctyptosporidiosis
Cryptosporidium parvum is a protozoan parasite that causes self-limiting gastroenteritis in normal hosts
but can cause severe, life-threatening disease in immunocompromised patients. First recognized as a
human pathogen in 1976, C. parvum can be present in natural and finished waters after fecal
contamination from either human or animal sources. 63 B-641

The health risks associated with drinking potable water contaminated with minimal numbers of C.
parvum oocysts are unknown. 642 It remains to be determined if immunosuppressed persons are more
susceptible to lower doses of oocysts than are immunocompetent persons. One study demonstrated that
a median 50% infectious dose (ID 50) of 132 oocysts of calf origin was sufficient to cause infection
among healthy volunteers. 643 In a second study, the same researchers found that oocysts obtained from
infected foals (newborn horses) were infectious for human volunteers at median ID 50 of 10 oocysts,
indicating that different strains or species of Cryptosporidium may vary in their infectivity for
humans_644 In a small study population of 17 healthy adults with pre-existing antibody to C. parvum,
the TD 5o was determined to be I ,880 oocysts, more than 20-fold higher than in seronegative persons. 645
These data suggest that pre-existing immunity derived from previous exposures to Ctyptosporidium
offers some protection from infection and illness that ordinarily would result from exposure to low
numbers of oocysts. 645• 646

Oocysts, pmticularly those with thick walls, are environmentally resistant, but their survival under
natural water conditions is poorly understood. Under laboratory conditions, some oocysts remain viable
and infectious in cold (41 op [5°C]) for months. 641 The prevalence of Ctyptosporidium in the U.S.
drinking water supply is notable. Two surveys of approximately 300 surface water supplies revealed
                                                                                  648
that 55'%--77% of the water samples contained Cryptosporidium oocysts.'47•            Because the oocysts are
highly resistant to common disinfectants (e.g., chlorine) used to treat drinking water, filtration of the
water is important in reducing the risk of waterborne transmission. Coagulation-floculation and
sedimentation, when used with filtration, can collectively achieve approximately a 2.5 logw reduction in
the number of oocysts. 649 However, outbreaks have been associated with both filtered and unfiltered
drinking water systems (e.g., the 1993 outbreak in Milwaukee, Wisconsin that affected 400,000
people). 641 • 65 0-652 The presence of oocysts in the water is not an absolute indicator that infection will
occur when the water is consumed, nor does the absence of detectable oocysts guarantee that infection
will not occur. Health-care-associated outbreaks of cryptosporidiosis primarily have been described
among groups of elderly patients and immunocompromised persons.'"

3. Water Systems in Health-Care Facilities
a. Basic Components and Point-of-Use Fixtures
Treated municipal water enters a health-care facility via the water mains and is distributed throughout
the building(s) by a network of pipes constructed of galvanized iron, copper, and polyvinylchloride
(PVC). The pipe runs should be as short as is practical. Where recirculation is employed, the pipe runs
should be insulated and long dead legs avoided in effmts to minimize the potential for water stagnation,
which favors the proliferation of Legionella spp. and NTM. In high-risk applications (e.g., PE areas for
severely immunosuppressed patients), insulated recirculation loops should be incorporated as a design
                                                                                                           47

feature. Recirculation loops prevent stagnation and insulation maintains return water temperature with
minimal loss.

Each water setvice main. branch main. riser, and branch (to a group of fixtures) has a valve and a means
to reach the valves via an access panel. 120 Each fixture has a stop valve. Valves pennit the isolation of
a portion of the water system within a facility during repairs or maintenance. Vacuum breakers and
other similar devices in the lines prevent water from back-flowing into the system. All systems that
supply water should be evaluated to determine risk for potential back siphonage and cross connections.

Health-care facilities generate hot water from municipal water using a boiler system. Hot water heaters
and storage vessels for such systems should have a drainage facility at the lowest point, and the henting
element should be located as close as possible to the bottom of the vessel to facilitate mixing and to
prevent water temperat:me stratification. TI10se hot or cold water systems that incoqJOrate an elevated
holding tank should be inspected and cleaned mmually. Lids should fit securely to exclude foreign
materials.

The most common point-of-use fixtures for wMer in patient-care areas are sinks. faucets, aerators,
showers, and toilets; eye-wash stations are found primarily in laboratories. The potential for these
fixtures to setve as a resetvoir for pathogenic microorganisms has long been recognized (Table 15). 509 •
65       6
  .,..'"   Wet surfaces and the production of aerosols facilitate the multiplication and dispersion of
microbes. The level of risk associated with aerosol production from point-of-use fixtures varies.
Aerosols from shower heads and aerators have been linked to a limited number of clusters of gram-
negative bactetial colonizations and infections. including Legionnaires disease, especially in areas
where in11nunocompromised patients are present (e.g.. surgical ICUs, transplant units, and oncology
units) 412 • 415 · 65""'59 In one report, clinical infection was not evident among immunocompetent persons
(e.g.. hospital staff) who used hospital showers when Legiouel/o pneumophila was present in the water
system 660 Given the infrequency of reported outbreaks associated with faucet aerators, consensus has
not been reached regarding the disinfection of or removal of these devices li'otn general use. If
additional clusters of infections or colonizations occm· in high-risk patient-care areas. it may be pmdent
to clean and decontaminate the aerators or to remove them. 658 •6' 9 ASHRAE recmmnends cleaning and
monthly disinfection of aerators in high-risk patient-care areas as pari of Legiouella controlmeasures. 661
Although aerosols are produced with toilet flnshing. 662 • 663 no epidemiologic evidence suggests that
these aerosols pose a direct infection hazard.

Although not considered a standard point-of-use fixture. decorative fountains are being installed in
increasing numbers in health-care facilities and other public buildings. Aerosols from a decorative
fountain have been associated with transmission of Legionella p11eumophilo serogroup 1 infection to a
small cluster of older adnlts 664 This hotel lobby fountain had been irregularly maintained, and water in
the fountain may have been heated by submersed lighting. all of which favored the proliferation of
Legionella in the system. 664 Because of the potential for generations of infectious aerosols, a pnrdent
prevention measure is to avoid locating these fixtures in or near high-risk patient-care areas and to
adhere to written policies for routine fountainmaintenance. 120

Tnble 15. Wnter and point-of-use fixtures ns sources and reservoirs ofwnterborne
pnthogens*
                    Assoeifttt>d                         Strength of       PJ'(>Vt>ntion And
  Re-servoir                          Transmission                                              Rt>ft>re-nc.es
                    pathogens                            e-vidNtCt>+            control
Potable water   Pseudomcnas. gnnn~       Contact          Moderate      Follow public henlth   (See Tables
                negative bacteria,                                      g1.1iddines.           12-14)
                NTM
48

                      Associated                            Strength of      Prevention and
  Reservoir                             Transmission                                                  References
                      pathoeens                             evidence+             control
Potable water     Legionella           Aerosol inhalation    Moderate     Provide supplemental        (See Table
                                                                          treatment for water.        11)
Holy water        Gram~ negative            Contact            Low        Avoid contact with          665
                  bacteria                                                severe burn injuries.
                                                                          Minimize use among
                                                                          immunocomprornised
                                                                          patients.
Dialysis water    Gram-negative             Contact          Moderate     Dialysate should be         2,527,666--
                  bacteria                                                ~2,000 cfu/mL; water        668
                                                                          should be <200 cfu/mL.
Automated         Gram-negative             Contact          Moderate     Use and maintain            669--675
endoscope         bacteria                                                equipment according to
rcprocessors                                                              instmctions; eliminate
and rinse water                                                           residual moisture by
                                                                          drying the channels
                                                                          (e.g., through alcohol
                                                                          rinse and forced air
                                                                          drying).
Water baths       Pseudomonas,              Contact          Moderate     Add germicide to the        29, 533, 676,
                  Burklwlderia,                                           water; wrap transfusion     677
                  Acinetobacter                                           products in protective
                                                                          plastic wrap if using the
                                                                          bath to modulate the
                                                                          temperature of these
                                                                          products.
Tub immersion     Pseudomonas,              Contact          Moderate     Drain and disinfect tub     67&-683
                  Enterobacter,                                           after each use; consider
                  Acinetobacter                                           adding germicide to the
                                                                          water; water in large
                                                                          hydrotherapy pools
                                                                          should be properly
                                                                          disinfected and filtered.
Ice and ice       NTM, Enterobacte1~   Ingestion, contact    Moderate     Clean periodically; use     601,684-687
machines          Pseudomonas,                                            automatic dispenser
                  Clyptosporidiunl                                        (avoid open chest
                                                                          storage compmiments
                  Le~ionella                                  Low         in patient areas).
Faucet aerators   Legionella           Aerosol inhalation    Moderate     Clean and disinfect         415,661
                                                                          monthly in high-risk
                                                                          patient areas; consider
                                                                          removing if additional
                                                                          infections occur.
Faucet aerators   Pseudomonas,          Contact, droplet       Low        No preca11tions arc         658, 659,
                  Acinetobacter,                                          necessary at present in     688,689
                  Stenotrophomonas,                                       immunocompetent
                  Ch1yseobacterium                                        patient-care areas.
Sinks             Pseudomonas           Contact, droplet     Moderate     Use separate sinks for      509, 653,
                                                                          handwashing and             685-693
                                                                          disposal of
                                                                          contaminated fluids.
Showers           Legionella           Aerosol inhalation      Low        Provide sponge baths        656
                                                                          for hematopoietic stem
                                                                          cell transplant patients;
                                                                          avoid shower use for
                                                                          immunocompromised
                                                                          patients when
                                                                          Legionella is detected
                                                                          in facility water.
                                                                                                                                       49

                           Associated                                          Str(>ngth of        Prevention nnd
    RPS£'1'\'0h'                                     Tt·nusmission                                                           Ref£>l'PUC('S
                           pnthogens                                            evidence+               control
Dentnl unit            Pseudomonas,                       Contact                  Low          Clean woter $ystems          636, 694-Q96
wale!' lines           Legionella,                                                              according to system
                       Sphingomonas,                                                            manufacturer's
                       Acinetobac/er                                                            instmctions.
Ice baths for          Ewiugella,                         Contact                   Low         Use sterile water.           697,698
thermodilution         Staphylococcus
catheters
Decorative             Legionel/a                   Aerosol inhalntion              l.h <>tations     518, 699, 700
stations               amoebae,                                                                 weekly; have sterile
                       L(l_gionella                                              Minimum        water aYnilable for eye
                                                                                                flushes.
Toilets                G-ranNlegntive                         -                  .Minimum       Clean regularly; use         662
                       bacteria                                                                 2:ood lumd hvQ:iene.
Flowers                Gram-negative                         -                   t>.·finimtun   Avoid use in inten~-ive      515, 701, 702
                       ba~;h:ria,                                                               care units and in
                       Aspergillus                                                              immunocompmmised
                                                                                                natk~nt-care settit12:s,

*   Modified from .reference 654 filld used with pennission of the publisher (Slack, Inc.)
+ 1\foileJ•ate: occasional well-deSt:nbed outbreak!>. Low: f~ well-described outbreaks. Minimal: actual infections not demonstrated.

b, Water Temperature ami Pressure
Hot water temperature is usually measured at the point of use or at the point at which the water line
enters equipment requiring hot water for proper operation, 120 Generally, tl1e hot water temperature in
hospital patient-care areas is no greater than a temperature within the range of 105°F-120°F (40.6°C-
490C), depending on the AlA guidance issued at the year in which the facility was built 110 Hot water
temperature in patient-care areas of skilled nursing-care facilities is set within a slightly lower range of
95°F-ll0°F (35°C-43YC) depending on the AlA guidance at the time of facility constmctionno
Jvlany states have adopted a temperature setting in these ranges into their health-care regulatious and
building codes, ASHRAK however, has reconunendcd higher settings!" Steam jets or booster heaters
are usually needed to meet the hot water temperature requirements in ce1tain service areas of the
hospital (e,g, the kitchen [120"F (49°C)] or the launchy [160°F (7!°C)])no Additionally, water lines
may need to be heated to a particular temperature specified by manufacturers of specific hospital
equipment Hot-water distribution systems serving patient-care areas are generally operated under
constant recirculation to provide continuous hot water at each hot-water outlet."0 !fa facilitv is or has
a hemodialysis unit, then continuously circulated, cold treated water is provided to that unit 11o

To minimize the growth and ~ersistence of gram-negative \~at~rborue bacteria (e,g,, thermophilic NTM
and Legionella spp,), 627' 703-70 cold water m health-care facrlltles should be stored and d1stnbutecl at
temperatures below 68°F (20°C:); hot water should be stored above 140°F (60°C) and circulated with a
minimum retum temperature of 124°F (51 °C), 661 or the highest temperamre specified in state
regulations and building codes, If the retm11 temperature setting of l24°F (51 °C) is permitted, then
installation of preset thermostatic mixing valves near the point-of-use can help to prevent scalding,
Valve maintenance is especially important in preventing valve failme, which can result in scalding,
New shower systems in large buildings, hospitals, and nursing homes should be designed to permit
mixing of hot and cold water near the shower head, TI1e wann water section of pipe between the control
valve and shower head should be selt~draining, Where buildings can not be retrofitted, other
50

approaches to minimize the growth of Legione/la spp. include a) periodically increasing the temperature
to at least 150°F [66°C] at the point of use [i.e., faucets] and b) adding additional chlorine and flushing
the water. 601 · 710 • 711 Systems should be inspected annually to ensure that thennost8ts are functioning
properly.

Adequate water pressure ensures suftlcient water supplies for a) direct patient care; b) operation of
water-cooled instnunents and equipment [e.g., lasers. computer systems, telecommunications systems.
and automated endoscope reprocessors712]; c) proper ftmction of vacuum suctioning systems: d) indoor
climate control; and e) fire-protection systems. Maintaining adequate pressure also helps to ensme the
integrity of the piping system.

c. Infectlon-Coutrol Impact of Water System Maintenance aud Repair
Conective measures for water-system failures have not been studied in well-designed experiments:
these measmes are instead based on empiric engineering and infection-control principles. Health-care
t1cilities can occasionally sustain both intentional cut-offs by the mtmicipal water authority to permit
new constmction project tie-ins and mtintentional dismptions in service when a water main breaks as a
result of aging infrastmcnu·e or a constmction accident. Vacuum breakers or other similar devices can
prevent backflow of water in the facility's distribution system during water-dismption emergendes. 11
To be prepared for such an emergency, all health-care facilities need contingency plans that identify a)
the total demand tor potable water. b) the quantity of replacement water [e.g., bottled water] required for
a minimum of 24 homs when the water system is do'Ml. c) mechanisms for emergency water
distribution, and 4) procedures for conecting drops in water pressure that affect operation of essential
devices and equipment that are driven or cooled by a water system [Table 16].713

Tnble 16. Water clemnnd in health-care facilities during water disruption emergencies
                                                              Potnble wntt>l'                                  Bottl{'d, stel'ile WlltN'
                                               Drinking water                                      Surgical scmb
                                               H;mdwa<;hing                                        Emergency surgicnl procedurec;
                                               Cnfeteria services                                  Phummceulical prepamlions
                                               Ice                                                 Patient-care equipment (e.g,, ventilators)§
                                               Manual flushing of toilets
                                               Patient baths, hygiene
                                               Hemodinlysis
           Wllt(>l' US(> ll(>('dS
                                               Hydt'ofhempy
                                               Fire prevention (e.g., ">prit1kkr ~ystems)
                                               Surgery and critical cnre nn:ns
                                               Laborat01y services
                                               LamKby and central sterile service!>*
                                               Cooling towers+
                                               Steam Q:euerntion
•          .                                       ., sef'i!Ces from anothl>r resource, Jfposstblc (e.g., ;mothe-r heahb·carc fnctbty ot controclor) .
    A.naug<:: to haw a conhugency pro\'lSton of these
+ Some cooling tower$ may use a potable water source, but most tmit'> use non~polable water.
§ Thi'> item is included in the table under the assumption that electrical power is available during the water emergency.

Detailed, np-to-dnte plans for hot and cold water piping systems should be readily available tor
maintenance and repair pmposes in case of system problems. Opening potable water systems for repair
or constmction and subjecting systems to water-pressure changes can result in water discoloration and
dramatic increases in the concentrations of Legionella spp. and other gram-negative bacteria. The
maintenance of a chlorine residual at all points within the piping system also offers some protection
from enny of contamination to the pipes in the event of inadvertent cross-cotmection between potable
and non-potable water lines. As a minimum preventive measure, ASHRAE reconunends a thorough
flushing of the system. 661 High-temperan1re flushing or hyperchlorination may also be appropriate
                                                                                                       51

strategies to decrease potentially high concentrations of waterborne organisms. The decision to pursue
either of these remediation strategies, however, should be made on a case-by-case basis. If only a
pottion of the system is involved, high temperature flushing or chlorination can be used on only that
pottion of the system. 661

When shock decontamination of hot water systems is necessary (e.g., after dismption caused by
construction and after cmss-connections), the hot water temperature should be raised to 160°F-170°F
(7 I °C-77°C) and maintained at that level while each outlet around the system is progressively flushed.
A minimum flush time of 5 minutes has been recommended;' the optimal flush time is not known,
however, and longer flush times may be necessary. 714 The number of outlets that can be flushed
simultaneously depends on the capacity of the water heater and the flow capability of the system.
Appropriate safety procedures to prevent scalding are essential. When possible, flushing should be
performed when the fewest building occupants are present (e.g., during nights and weekends).

When thermal shock treatment is not possible, shock chlorination may serve as an alternative method.661
Experience with this method of decontamination is limited, however, and high levels of free chlorine
can corrode metals. Chlorine should be added, preferably overnight, to achieve a free chlorine residual
of at least 2 mg/L (2 ppm) throughout the system. 661 This may require chlorination of the water heater
or tank to levels of2G-50 mg/L (2G-50 ppm). The pH of the water should be maintained at 7.G-8.0.661
After completion of the decontamination, recolonization of the hot water system is likely to occur unless
proper temperatures are maintained or a pmcedure such as continuous supplemental chlorination is
continued.

Interruptions of the water supply and sewage spills are situations that require immediate recovery and
remediation measures to ensure the health and safety of patients and staff. 715 When delivery of potable
water through the municipal distribution system has been dismpted, the public water supplier must issue
a "boil water" advisory if microbial contamination presents an immediate public health risk to
customers. The hospital engineer should oversee the restoration of the water system in the facility and
clear it for use when appropriate. Hospitals must maintain a high level of surveillance for waterborne
disease among patients and staff after the advisory is lifted."42

Flooding fi'om either external (e.g., from a hurricane) or internal sources (e.g., a water system break)
usually results in property damage and a temporary loss of water and sanitation. 71 '" 718 JCAHO requires
all hospitals to have plans that address facility response for recovery from both intemal and external
disasters. 713 • 719 The plans are required to discuss a) general emergency preparedness, b) staffing, c)
regional planning among area hospitals, d) emergency supply of potable water, e) infection control and
medical services needs, f) climate control, and g) remediation. The basic principles of structural
recovery from flooding are similar to those for recovery from sewage contamination (Box 9 and I 0).
Following a major event (e.g., flooding), facilities may elect to conduct microbial sampling of water
after the system is restored to verifY that water quality has been returned to safe levels (<500 CFU!mL,
heterotrophic plate count). This approach may help identifY point-of-use fixtures that may harbor
contamination as a result of design or engineering features. 720 Medical records should be allowed to
dry and then either photocopied or placed in plastic covers before returning them to the record.

Moisture meters can be used to assess water-damaged structural materials. If porous structural materials
for walls have a moisture content of>20% after 72 hours, the affected material should be removed.' 66•
278 313
   •    The management of water-damaged structural materials is not strictly limited to major water
catastrophes (e.g., flooding and sewage intrusions); the same principles are used to evaluate the damage
from leaking roofs, point-of-use fixtures, and equipment. Additional sources of moisture include
condensate on walls from boilers and poorly engineered humidification in HVAC systems.
52

Box 9. Recovery and remediation measures for water-related emergencies*

Potable water disruptions

Contingency plan items
        Ensure access to plumbing network so that repairs can be easily made.
        Provide sufficient potable water, either from bottled sources or truck delivery.
        Post advisory notices against consuming tap water, ice, or beverages made with water.
        Rope off or bag drinking fountains to designate these as being "out of service" until further notice.
        Rinse raw foods as needed in disinfected water.
        Disconnect ice machines whenever possible.+
        Postpone laund1y services until after the water system is restored.
Water treatment
        Heat water to a rolling boil for .2:1 minute.
Remediation of the water system after the "boil water" advisory is rescinded
        Flush fixtures (e.g., faucet., and drinking fountains) and equipment for several minutes and restmt.
        Run water softene1·s through a regeneration cycle.
        Drain, disinfect, and refill water storage tanks, if needed.
        Change pretreatment filters and disinfect the dialysis water system.

Sewage spills/malfunction

Overall strategy
        Move patients and clean/sterile supplies out of the area.
        Redirect tratlic away from the. area.
        Close the doors or use plastic sheeting to isolate the area prior to clean~ up.
        Restore sewage system function first, then the potable water system (if both are malfunctioning).
        Remove sewage solids, drain the area, and let dry.
Remediation of the structure
        Hard surfaces: clean with detergent/disinfectant after the area has been drained.
        Carpeting, loose tiles, buckled flooring: remove and allow the support surface to dry; replace the items; wet down
          carpeting with a low~ level disinfectant or sanitizer prior to removal to minimize dust dispersion to the air.
        Wallboard and other porous structural materials: remove and replace if they cannot be cleaned and dried within
          72 hours.§
Furniture
        Hard surface furniture (e.g., metal or plastic furniture): clean and allow to dry.
        Wood furniture: let dry, sand the wood surface, and reapply varnish.
        Cloth fumiture: replace.
Electrical equipment
            Replace ifthe item cannot be easily dismantled, cleaned, and reassembled.

*   Material in this box iscompiled from references 266, 278, 315, 713, 716-719, 721-729.
+ Ice machines should always be disconnected from the water source in advance of planned water disruptions.
* Moisture meter readings should be <20% moisture content.

An exception to these 1·ecommendations is made for hemodialysis units where water is further
treated either by portable water treatment or large-scale water treatment systems usually involving
reverse osmosis (RO). In the United States, >97% of dialysis facilities use RO treatment for their
water. 721 However, changing pre-treatment filters and disinfecting the system to prevent colonization
of the RO membrane and microbial contamination down-stream of the pre-treatment filter are prudent
measures.
                                                                                                                                    53

Box 10. Contingency planning for flooding

General emergency preparedness
           Ensure that emergency electrical generators are not located in flood-prone areas of the facility.
           Develop alternative strategies for moving patients, water containers, medical records, equipment, and supplies in the
             event that the elevators are inoperable.
           Establish in advance a centralized base of operations with batteries, flashlights, and cellular phones.
           Ensure sufficient supplies of sandbags to place at the entrances and the area around boilers, incinerators, and
             generators.
           Establish alternative strategies for bringing core employees to the facility if high water prevents travel.
Staffing Patterns
           Temporarily reassign licensed staff as needed to critical care areas to provide manual ventilation and to perfmm
             vital assessments on patients.
           Designate a core group of employees to remain on site to keep all services operational if the facility remains open.
           Train all employees in emergency preparedness procedures.
Regional planning among are facilities for disaster management
           Incorporate community suppmt and involvement (e.g., media alerts, news, and transportation).
           Develop in advance strategies for transfetTing patients, as needed.
           Develop strategies for sharing supplies and providing essential services among participating facilities (e.g., eenlral
             sterile department setvices, and laundry setvices).
           Identify sources for emergency provisions (e.g., blood, emergency vehicles, and bottled water).
Medical services and infection control
           Use alcohol-based hand rubs in general patient-care areas.
           Postpone elective surgeries until full se1vices are restored, or transfer these patients to other facilities.
           ConsideJ' using pmtable dialysis machines.+
           Provide an adequate supply of tetanus and hepatitis A immunizations for patients and staff.
Climate control
           Provide adequate water for cooling towers.§

* Material in this box was compiled from references 713, 716-719.
+ Portable dialysis machines require less water compared to the larger units situated in dialysis settings.
§ Water for cooling towers may need to be trucked in, especially if the tower uses a potable water source.

4. Strategies for Controlling Waterborne Microbial Contamination
a. Supplemental Treatment of Water with Heat and/or Chemicals
In addition to using supplemental treatment methods as remediation measures after inadvertent
contamination of water systems, health-care facilities sometimes use special measures to control
waterborne microorganisms on a sustained basis. This decision is most often associated with outbreaks
of legionellosis and subsequent efforts to controllegionellae,722 although some facilities have tried
supplemental measures to better control thermophilic NTM. 627

The primary disinfectant for both cold and hot water systems is chlorine. However, chlorine residuals
are expected to be low, and possibly nonexistent, in hot water tanks because of extended retention time
in the tank and elevated water temperature. Flushing, especially that which removes sludge from the
bottom of the tank, probably provides the most effective treatment of water systems. Unlike the
situation for disinfecting cooling towers, no equivalent recommendations have been made for potable
                                                                                 403 723
wate1· systems, although specific intervention strategies have been published. '         The principal
approaches to disinfection of potable systems are heat flushing using temperatures 160°F-170°F (71 o_
770C), hyperchlorination, and physical cleaning of hot-water tanks. 3 • 403' 661 Potable systems are easily
recolonized and may require continuous intervention (e.g., raising of hot water temperatures or
continuous chlorination).' 03 • 711 Chlorine solutions lose potency over time, thereby rendering the
stocking of large quantities of chlorine impractical.
54

Some hospitals with hot water systems identified as the source of Legionel!a spp. have performed
emergency decontamination of their systems by pulse (i.e., one-time) thermal disinfection/superheating
or hyperchlorination. 711 • 714 • 724 • 725 After either of these procedures, hospitals either maintain their
heated water with a minimum return temperature of 124 °F (51 °C) and cold water at <68°F (<20°C) or
                                                                                                              70
chlorinate their hot water to achieve 1-2 mg/L (1-2 ppm) offi·ee residual chlorine at the tap. 26 • 437• ,_711 •
726 727
   '    Additional measures (e.g., physical cleaning or replacement of hot-water storage tanks, water
heaters, faucets, and shower heads) may be required to help eliminate accumulations of scale and
sediment that protect organisms from the biocidal effects of heat and chlorine. 457• 711 Alternative
methods for controlling and eradicating legionellae in water systems (e.g., treating water with chlorine
dioxide, heavy metal ions [i.e., copper/silver ions], ozone, and UV light) have limited the growth of
legionellae under laboratory and operating conditions. 72 s-742 Further studies on the long-term efficacy
of these treatments are needed before these methods can be considered standard applications.

Renewed interest in the use of chloramines stems from concerns about adverse health effects associated
with disinfectants and disinfection by-products. 743 Monochloramine usage minimizes the formation of
disinfection by-products, including trihalomethanes and haloacetic acids. Monochloramine can also
reach distal points in a water system and can penetrate into bacterial biofilms more effectively than free
chlorine. 744 However, monochloramine use is limited to municipal water treatment plants and is
currently not available to health-care facilities as a supplemental water-treatment approach. A recent
study indicated that 90% of Legionnaires disease outbreaks associated with drinking water could have
been prevented ifmonochloramine rather than fi·ee chlorine has been used for residual disinfection. 745
In a retrospective comparison of health-care--associated Legionnaires disease incidence in central Texas
hospitals, the same research group documented an absence of cases in facilities located in communities
with monochloramine-treated municipal water. 746 Additional data are needed regarding the
effectiveness of using monochloramine before its routine use as a disinfectant in water systems can be
recommended. No data have been published regarding the effectiveness ofmonochloramine installed at
the level of the health-care facility.

Additional filtration of potable water systems is not routinely necessaty. Filters are used in water lines
in dialysis units, however, and may be inserted into the lines for specific equipment (e.g., endoscope
washers and dis infectors) for the purpose of providing bacteria-free water for instmment reprocessing.
Additionally, an RO unit is usually added to the distribution system leading toPE areas.

b. Primary Prevention of Legionnaires Disease (No Cases Identified)
The primary and secondmy environmental infection-control strategies described in this section on the
guideline pertain to health-care facilities without transplant units. Infection-control measures specific to
PE or transplant units (i.e., patient-care areas housing patients at the highest risk for morbidity and
mortality from Legionella spp. infection) are described in the subsection titled Preventing Legionnaires
Disease in Protective Environments.

Health-care facilities use at least two general strategies to prevent health-care--associated legionellosis
when no cases or only sporadic cases have been detected. The first is an environmental surveillance
approach involving periodic culturing of water samples from the hospital's potable water system to
monitor for Legionella spp 747- 750 If any sample is culture-positive, diagnostic testing is recommended
for all patients with health-care--associated pneumonia. 748' 749 In-house testing is recommended for
facilities with transplant programs as pmt of a comprehensive treatment/management program. lf2:30%
of the samples are culture-positive for Legionella spp., decontamination of the facility's potable water
system is warranted. 748 The premise for this approach is that no cases of health-care--associated
legionellosis can occur if Legionella spp. are not present in the potable water system, and, conversely,
cases of health-care--associated legionellosis could potentially occur if Legionella spp. are cultured fi·om
the water."· 751 Physicians who are informed that the hospital's potable water system is culture-positive
                                                                                                                55

for Legionella spp. are more likely to order diagnostic tests for legionellosis.

A potential advantage of the environmental surveillance approach is that periodic culturing of water is
less costly than routine laboratory diagnostic testing for all patients who have health-care-associated
pneumonia. The primmy argument against this approach is that, in the absence of cases, the relationship
between water-culture results and legionellosis risk remains undefined.' Legionnella spp. can be
present in the water systems ofbuildings752 without being associated with known cases of disease. 437• 707•
753
     In a study of 84 hospitals in Quebec, 68% of the water systems were found to be colonized with
Legionella spp., and 26% were colonized at> 30% of sites sampled; cases of Legionnaires disease,
however, were infrequently reported from these hospitals. 707

Other factors also argue against environmental surveillance. Interpretation of results from periodic
water culturing might be confounded by differing results among the sites sampled in a single water
system and by fluctuations in the concentration of Leglonella spp. at the same site. 709' 754 In addition,
the risk for illness after exposure to a given source might be influenced by several factors other than the
presence or concentration of organisms, including a) the degree to which contaminated water is
aerosolized into respirable droplets, b) the proximity of the infectious aerosol to the potential host, c) the
susceptibility of the host, and d) the vimlence properties of the contaminating strain. 75 ,_757 Thus, data
are insufficient to assign a level of disease risk even on the basis of the number of colony- forming units
detected in samples from areas for immunocompetent patients. Conducting environmental surveillance
would obligate hospital administrators to initiate water-decontamination programs if Legionella spp. are
identified. Therefore, periodic monitoring of water fi·om the hospital's potable water system and from
aerosol-producing devices is not widely recommended in facilities that have not experienced cases of
health-care-associated legionellosis. 661 • 758

The second strategy to prevent and control health-care-associated legionellosis is a clinical approach, in
which providers maintain a high index of suspicion for legionellosis and order appropriate diagnostic
tests (i.e., culture, urine antigen, and direct fluorescent antibody [DFA] serology) for patients with
health-care-associated pneumonia who are at high risk for legionellosis and its complications."'· 759• 760
The testing of autopsy specimens can be included in this strategy should a death resulting from health-
care-associated pneumonia occur. Identification of one case of definite or two cases of possible health-
care-associated Legionnaires disease should prompt an epidemiologic investigation for a hospital
source of Legionella spp., which may involve culturing the facility's water for Legionella. Routine
maintenance of cooling towers, and use of sterile water for the filling and terminal rinsing of
nebulization devices and ventilation equipment can help to minimize potential sources of contamination.
Circulating potable water temperatures should match those outlined in the subsection titled Water
Temperature and Pressure, as permitted by state code.

c. Secondary prevention of Legionnaires Disease (With Identified Cases)
The indications for a full-scale environmental investigation to search for and subsequently
decontaminate identified sources of Legionella spp. in health-care facilities without transplant units
have not been clarified; these indications would likely differ depending on the facility. Case categories
for health-care-associated Legionnaires disease in facilities without transplant units include definite
cases (i.e., laboratory-confirmed cases oflegionellosis that occur in patients who have been hospitalized
continuously for 2:10 days before the onset of illness) and possible cases (i.e., laboratmy-confirmed
infections that occur 2-9 days after hospital admission).' In settings in which as few as one to three
health-care-associated cases are recognized over several months, intensified surveillance for
Legionnaires disease has frequently identified numerous additional cases. 405 • 408• 432 • 453 • 739• 759• 760 This
finding suggests the need for a low threshold for initiating an investigation after laboratory confirmation
of cases of health-care-associated legionellosis. When developing a strategy for responding to such a
finding, however, infection-control personnel should consider the level of risk for health-care-
56

associated acquisition of, and mortality from, Legione!la spp. infection at their particular facility.

An epidemiologic investigation conducted to determine the source of Legionella spp. involves several
important steps (Box II). Laboratory assessment is crucial in supporting epidemiologic evidence of a
link between human illness and a specific environmental source. 761 Strain determination from subtype
analysis is most frequently used in these investigations 410• 762- 764 Once the environmental source is
established and confi1med with laboratory support, supplemental water treatment strategies can be
initiated as appropriate.

Box 11. Steps in an epidemiologic investigation for legionellosis

        Review medical and microbiologic records.
        Initiate active surveillance to identify all recent or ongoing cases.
        Develop a line listing of cases by time, place, and person.
        Determine the type of epidemiologic investigation needed for assessing risk factors:
            • Case-control study,
            • Cohort study.
        Gather and analyze epidemiologic information:
           • Evaluate risk factors associated with potential environmental exposures (e.g., showers,
                cooling towers, and respiratory-therapy equipment).
        Collect water samples:
           • Sample environmental sources implicated by epidemiologic investigation,
           • Sample other potential source of water aerosols.
        Subtype strains of Legionel/a spp. cultured from both patients and environmental sources.
        Review autopsy records and include autopsy specimens in diagnostic testing.

The decision to search for hospital environmental sources of Legionella spp. and the choice of
procedures to eradicate such contamination are based on several considerations, as follows: a) the
hospital's patient population; b) the cost of an environmental investigation and institution of control
measures to eradicate Legionella spp. from the water supply;76,_768 and c) the differential risk, based on
host factors, for acquiring health-care--associated legionellosis and developing severe and fatal
infection.

d. Preventing Legionnaires Disease in Protective Environments
This subsection outlines infection-control measures applicable to those health-care facilities providing
care to severely immunocompromised patients. Indigenous microorganisms in the tap water of these
facilities may pose problems for such patients. These measures are designed to prevent the generation
of potentially infectious aerosols from water and the subsequent exposure ofPE patients or other
immunocompromised patients (e.g., transplant patients) (Table 17). Infection-control measures that
address the use of water with medical equipment (e.g., ventilators, nebulizers, and equipment
humidifiers) are described in other guidelines and publications.'·"'

If one case of laboratory-confirmed, health-care--associated Legionnaires disease is identified in a
patient in a solid-organ transplant program or in PE (i.e., an inpatient in PE for all or part of the 2-10
days prior to onset of illness) or if two or more laboratory-confirmed cases occur among patients who
had visited an outpatient PE setting, the hospital should report the cases to the local and state health
departments. The hospital should then initiate a thorough epidemiologic and environmental
investigation to determine the likely environmental sources of Legionella spp.' The source of
Legionella should be decontaminated or removed. Isolated cases may be difficult to investigate.
Because transplant recipients are at substantially higher Jisk for disease and death from legionellosis
                                                                                                                                          57

compared with other hospitalized patients, peliodic cultr1ring for Legionella spp. in water samples from
the potable water in the solid-organ transplant and/or PE unit can be perfonned as part of an overall
strategy to prevent Legionnaires disease in PE units. 9.431 , 710• 769 TI1e optimal methodology (Le.,
frequency and number of sites) for environmental surveillance cultures in PE units has not been
detennined, and the cost-effectiveness of this strategy has not been evaluated. Because transplant
recipients are at high lisk for Legimmaires disease and because no data are available to detennine a safe
concentration of legionellae organisms in potable water. the goal of environmental surveillance for
Legionella spp. should be to maintain water systems with no detectable organismsY· 431 Culhrring for
legionellae may be used to assess the effectiveness of water treatment or decontamination methods, a
practice that provides benefits to both patients and health-care workers. 767• no

Tnble 17. Additionnl infection-control measures to prevent exposure of high-risk patients
to waterborne pathogens
                                             M('HSUJ'eS                                                             Rl"fE't'('U('.(>S
• Restl'ict patients from taking !>hower.s if the water is contaminated with Legionclla                 • 407,412, 654, 655, 658
   spp.
• Use water thai is not ~;ontaminures can be comidered in settings where legionellosis cases have occurred. Titese mN\S\Ires are not generally recommended in
        routine patient-cnre ~etting..
+   'fi1ese items have been associated with outbreaks of PMmdommms.

Protecting patient-care devices and il1stnrments 11-om inadvertent tap water contamination during room
cleaning procedures is also important in any inununocompromised patient-care area. In a recent
outbreak of gram-negative bacteremias among open-heart-surgery patients, pressure-monitoring
equipment that was assembled and left uncovered ovemight prior to tile next day's surgeries was
inadvertently contaminated with mists and splashing water from a hose-disinfectant system used for
cleaning. 771

5. Cooling Towers and Evaporative Condensers
lviodem health-care facilities maintain indoor climate control during wann weather by use of cooling
towers (large facilities) or evaporative condensers (smaller buildings). A cooling tower is a wet-type,
evaporative heat tr-ansfer device used to discharge to the atmosphere waste heat from a building's air
conditioning condensers (Figme 5). 772 • 773 Warm water from air-conditioning condensers is piped to the
cooling tower where it is sprayed downward into a counter- or cross-current air flow. To accelerate heat
transfer to the air, the water passes over the till, which either breaks water into droplets or causes it to
spread into a thin film. m. 773 Most systems use fans to move air tln'Ough the tower, although some large
industrial cooling towers rely on natural draft circulation of air. TI1e cooled water from the tower is
piped back to the condenser, where it again picks up heat generated during the process of chilling the
system's refrigerant. The water is cycled back to the cooling tower to be cooled. Closed-circuit cooling
towers and evaporative condensers are also evaporative heat-transfer devices. llr these systems, the
58

process fluid (e.g., water, ethylene glycol/water mixture, oil, or a condensing refi'igerant) does not
directly contact the cooling air, but is contained inside a coil assembly. 661

Figure 5. Diagram of a typical air conditioning (induced draft) cooling tower*

                                                                                                     Heated
                                                                                                    Refrigerant

                                                                                                  Chilled

                       Water (80''Fl

Wate1· temperatures are approximate and may differ substantially according to system use and design. Wann water fi·om the
condenser (or chiller) is sprayed downward into a counter~ or cross-cuJTent air flow. Water passes over the fill (a component of
the system designed to increase the surface area of the water exposed to air), and heat from the water is transferred to the air.
Some of the water becomes aerosolized during this process, although the volume of aerosol discharged to the air can be
reduced by the placement of a drift eliminator. Water cooled in the towe1· returns to the heat source to cool refrigerant fi·om the
air conditioning unit
* This figure is reprinted with permission of the publisher of reference 773 (Plenum Medical).
Cooling towers and evaporative condensers incorporate inertial stripping devices caiJed drift eliminators
to remove water droplets generated within the unit. Although the effectiveness of these eliminators
varies substantiaiJy depending on design and condition, some water droplets in the size range of <5 ~m
will likely leave the unit, and some larger droplets leaving the unit may be reduced to ,:'05 ~m by
evaporation. Thus, even with proper operation, a cooling tower or evaporative condenser can generate
and expel respirable water aerosols. If either the water in the unit's basin or the make-up water (added
to replace water lost to evaporation) contains Legionella spp. or other waterborne microorganisms, these
organisms can be aerosolized and dispersed from the unit. 774 Clusters of both Legionnaires disease and
Pontiac fever have been traced to exposure to infectious water aerosols originating from cooling towers
and evaporative condensers contaminated with Legionella spp. Although most of these outbreaks have
been community-acquired episodes of pneumonia, 77 s-782 health-care-associated Legionnaires disease
                                                                                                           59

has been linked to cooling tower aerosol exposure. 404 • 405 Contaminated aerosols from cooling towers
on hospital premises gained entry to the buildings either through open windows or via air handling
system intakes located near the tower equipment.

Cooling towers and evaporative condensers provide ideal ecological niches for Legionel/a spp. The
typical temperature of the water in cooling towers ranges from 85°F-95°F (29°C-35'C), although
temperatures can be above l20°F (49°C) and below 70°F (21 °C) depending on system heat load,
ambient temperature, and operating strategy. 661 An Australian study of cooling towers found that
legionellae colonized or multiplied in towers with basin temperatures above 60.8°F (l6°C), and
multiplication became explosive at temperatures above 73.4'F (23°C). 783 Water temperature in closed-
circuit cooling towers and evaporative condensers is similar to that in cooling towers. Considerable
variation in the piping arrangement occurs. In addition, stagnant areas or dead legs may be difficult to
clean or penetrate with biocides.

Several documents address the routine maintenance of cooling towers, evaporative condensers, and
whirlpool spas. 661 • 784-787 They suggest following manufacturer's recommendations for cleaning and
biocide treatment of these devices; all health-care facilities should ensure proper maintenance for their
cooling towers and evaporative condensers, even in the absence of Legion ella spp (Appendix C).
Because cooling towers and evaporative condensers can be shut down during periods when air
conditioning is not needed, this maintenance cleaning and treatment should be performed before sta1ting
up the system for the first time in the warm season. 782 Emergency decontamination protocols
describing cleaning procedures and hyperchlorination for cooling towers have been developed for
towers implicated in the transmission of legionellosis. 786 • 787

6, Dialysis Water Quality and Dialysate
a. Rationale for Water Treatment i11 Hemodialysis
Hemodialysis, hemofiltration, and hemodiafiltration require special water-treatment processes to
prevent adverse patient outcomes of dialysis therapy resulting from improper formulation of dialysate
with water containing high levels of ce1tain chemical or biological contaminants. The Association for
the Advancement of Medical Instrumentation (AAMI) has established chemical and microbiologic
standards for the water used to prepare dialysate, substitution fluid, or to reprocess hemodialyzers for
renal replacementtherapy. 78... 792 The AAMT standards address: a) equipment and processes used to
purify water for the preparation of concentrates and dialysate and the reprocessing of dialyzers for
multiple use and b) the devices used to store and distribute this water. Future revisions to these
standards may include hemofiltration and hemodiafiltration.

Water treatment systems used in hemodialysis employ several physical and/or chemical processes either
singly or in combination (Figure 6). These systems may be pmtable units or large systems that feed
several rooms. In the United States, >97% of maintenance hemodialysis facilities use RO alone or in
combination with deionization. 793 Many acute-care facilities use portable hemodialysis machines with
attached portable water treatment systems that use either deionization or RO. These machines were
exempted fi·om earlier versions of AAMT recommendations, but given current knowledge about toxic
exposures to and inflammatmy processes in patients new to dialysis, these machines should now come
                                                                                                     788
into compliance with current AAMI recommendations for hemodialysis water and dialysate quality. '
789
     Previous recommendations were based on the assumption that acute-care patients did not
experience the same degree of adverse effects from short-term, cumulative exposures to either
chemicals or microbiologic agents present in hemodialysis fluids compared with the effects encountered
by patients during chronic, maintenance dialysis. 788 • 789 Additionally, JCAHO is reviewing inpatient
60

practices and record-keeping for dialysis (acute and maintenance) for adherence to AAMI standards and
reconnnended practices.

Figure 6. Dialysis water treatment system*

                                                                                                             water

    Potable water

       Blending
         valve

             Mullimedia/   Softener    Carbon adsorption     Particulate/    Reverse   Storage tank and/or
             sand/depth                  media (2 beds in     1 pm filter    osmosis   optional additional
              filtration                      series)                                  components:
                                                                                       deionization tanks
                                                                                       UVIamp
                                                                                       ultrafilters

*   Sec text for de<;cription of the phtcement and function of these components.

Neither the water used to prepare dialysate nor the dialysate itself needs to be sterile. but tap water can
not be used without additional treatment. Infections caused by rapid-growing NTM (e.g.,
Mycobacterium chelouae and M. abscessus) present a potential risk: to hemodialysis patients (especially
those in hemodialyzer reuse progrmns) if disinfection procedures to inactivate mycobacteria in the water
(low-level disinfection) and the hemodialyzers (high-level disinfection) are inadequate. 31 · 32 •633 Other
factors associated with microbial contamination in dialysis systems could involve the water treatment
system, the water and dialysate distribution systems, mld the type ofhemodialyzer. 666• 667 • 794-799
Understanding the various factors and their influence on contamination levels is the key to preventing
high levels of microbial contamination in dialysis therapy.

In several studies, pyrogenic reactions were demonstrated to have been caused by lipopolysaccharide or
endotoxin associated with gram-negative bacteria. 794 ·'0o--803 Early studies demonstmted that parenteral
exposure to endotoxin at a concentration of I nglkg body weight/hom was the tlu·eshold dose for
producin,ll ~6;rogenic reactions in humans, and that the relative potencies of endotoxin differ by bacterial
species.' · 5 Gram-negative water bacteria (e.g., Pseudomonas spp.) have been shown to multiply
rapidly in a variety of hospital-associated fluids that can be used as supply water for hemodialysis (e.g.,
distilled water, deionized water, RO water, and softened water) and in dialysate (a balanced salt solution
made with this water). 806 Several studies have demonstrated that the attack: rates of pyrogenic reactions
are directly associated with the munber of bacteria in dialysate. 666• 667• 807 TI1ese studies provided the
rationale for setting the heterotrophic bacteria standards in the first AAMI hemodialysis guideline at
::;2,000 CFU/mL in dialysate and one log lower (;::200 CFU/mL) for the water used to prepare
dialysate. 668• 788 If the level of bacterial contamination exceeded 200 CFU/mL in water, this level could
be amplified in the system and effectively constitute a high inoculum for dialysate at the stmt of a
                                                                                                          61

                      808
dialysis treatment.'"·      Pyrogenic reactions did not appear to occur when the level of contamination
was below 2,000 CFU/mL in dialysate unless the source of the endotoxin was exogenous to the dialysis
system (i.e., present in the community water supply). Endotoxins in a community water supply have
been linked to the development of pyrogenic reactions among dialysis patients. 794

Whether endotoxin actually crosses the dialyzer membrane is controversial. Several investigators have
shown that bacteria growing in dialysate-generated products that could cross the dialyzer membrane. 809'
810
      Gram-negative bacteria growing in dialysate have produced endotoxins that in turn stimulated the
production of anti-endotoxin antibodies in hemodialysis patients; 801 • 811 these data suggest that bacterial
en do toxins, although large molecules, cross dialyzer membranes either intact or as fragments. The use
of the very permeable membranes known as high-flux membranes (which allow large molecules [e.g.,
p2 microglobulin] to traverse the membrane) increases the potential for passage ofendotoxins into the
blood path. Several studies support this contention. In one such study, an increase in plasma endotoxin
concentrations during dialysis was observed when patients were dialyzed against dialysate containing
 I 03-1 04 CFU/mL Pseudomonas spp. 812 In vitro studies using both radio labeled lipopolysaccharide and
biologic assays have demonstrated that biologically active substances derived from bacteda found in
dialysate can cross a variety of dialyzer membranes.'"· 81 ,_816 Patients treated with high-flux
membranes have had higher levels of anti-endotoxin antibodies than subjects or patients treated with
conventional membranes. 817 Finally, since 1989, 19%--22% of dialysis centers have reported pyrogenic
       '
reactiOns   ' h b           f    .    . 818 819
            tn t e a sence o septJCemm. '

Investigations of adverse outcomes among patients using reprocessed dialyzers have demonstrated a
greater risk for developing pyrogenic reactions when the water used to reprocess these devices
contained >6 ng/mL endotoxin and >I 0 4 CFU/mL bacteria. 820 In addition to the variability in
endotoxin assars, host factors also are involved in determining whether a patient will mount a response
to endotoxin. 80 Outbreak investigations of pyrogenic reactions and bacteremias associated with
hemodialyzer reuse have demonstrated that pyrogenic reactions are prevented once the endotoxin level
in the water used to reprocess the dialyzers is returned to below the AAMI standard level. 821

Reuse of dialyzers and use of bicarbonate dialysate, high-flux dialyzer membranes, or high-flux dialysis
may increase the potential for pyrogenic reactions if the water in the dialysis setting does not meet
standards. 796- 798 Although investigators have been unable to demonstrate endotoxin transfer across
dialyzer membranes, 803 • 822• 823 the preponderance of repotts now suppotts the ability of endotoxin to
transfer across at least some high-flux membranes under some operating conditions. In addition to the
acute risk of pyrogenic reactions, indirect evidence in increasingly demonstrating that chronic exposure
to low amounts of endotoxin may play a role in some of the long-term complications of hemodialysis
therapy. Patients treated with ultrafiltered dialysate for 5-6 months have demonstrated a decrease in
serum p, microglobulin concentrations and a decrease in markers of an inflammatory response. 824-
                                                                                                      826
                                                                                                          In
studies of longer duration, use of microbiologically ultrapure dialysate has been associated with a
decreased incidence of p2 microglobulin-associated amyloidosis.'"· 828

Although patient benefit likely is associated with the use of ultrapure dialysate, no consensus has been
reached regarding the potential adoption of this as standard in the United States. Debate continues
regarding the bacterial and endotoxin limits for dialysate. As advances in water treatment and
hemodialysis processes occur, effotts are underway to move improved technology from the
manufacturer out into the user community. Cost-benefit studies, however, have not been done, and
substantially increased costs to implement newer water treatment modalities are anticipated.

To reconcile AAMI documents with current International Organization for Standardization (ISO)
format, AAMI has determined that its hemodialysis standards will be discussed in the following four
installments: RD 5 for hemodialysis equipment, RD 62 for product water quality, RD 47 for dialyzer
62

reprocessing, ~nd RD 52 for di~lys~te quality. Tire Renal Dise~ses and Dialysis Committee of Ai\.MI is
expected to finalize and promulgated the dialysate standard pertinent to the user community (RD 52),
adopting by reference the bacterial and endotoxin limits in product water as cnnently outlined in the
AAMI standard that applies to systems manufacturers (RD 62). At present, the user conummity should
continue to observe water quality and dialysate standards as outlined in MMI RD 5 (Hemodialysis
Systems. 1992) and MMI RD 47 (Reuse ofHemodialyzers. 1993) 1mtil the new RD 52 standard
becomes available (Table 18)n9• 791

Table 18. Microbiologic limits for hemodialysis fluids*
                                                      Maximum total ht"h.•rotrophs                       l\tlRximum (\Udotoxin Jevtll
            Hemodlnlysls fluid
                                                            (CFU!mL)+                                            (EU/mL)§
Present standard
Product wntet,
    Used to prepare dialy.sate                                         200                                       No standntd
      Used to reprocess dialyurs                                       200                                             5
Dialysate                                                             2,000                                      No !i.hmdard
Proposed standard**
Product m1ter                                                          200                                            2
Dialysate                                                              200                                            2

*   The mi\terial in this table was compiled from refere11ces 789 and 791 (ANSIIAAMI standards RD 5.1992: and ANSIIAAMI RD 47-1993).
+ Colony tbnuing units per milhlih'r.
§ Endotoxin units per ttUIIiliter.
~   Product water presently includes water 11sed 10 prepare dial~te and water used to reproces:; dialyzers.
** Dialysate for hemodialysis, RD 52. under development, American National Standard'> Institute, Association for the Advancement of
      Medicallnstmmentation (AAMI).

The cunent AAMI stand~rd directed at systems manufacturers (RD 62 [Water Tre~tment Equipment for
Hemodialysis Applications. 2001]) now specitles that all product water used to prepare dialysate or to
reprocess dialyzers for nmltiple use should contain <2 endotoxin units per milliliter (EU/mL). 792 A
level of 2 EU/mL was chosen as the upper limit for endotoxin because this level is easily achieved with
contempormy water treatment systems using RO and/or ultrafiltration. CDC h~s ~dvocated monthly
endotoxin testing along with microbiologic assays of water, because endotoxin activity may not
conespond to the total heterotrophic plate counts. 829 Additionally, the cmTent AAl'vll st~udard RD 62
for manufacturers includes action levels for product water. Because 48 hours can elapse between the
time of sampling water for microbial contamin~tion and the time when results are received, and bec~use
bacterial proliferation can be rapid, action levels for microbial counts and endotoxin concentrations are
reported as 50 CFU/mL and 1 EUimL, respectively, in this revision of the standard. 792 These
recommendations will allow users to initiate corrective action before levels exceed the maximum levels
established by the standard.

In hemodialysis, the net movement of water is from the blood to the dialys~te, although within the
dialyzer, loc~l movement of water fi·om the dialysate to the blood tlu'Ough the phenomenon ofback-
tlltration may occur. p~rticularly in dialyzers with highly penne~ble membranes. 830 In contrast,
hemoliltration m1d hemodiallltration feature infusion of large volumes of electrolyte solution (20-70 L)
into the blood. Increasingly. this electrolyte solution is being prepared on-line from water and
concentrate. Because of the large volumes of t1uid infused. AAMI considered the necessity of setting
more stringent requirements for w~ter to be used in this application, but this organiz~tion has not yet
established these because of lack of expert consensus and insufticient experience with on-line therapies
in the United States. On-line hemofiltration and hemotliafiltration systems use sequential ultrafiltration
as the final step in the preparation of infusion t1uid. Several experts fi·om A.AMI concm that these
                                                                                                                                  63

point-of-use ultrafiltration systems should be capable of further reducing the bacteria and endotoxin
burden of solutions prepared from water meeting the requirements of the AAMI standard to a safe level
for infusion.

b. Microbial Co/llrol Strategies
The strategy for controlling massive accumulations of gram-negative water bacteria and NTh! in
dialysis systems primarily involves preventing their growth tluough proper disinfection of water-
treatment systems and hemodialysis machines. Gram-negative water bacteria, their associakd
lipopolysaccharides (bacterial endotoxins). and NTlv! ultimately come fi·om the community water
supply, and levels of these bacteria can be amplified depending on the water treatment sy,stem, dialysate
distribution system, type of dialysis machine. and method of disinfection (Table 19). 634• 94• '" Control
strategies are designed to reduce levels of microbial contamination in water and dialysis t1uid to
relatively low levels but not to completely eradicate it.

Table 19. Factors influencing microbial contnmination in bemodinlysis systems
                     Fnc:tors                                                        Commt'uts
Water supplv
Source of community water
    Gr01md water                                   Contains endotoxin and bacteria
    Smface water                                   Contnins high levels of endotoxin and bacterin
Water treatment at the dialr.sif center
None                                               Not recommended
Filtration
     Prdilter                                      Pnrticulnte filier to protect equipment: doe<> not remove lllicrool'g.auisms
     Ab.solute filter (depth or membrane tiller)   Removes bncteria, howevel', unles'> the filter is changed frequently or
                                                        disiutCcted, bacteria will accmnulate and grow through the filter; acts
                                                        a<, a '>ignificant reservoir of bacteria and endotoxin
    Activated carbon filiet·                       Removes organics and available chlorine or chJonunines; acts as a
                                                        si~mificant reservoir of bacteria and endotoxin
Water h·eqhllent device.s
Deiouizntion!iou-cxchange softener                 Both ~of!encrs and deionizers are significant n!'>ervoirs of bacteria and do
                                                        not remove endotoxin.
    Reverse osmosis (RO)                           Remows bacteria and endotoxin, but must be disinfected: op¢rntes at high
                                                       wnter pressure
    Ultraviolet light                              Kills so!ue bacteria, but thel'e is no xesidual; ultraviolet-l'esistant bacterin
                                                        cuu develop if the 1mit is not properly maintained
    Ultmfi1ter                                     Removes bacteria and endotoxin: opemtes on nonnal Hue pre<>Sure; can be
                                                       positioned distal to deionizer; must be disinfected
Water and dialysate distribution svstem
Distribution pipes
    Size                                           Oversized diameter nud length decrease tluid flow aud increase bacteTinl
                                                       t·eser\'oir fol' both treated water and centmlly·p1·epnred dialysate.
    Construction                                   Rough joint::., dead ends, mm.sed hrnnchec;, and poJyviuyl chloride (PVC)
                                                       piping: can net a;; bactl!l'ial reservoir<>.
    Elevation                                      Outlet taps should be located at the highest el~vation to pJevent loss of
                                                       disinfectant: keep t1 recirculation loop in the system; flush unused ports
                                                       routinely.
    Storage t(\uks                                 Tanks are 'mdesirable becrmse they uct as a reservoir for water bacteria; if
                                                       tnnks are present, they must be routinely scntbbed and disinfected.
Dialvsis machines
Sing:le~pass                                       DisinfeCtant should have contact with all pru1'> of the machine that are
                                                       exposed to water or dlnlysis fluid.
Recirculating: single-pass or recircnlaiing        Recirculi\ling pump'> and machine design allow for massiv-e contmnination
    (bntch)                                            levels if uot pmpet'ly disinfected; ovemight chemical gennicide
                                                       treatment is reconunended,
64

Two components of hemodialysis water distribution systems- pipes (particularly those made of
polyvinyl chloride [PVC]) and storage tanks- can serve as resel'Yoirs of microbial contamination.
Hemodialysis systems frequently use pipes that are wider and longer than are needed to handle the
required flow, which slows the fluid velocity and increases both the total fluid volume and the wetted
surface area of the system. Gram-negative bacteria in fluids remaining in pipes overnight multiply
rapidly and colonize the wet surfaces, producing bacterial populations and endotoxin quantities in
proportion to the volume and surface area. Such colonization results in formation of protective biofilm
that is difficult to remove and protects the bacteria from disinfection.'" Routine (i.e., monthly), low-
level disinfection of the pipes can help to control bacterial contamination of the distribution system.
Additional measures to protect pipes from contaminations include a) situating all outlet taps at equal
elevation and at the highest point of the system so that the disinfectant cannot drain from pipes by
gravity before adequate contact time has elapsed and b) eliminating rough joints, dead-end pipes, and
unused branches and taps that can trap fluid and serve as reservoirs of bacteria capable of continuously
inoculating the entire volume of the system. 800 Maintain a flow velocity of3-5 ft/sec.

A storage tank in the distribution system greatly increases the volume of fluid and surface area available
and can serve as a niche for water bacteria. Storage tanks are therefore not recommended for use in
dialysis systems unless they are frequently drained and adequately disinfected, including scrubbing the
                                                                                                        808
sides of the tank to remove bacterial biofilm. An ultrafilter should be used distal to the storage tank. '
833

Microbiologic sampling of dialysis fluids is recommended because gram-negative bacteria can
proliferate rapidly in water and dialysate in hemodialysis systems; high levels of these organisms place
                                                                                   668 808
patients at risk for pyrogenic reactions or health-care--associated infection. 667• •

Health-care facilities are advised to sample dialysis fluids at least monthly using standard microbiologic
assay methods for waterborne microorganisms.'"· 793 • 799• 83.,_ 836 Product water used to prepare dialysate
and to reprocess hemodialyzers for reuse on the same patient should also be tested for bacterial
endotoxin on a monthly basis. 792 • 829• 837 (See Appendix C for information about water sampling
methods for dialysis.)

Cross-contamination of dialysis machines and inadequate disinfection measures can facilitate the spread
of waterborne organisms to patients. Steps should be taken to ensure that dialysis equipment is
performing correctly and that all connectors, lines, and other components are specific for the equipment,
in good repair, and properly in place. A recent outbreak of gram-negative bacteremias among dialysis
patients was attributed to faulty valves in a drain port of the machine that allowed backflow of saline
used to flush the dialyzer before patient use. 838' 839 This backflow contaminated the drain priming
connectors, which contaminated the blood lines and exposed the patients to high concentrations of
gram-negative bacteria. Environmental infection control in dialysis settings also includes low-level
disinfection of housekeeping surfaces and spot decontamination of spills of blood (see Environmental
Services in PattI of this guideline for further information).

c. Infection-Control Issues in Peritoneal Dialysis
Peritoneal dialysis (PD), most commonly administered as continuous ambulatory peritoneal dialysis
(CAPD) and continual cycling peritoneal dialysis (CCPD), is the third most common treatment for end-
                                                                                              840
stage renal disease (ESRD) in the United States, accounting for 12% of all dialysis patients.
Peritonitis is the primary complication ofCAPD, with coagulase-negative staphylococci the most
clinically significant causative organisms. 841 Other organisms that have been found to produce
peritonitis include Staphylococcus aureus, Mycobacteriumfortuitum, M. mucogenicum,
Stenotrophomonas maltophilia, Burkholderia cepacia, Cmynebacteriumjeikeium, Candida spp., and
                                                                                                           65

other fungi. 84 2-sso Substantial morbidity is associated with peritoneal dialysis infections. Removal of
peritoneal dialysis catheters usually is required for treatment of peritonitis caused by fungi, NTM, or
other bacteria that are not cleared within the first several days of effective antimicrobial treatment.
Furthermore, recurrent episodes of peritonitis may lead to fibrosis and loss of the dialysis membrane.

Many reported episodes of peritonitis are associated with exit-site or tunneled catheter infections. Risk
factors for the development of peritonitis in PD patients include a) under dialysis, b) immune
suppression, c) prolonged antimicrobial treatment, d) patient age [more infections occur in younger
patients and older hospitalized patients], e) length of hospital stay, and f) hypoalbuminemia. 844• ' 51 • 852
Concern has been raised about infection risk associated with the use of automated cyclers in both
inpatient and outpatient settings; however, studies suggest that PD patients who use automated cyclers
have much lower infection rates. 853 One study noted that a closed-drainage system reduced the
incidence of system-related peritonitis among intermittent peritoneal dialysis (TPD) patients from 3.6 to
1.5 cases/ I 00 patient days. 854 The association of peritonitis with management of spent dialysate fluids
requires additional study. Therefore, ensuring that the tip of the waste line is not submerged beneath the
water level in a toilet or in a drain is ptudent.

7. Ice Machines and Ice
Microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main
sources of microorganisms in ice are the potable water from which it is made and a transferral of
organisms from hands (Table 20). Ice from contaminated ice machines has been associated with patient
colonization, blood stream infections, pulmonmy and gastrointestinal illnesses, and pseudoinfections. 602 '
603 683 684 854 855
   •   •   •   •    Microorganisms in ice can secondarily contaminate clinical specimens and medical
solutions that require cold temperatures for either transport or holding. 601 • 620 An outbreak of surgical-
site infections was interrupted when sterile ice was used in place of tap water ice to cool cardioplegia
solutions. 601

Table 20. Microorganisms and their sources in ice and ice machines

Sources of microorganisms                                           References

From potable water
        Legionelta spp.                                              684,685,857,858
        Nontuberculous mycobacteria (NTM)                            602, 603, 859
        Pseudomonas aeruginosa                                       859
        Burkholderia cepacia                                         859, 860
        Stenotrophomonas ma!tophilia                                 860
        Flavobacterium spp.                                          860
From fecally-contaminated water
        Nmwalk virus                                                 861-863
        Giardia Iamblia                                              864
        Cryptosporidium parvum                                       685
From hand-transfer of organisms
        Acinetobacter spp.                                           859
        Coagulasc~negative staphylococci                             859
        Salmonella enteriditis                                       865
        Cryptosporidium parvum                                       685
66

In a study comparing the microbial populations of hospital ice machines with organisms recovered from
ice samples gathered from the community, samples from 27 hospital ice machines yielded low numbers
(<10 CFU/mL) of several potentially opportunistic microorganisms, mainly gram-negative bacilli.'"
During the survey period, no health-care--associated infections were attributed to the use of ice. Ice
from community sources had higher levels of microbial contamination (75o/o-95% of 194 samples had
total heterotrophic plate counts <500 CFU/mL, with the proportion of positive cultures dependent on the
incubation temperature) and showed evidence of fecal contamination from the source water. 859 Thus,
ice machines in health-care settings are no more heavily contaminated compared with ice machines in
the community. If the source water for ice in a health-care facility is not fecally contaminated, then ice
from clean ice machines and chests should pose no increased hazard for immunocompetent patients.
Some waterborne bacteria found in ice could potentially be a risk to immunocompromised patients if
they consume ice or drink beverages with ice. For example, Burkholderia cepacia in ice could present
an infection risk for cystic fibrosis patients.'"· 860 Therefore, protecting immunosuppressed and
otherwise medically at-risk patients from exposure to tap water and ice potentially contaminated with
opportunistic pathogens is prudent. 9

No microbiologic standards for ice, ice-making machines, or ice storage equipment have been
established, although several investigators have suggested the need for such standards.'"· 866 Culturing
of ice machines is not routinely recommended, but it may be useful as part of an epidemiologic
investigation. 867- 869 Sampling might also help determine the best schedule for cleaning open ice-storage
chests. Recommendations for a regular program of maintenance and disinfection have been
published. 866-869 Health-care facilities are advised to clean ice-storage chests on a regular basis. Open
ice chests may require a more frequent cleaning schedule compared with chests that have covers.
Pmtable ice chests and containers require cleaning and low-level disinfection before the addition of ice
intended for consumption. Ice-making machines may require less frequent cleaning, but their
maintenance is important to proper performance. The manufacturer's instructions for both the proper
method of cleaning and/or maintenance should be followed. These instructions may also recommend an
EPA-registered disinfectant to ensure chemical potency, materials compatibility, and safety. In the
event that instructions and suitable EPA-registered disinfectants are not available for this process, then a
generic approach to cleaning, disinfecting, and maintaining ice machines and dispensers can be used
(Box 12).

lee and ice-making machines also may be contaminated via improper storage or handling of ice by
patients and/or staff. 68<- 686• 85 '-858• 870 Suggested steps to avoid this means of contamination include a)
minimizing or avoiding direct hand contact with ice intended for consumption, b) using a hard-surface
scoop to dispense ice, and c) installing machines that dispense ice directly into pmtable containers at the
touch of a control. 687' 869

Box 12. General steps for cleaning and maintaining ice machines, dispensers, and storage
chests*+

     1.   Disconnect unit from power supply.
     2.   Remove and discard ice from bin or storage chest.
     3,   Allow unit to warm to room temperature.
     4.   Disassemble removable parts of machine that make contact with water to make ice.
     5.   Thoroughly clean machine and parts with water and detergent.
     6.   Dry external surfaces of removable parts before reassembling.
     7.   Check for any needed repair.
     8.   Replace feeder lines, as appropriate (e.g., when damaged, old, or difficult to clean).
     9.   Ensure presence of an air space in tubing leading from water inlet into water distribution system of
            machine.
                                                                                                                                       67

(Box 12. continued)

        10. Inspeft for rodt>ut or ins<>cf iufest.ntions undt>l' th<> unit and treat, as             U('edt'd~
        11. Check door gaskets (oJ>Nl comp;ufJU('Ut modt'ls) for e-vidNtre of leakage or dripping into the .
             storagE' dt('st.
        12. Clenn the INH;tpm solution), or 4 hom~ (~0 ppm solution).
        14. Drain sodium hypoellJorite solutions and flush with fr<>slt tnp wntN".
        15. Allow an surfaces of \l:quipmt>nt to dr;r b('fOI'e t•etnruing to setvkE".

* Material in this box is adapted from reference 869.
·~   11ICst." general guidelines should be used only when.• manufacturer-.recommeuded methods nnd EPA-registereddisinf~tauts are not
        available.

8. Hydrotherapy Tanks and Pools
a. General Information
Hydrotherapy equipment (e.g., pools, whirlpools. whirlpool spas, hot tubs, and physiotheraJ?t tmtks)
traditionally has been used to treat patients with certain medical conditions (e.g .. bums."'· septic
ulcers. lesions, amputations,m orthopedic impainnents and injuries, artlu·itis,'74 and kidney
lithotripsy). 654 Wound-care medicine is increasingly moving away fi·om hydrotherapy, however, in
favor of bedside pulsed-lavage therapy using sterile solutions for cleaning and irrigation. 492 •875_. 78
Several episodes of health-care-associated infections have been linked to use of hydrotherapy
equipment (Table 21). Potential rontes of infection include incidental ingestion of the water, S]Jrays and
aerosols, and direct contact with wounds and intact skin (folliculitis). Risk factors for infection include
a) age and sex of the patient, b) underlying medic~] conditions, c) length of time spent in the
hydrotherapy water, and d) pm1als of entry.819

Table 21. Infections associated with use of hydrotherapy equipment
               Microore:anisms                                       i\I~dic-nl   conditions                          R('fe-reuct.>S
Acinetobacter bmmumii                               Sep<:.is                                                  572
Cih·obacter {l'eundii                               Cellulitis                                                880
Enterobacter cloacae                                Sepsis                                                    881
Lezionella spp.                                     Lee:ionello~is                                            882
Mycobnctet1um abscessus, Mycobncterittm
                                                    Skin ulcers nnd soft tissue intections                    621-{;23,883
 jorruitum, P,Iycoba('/erium marimtm
                                                    Sepsis. soft tissue infections, follic\Jlitis, mld
Pseudomonas aerugiuosa                                                                                        492,493.506,679,884-888
                                                     wound infection'>
Adenovi.tm, adeno-assodated vims                    Conjunctivitis                                            889

Infection control for hydrotherapy tanks, pools, or bhthing tattks presents unique challenges because
indigenous microorganisms are always present in the water during treatments. In addition, some studies
have found free living amoebae (i.e., Naegleria lomniensis), which m·e conunonly found in association
with Naegleriafow/eri, in hospital hydrotherapy pools 890 Although hydrotherapy is at times
appropliate for patients with wounds, bums. or other types of non-intact skin conditions (determined on
a case-by-case basis), this equipment should not be considered "semi-critical" in accordance with the
Spaulding classification. 891 Microbial data to evaluate the Jisk of infection to patients using
hydrotherapy pools and birthing tanks are insufficient. Nevettheless, health-care facilities should
maintain stringent cleaning and disinfection practices in accordance with the manufacturer's instmctions
68

and with relevant scientific literature until data supporting more rigorous infection-control measures
become available. Factors that should be considered in therapy decisions in this situation would include
a) availability of alternative aseptic techniques for wound management and b) a risk-benefit analysis of
using traditional hydrotherapy.

b. Hydrotherapy Tanks
Hydrotherapy tanks (e.g., whirlpools, Hubbard tanks and whirlpool bath tubs) are shallow tanks
constructed of stainless steel, plexiglass, or tile. They are closed-cycle water systems with hydrojets to
circulate, aerate, and agitate the water. The maximum water temperature range is 50°F-I 04 op (I 0°G-
400C). The wann water temperature, constant agitation and aeration, and design of the hydrotherapy
tanks provide ideal conditions for bacterial proliferation if the equipment is not properly maintained,
cleaned, and disinfected. The design of the hydrotherapy equipment should be evaluated for potential
infection-control problems that can be associated with inaccessible surfaces that can be difficult to clean
and/or remain wet in between uses (i.e., recessed drain plates with fixed grill plates). 887 Associated
equipment (e.g., parallel bars, plinths, Hoyer lifts, and wheelchairs) can also be potential reservoirs of
microorganisms, depending on the materials used in these items (i.e., porous vs. non-porous materials)
and the surfaces that may become wet during use. Patients with active skin colonizations and wound
infections can serve as sources of contamination for the equipment and the water. Contamination from
spilled tub water can extend to drains, floors, and walls:'a- 683 Health-care-associated colonization or
infection can result from exposure to endogenous sources of microorganisms (autoinoculation) or
exogenous sources (via cross-contamination from other patients previously receiving treatment in the
unit).

Although some facilities have used tub liners to minimize environmental contamination of the tanks, the
use of a tub liner does not eliminate the need for cleaning and disinfection. Draining these small pools
and tanks after each patient use, thoroughly cleaning with a detergent, and disinfecting according to
manufacturers' instructions have reduced bacterial contamination levels in the water from I 04 CFU/mL
to     small sizt>
High                         +§                     +                    +~                     +                     +                    +
Inlennediate                 +                      +                    -**                    +                     +                    +"
Low                          +                      -                     -                     +                     +                    +
* Material in this table compiled front reference-'> 2 nnd 951.
+ 1l1is class of microorganisms includes ;H;ex.ual spores but not uecess11rily cblamydospores or sexual spores.
§ The "'phls" sign indica!~ that a killing effect can be expec1ed when the normal use-concenfrntioos of chemical disinfe<::tants or pasteurization
   are properly employed; a "negative" -~ign indicates little or no killing effect.
'): Only with extended ex.posure times are high-level disinfectant d1eJnicals capable ofkilling: high numbers of bacterial spores iu laboratory
     1t'sts; they are, however, capable of sporicidal activity.
 '** Some imermediate-level disinfectants (e.g., hypochlorites) Cl'lll exhibit some sporicidal activity; other'> (e.g., alcohols and phenolics) lmve
     no demoustmble sporicidal activity.
++ Some in1ennediate-level disinfectant<>, although they are tuberculocida1, may have limited virucidal acli\'ity.

The process ofhigh-level disinfection, an appropriate standard of treatment for heat-sensitive, senti-
critical medical instnuuents (e.g .. flexible, fiberoptic endoscopes), inactivates all vegetative bacteria,
mycobaetelia, vimses, timgi, and some bactelial spores. High-level disinfection is accomplished with
powerfuL sporicidal chemicals (e.g., glutaraldehyde, peracetic acid, and hydrogen peroxide) that are not
appropriate for use on housekeeping surfaces. Tirese liquid chentical sterilantslhigh-level disinfectants
                                                                                                         73

are highly toxic. 961- 963 Use of these chemicals for applications other than those indicated in their label
instructions (i.e., as immersion chemicals for treating heat-sensitive medical instruments) is not
appropriate. 964 Intermediate-level disinfection does not necessarily kill bacterial spores, but it does
inactivate Mycobacterium tuberculosis var. bovis, which is substantially more resistant to chemical
germicides than ordinmy vegetative bacteria, fungi, and medium to small viruses (with or without lipid
envelopes). Chemical germicides with sufficient potency to achieve intermediate-level disinfection
include chlorine-containing compounds (e.g., sodium hypochlorite), alcohols, some phenolics, and some
iodophors. Low-level disinfection inactivates vegetative bacteria, fungi, enveloped viruses (e.g., human
immunodeficiency virus [HIV], and influenza viruses), and some non-enveloped viruses (e.g.,
adenoviruses). Low-level disinfectants include quaternary ammonium compounds, some phenolics, and
some iodophors. Sanitizers are agents that reduce the numbers of bacterial contaminants to safe levels
as judged by public health requirements, and are used in cleaning operations, particularly in food service
and dairy applications. Germicidal chemicals that have been approved by FDA as skin antiseptics are
not appropriate for use as environmental surface disinfectants."'

The selection and use of chemical germicides are largely matters of judgment, guided by product label
instructions, information, and regulations. Liquid sterilant chemicals and high-level disinfectants
intended for use on critical and semi-critical medical/dental devices and instruments are regulated
exclusively by the FDA as a result of recent memoranda of understanding between FDA and the EPA
that delineates agency authority for chemical germicide regulation."'· 966 Environmental surface
germicides (i.e., primarily intermediate- and low-level disinfectants) are regulated by the EPA and
labeled with EPA registration numbers. The labels and technical data or product literature of these
germicides specify indications for product use and provide claims for the range of antimicrobial activity.
The EPA requires certain pre-registration laboratory potency tests for these products to support product
label claims. EPA verifies (through laboratoty testing) manufacturers' claims to inactivate
microorganisms for selected products and organisms. Germicides labeled as "hospital disinfectant"
have passed the potency tests for activity against three representative microorganisms- Pseudomonas
aeruginosa, Staphylococcus aureus, and Salmonella cholerae suis. Low-level disinfectants are often
labeled "hospital disinfectant" without a tuberculocidal claim, because they lack the potency to
inactivate mycobacteria. Hospital disinfectants with demonstrated potency against mycobacteria (i.e.,
intermediate-level disinfectants) may list "tuberculocidal" on the label as well. Other claims (e.g.,
"fungicidal," "pseudomonicidal,'' and "virucidal") may appear on labels of environmental surface
germicides, but the designations of "tuberculocidal hospital disinfectant" and "hospital disinfectant"
correlate directly to Spaulding's assessment of intermediate-level disinfectants and low-level
  .. ~
dtStnJectan ts, respect'tve Iy. 951

A common misconception in the use of surface disinfectants in health-care settings relates to the
underlying purpose for use ofproprietmy products labeled as a "tuberculocidal" germicide. Such
products will not interrupt and prevent the transmission ofTB in health-care settings because TB is not
acquired from environmental surfaces. The tuberculocidal claim is used as a benchmark by which to
measure germicidal potency. Because mycobacteria have the highest intrinsic level of resistance among
the vegetative bacteria, viruses, and fungi, any germicide with a tuberculocidal claim on the label (i.e.,
an intermediate-level disinfectant) is considered capable of inactivating a broad spectrum of pathogens,
including much less resistant organisms such the bloodborne pathogens (e.g., hepatitis B virus [HBV],
hepatitis C virus [HCV], and HIV). It is this broad spectrum capability, rather than the product's
specific potency against mycobacteria, that is the basis for protocols and OSHA regulations indicating
the appropriateness of using tuberculocidal chemicals for surface disinfection.'"
74

2. General Cleaning Strategies for Patient-Care Areas
The number and types of microorganisms present on environmental surfaces are influenced by the
following factors: a) number of people in the environment, b) amount of activity, c) amount of moisture,
d) presence of material capable of suppotting microbial growth, e) rate at which organisms suspended in
the air are removed, and f) type of surface and orientation [i.e., horizontal or vertica1]. 968 Strategies for
cleaning and disinfecting surfaces in patient-care areas take into account a) potential for direct patient
contact, b) degree and frequency of hand contact, and c) potential contamination of the surface with
body substances or environmental sources of microorganisms (e.g., soil, dust, and water).

a. Cleaning of Medical Equipment
Ma~ufactw·ers of medical equipment should provide care and maintenance instructions specific to their
equipment. These instructions should include information about a) the equipments' compatibility with
chemical germicides, b) whether the equipment is water-resistant or can be safely immersed for
cleaning, and c) how the equipment should be decontaminated if servicing is required. 967 In the
absence of manufacturers' instructions, non-critical medical equipment (e.g., stethoscopes, blood
pressure cuffs, dialysis machines, and equipment knobs and controls) usually only require cleansing
followed by low- to intermediate-level disinfection, depending on the nature and degree of
contamination. Ethyl alcohol or isopropyl alcohol in concentrations of 60%-90% (v/v) is often used to
disinfect small surfaces (e.g., rubber stoppers of multiple-dose medication vials, and thermometers)'"·
969
    and occasionally external surfaces of equipment (e.g., stethoscopes and ventilators). However,
alcohol evaporates rapidly, which makes extended contact times difficult to achieve unless items are
immersed, a factor that precludes its practical use as a large-surface disinfectant. 951 Alcohol may cause
discoloration, swelling, hardening, and cracking of rubber and certain plastics after prolonged and
repeated use and may damage the shellac mounting of lenses in medical equipment. 970

Barrier protection of surfaces and equipment is useful, especially if these surfaces are a) touched
fi·equently by gloved hands during the delivery of patient care, b) likely to become contaminated with
body substances, or c) difficult to clean. Impervious-backed paper, aluminum foil, and plastic or fluid-
resistant covers are suitable for use as barrier protection. An example of this approach is the use of
plastic wrapping to cover the handle of the operatory light in dental-care settings. 936' 942 Coverings
should be removed and discarded while the health-care worker is still gloved. 936 ' 942 The health-care
worker, after ungloving and performing hand hygiene, must cover these surfaces with clean materials
before the next patient encounter.

b. Cleaning Housekeeping Surfaces
Housekeeping surfaces require regular cleaning and removal of soil and dust. Dry conditions favor the
persistence of gram-positive cocci (e.g., coagulase-negative Staphylococcus spp.) in dust and on
surfaces, whereas moist, soiled environments favor the growth and persistence of gram-negative
bacilli. 948• 971 • 972 Fungi are also present on dust and proliferate in moist, fibrous material.

Most, if not all, housekeeping surfaces need to be cleaned only with soap and water or a
detergent/disinfectant, depending on the nature of the surface and the type and degree of contamination.
Cleaning and disinfection schedules and methods vary according to the area of the health-care facility,
type of surface to be cleaned, and the amount and type of soil present. Disinfectant/detergent
formulations registered by EPA are used for environmental surface cleaning, but the actual physical
removal of microorganisms and soil by wiping or scrubbing is probably as important, if not more so,
than any antimicrobial effect of the cleaning agent used. 973 Therefore, cost, safety, product-surface
compatibility, and acceptability by housekeepers can be the main criteria for selecting a registered
agent. !fusing a proprietary detergent/disinfectant, the manufacturers' instructions for appropriate use
                                                                                                           75

of the product should be followed. 974 Consult the products' material safety data sheets (MSDS) to
determine appropriate precautions to prevent hazardous conditions during product application. Personal
protective equipment (PPE) used during cleaning and housekeeping procedures should be appropriate to
the task.

Housekeeping surfaces can be divided into two groups- those with minimal hand-contact (e.g., floors,
and ceilings) and those with frequent hand-contact ("high touch surfaces"). The methods, thoroughness,
and frequency of cleaning and the products used are determined by health-care facility policy.'
However, high-touch housekeeping surfaces in patient-care areas (e.g., doorknobs, bedrails, light
switches, wall areas around the toilet in the patient's room, and the edges of privacy curtains) should be
cleaned and/or disinfected more frequently than surfaces with minimal hand contact. Infection-control
practitioners typically use a risk-assessment approach to identity high-touch surfaces and then
coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff.

Horizontal surfaces with infrequent hand contact (e.g., window sills and hard-surface flooring) in
routine patient-care areas require cleaning on a regular basis, when soiling or spills occur, and when a
patient is discharged from the facility.' Regular cleaning of surfaces and decontamination, as needed, is
also advocated to protect potentially exposed workers. 967 Cleaning of walls, blinds, and window
                                                           973 975
curtains is recommended when they are visibly soiled?"· •          Disinfectant fogging is not
recommended for general infection control in routine patient-care areas.'· 976 Further,
paraformaldehyde, which was once used in this application, is no longer registered by EPA for this
purpose. Use of paraformaldehyde in these circumstances requires either registration or an exemption
issued by EPA under the Federal Insecticide, Fungicide, and Rodenticide Act (FTFRA). Infection
control, industrial hygienists, and environmental services supervisors should assess the cleaning
procedures, chemicals used, and the safety issues to determine if a temporary relocation of the patient is
needed when cleaning in the room.

Extraordinaty cleaning and decontamination of floors in health-care settings is unwarranted. Studies
have demonstrated that disinfection of floors offers no advantage over regular detergent/water cleaning
           · · 1 or no Impact
an dh as mmtma          ·       on the occurrence ofh ea lth-care-assocta         ~ t'tons. 947948977-980
                                                                         · te d'mtec          · '
Additionally, newly cleaned floors become rapidly recontaminated from airborne microorganisms and
those transferred from shoes, equipment wheels, and body substances?71 • 975• 981 Nevertheless, health-
care institutions or contracted cleaning companies may choose to use an EPA-registered
detergent/disinfectant for cleaning low-touch surfaces (e.g., floors) in patient-care areas because of the
difficulty that personnel may have in determining if a spill contains blood or body fluids (requiring a
detergent/disinfectant for clean-up) or when a multi-drug resistant organism is likely to be in the
environment. Methods for cleaning non-porous floors include wet mopping and wet vacuuming, dry
                                                                 984
dusting with electrostatic materials, and spray buffing.'"· 982-     Methods that produce minimal mists
                                                                          20 109 272
and aerosols or dispersion of dust in patient-care areas are prefetTed.'· • •

Patt of the cleaning strategy is to minimize contamination of cleaning solutions and cleaning tools.
Bucket solutions become contaminated almost immediately during cleaning, and continued use of the
                                                                                                       971 981
solution transfers increasing numbers of microorganisms to each subsequent surface to be cleaned. ' '
985
     Cleaning solutions should be replaced frequently. A variety of"bucket" methods have been devised
to address the frequency with which cleaning solutions are replaced.'"· 987 Another source of
contamination in the cleaning process is the cleaning cloth or mop head, especially ifleft soaking in
dirty cleaning solutions. 971 • 98 ,_990 Laundering of cloths and mop heads after use and allowing them to
dry before re-use can help to minimize the degree of contamination.'" A simplified approach to
cleaning involves replacing soiled cloths and mop heads with clean items each time a bucket of
detergent/disinfectant is emptied and replaced with fresh, clean solution (B. Stover, Kosair Children's
Hospital, 2000). Disposable cleaning cloths and mop heads are an alternative option, if costs permit.
76

Another reservoir for microorganisms in the cleaning process may be dilute solutions of the detergents
or disinfectants, especially if the working solution is prepared in a dirty container, stored for long
periods of time, or prepared inconectly. 547 Gram-negative bacilli (e.g., Pseudomonas spp. and Serratia
marcescens) have been detected in solutions of some disinfectants (e.g., phenolics and quaternary
ammonium compounds). 547• 991 Contemporary EPA registration regulations have helped to minimize
this problem by asking manufacturers to provide potency data to support label claims for
detergent/disinfectant properties under real- use conditions (e.g., diluting the product with tap water
instead of distilled water). Application of contaminated cleaning solutions, particularly from small-
quantity aerosol spray bottles or with equipment that might generate aerosols during operation, should
be avoided, especially in high-risk patient areas.'"· 993 Making sufficient fresh cleaning solution for
daily cleaning, discarding any remaining solution, and drying out the container will help to minimize the
degree of bacterial contamination. Containers that dispense liquid as opposed to spray-nozzle
dispensers (e.g., quart-sized dishwashing liquid bottles) can be used to apply detergent/disinfectants to
surfaces and then to cleaning cloths with minimal aerosol generation. A pre-mixed, "ready-to-use"
detergent/disinfectant solution may be used if available.

c, Cleaning Special Care Areas
Guidelines have been published regarding cleaning strategies for isolation areas and operating rooms.'· 7
The basic strategies for areas housing immunosuppressed patients include a) wet dusting horizontal
surfaces daily with cleaning cloths pre-moistened with detergent or an EPA-registered hospital
disinfectant or disinfectant wipes;94 • 98463 b) using care when wet dusting equipment and surfaces above
the patient to avoid patient contact with the detergent/disinfectant; c) avoiding the use of cleaning
equipment that produces mists or aerosols; d) equipping vacuums with HEPA filte", especially for the
exhaust, when used in any patient-care area housing immunosuppressed patients;'· 94 • 986 and e) regular
cleaning and maintenance of equipment to ensure efficient particle removal. When preparing the
cleaning cloths for wet-dusting, freshly prepared solutions of detergents or disinfectants should be used
rather than cloths that have soaked in such solutions for long periods of time. Dispersal of
microorganisms in the air from dust or aerosols is more problematic in these settings than elsewhere in
health-care facilities. Vacuum cleaners can serve as dust disseminators if they are not operating
properly. 994 Doors to immunosuppressed patients' rooms should be closed when nearby areas are being
vacuumed.' Bacterial and fungal contamination of filters in cleaning equipment is inevitable, and these
filters should be cleaned regularly or replaced as per equipment manufacturer instructions.

Mats with tacky surfaces placed in operating rooms and other patient-care areas only slightly minimize
the overall degree of contamination of floors and have little impact on the incidence rate of health-care-
associated infection in general. 351 • 971 • 983 An exception, however, is the use of tacky mats inside the
entry ways of cordoned-off construction areas inside the health-care facility; these mats help to
minimize the intrusion of dust into patient-care areas.

Special precautions for cleaning incubators, mattresses, and other nursery surfaces have been
recommended to address reports of hyperbilirubinemia in newborns linked to inadequately diluted
solutions of phenolics and poor ventilation.'',__,, These medical conditions have not, however, been
associated with the use of properly prepared solutions of phenolics. Non-porous housekeeping surfaces
in neonatal units can be disinfected with properly diluted or pre-mixed phenolics, followed by rinsing
with clean water. 997 However, phenolics are not recommended for cleaning infant bassinets and
incubators dming the stay of the infant. Infants who remain in the nursery for an extended period
should be moved periodically to freshly cleaned and disinfected bassinets and incubators.'" If
phenolics are used for cleaning bassinets and incubators after they have been vacated, the surfaces
should be rinsed thoroughly with water and dl'ied before either piece of equipment is reused. Cleaning
                                                                                                           77

and disinfecting protocols should allow for the full contact time specified for the product used. Bassinet
mattresses should be replaced, however, if the mattress cover surface is broken. 997

3. Cleaning Strategies for Spills of Blood and Body Substances
Neither HBV, HCV, nor HIV has ever been transmitted from a housekeeping surface (i.e., floors, walls,
or countertops). Nonetheless, prompt removal and surface disinfection of an area contaminated by
either blood or body substances are sound infection-control practices and OSHA requirements. 967

Studies have demonstrated that HIV is inactivated rapidly after being exposed to commonly used
chemical germicides at concentrations that are much lower than those used in practice. 99,_ 1003 HBV is
readily inactivated with a variety of germicides, including quaternary ammonium compounds. 1004
                                                                                                      1005
Embalming fluids (e.g., formaldehyde) are also capable of completely inactivating HIV and HBV. ·
1006 OSHA has revised its regulation for disinfecting spills of blood or other potentially infectious
material to include proprieta1y products whose label includes inactivation claims for HBV and HIV,
provided that such surfaces have not become contaminated with agent(s) or volumes of or
                                                                                     1007
concentrations of agent(s) for which a higher level of disinfection is recommended.       These
registered products are listed in EPA's List D- Registered Antimicrobials Effective Against Hepatitis B
Virus and Human HIV-1, which may include products tested against duck hepatitis B virus (DHBV) as a
surrogate for HBV. 1008· 1009 Additional lists of interest include EPA's List C-Registered Antimicrobials
Effective Against Human HIV-1 and EPA's List E- Registered Antimicrobials Effective Against
Mycobacterium spp., Hepatitis B Virus, and Human HIV-1.
                                                                                                    1010
Sodium hypochlorite solutions are inexpensive and effective broad-spectrum germicidal solutions. '
1011 Generic sources of sodium hypochlorite include household chlorine bleach or reagent grade
chemical. Concentrations of sodium hypochlorite solutions with a range of5,000--6,150 ppm (I :10 v/v
dilution of household bleaches marketed in the United States) to 500--615 ppm (1:100 v/v dilution) fi·ee
chlorine are effective depending on the amount of organic material (e.g., blood, mucus, and urine)
present on the surface to be cleaned and disinfected. 1010' 1011 EPA-registered chemical germicides may
be more compatible with certain materials that could be corroded by repeated exposut'e to sodium
hypochlorite, especially the 1:10 dilution. Appropriate personal protective equipment (e.g., gloves and
goggles) should be worn when preparing and using hypochlorite solutions or other chemical
      ' 'd es. 967
germtcl

Despite laboratory evidence demonstrating adequate potency against bloodborne pathogens (e.g., HIV
and HBV), many chlorine bleach products available in grocery and chemical-supply stores are not
registered by the EPA for use as surface disinfectants. Use of these chlorine products as surface
disinfectants is considered by the EPA to be an "unregistered use." EPA encourages the use of
registered products because the agency reviews them for safety and performance when the product is
used according to label instructions. When unregistered products are used for surface disinfection, users
do so at their own risk.

Strategies for decontaminating spills of blood and other body fluids differ based on the setting in which
they occur and the volume of the spill. 1010 In patient-care areas, workers can manage small spills with
cleaning and then disinfecting using an intermediate-level germicide or an EPA-registered germicide
from the EPA List D or E. 967• 1007 For spills containing large amounts of blood or other body
substances, workers should first remove visible organic matter with absorbent material (e.g., disposable
paper towels discarded into leak-proof, properly labeled containment) and then clean and decontaminate
the area. 1002· 1003· 1012 If the surface is nonporous and a generic form of a sodium hypochlorite solution is
used (e.g., household bleach), a 1:100 dilution is appropriate for decontamination assuming that a) the
78

worker assigned to clean the spill is wearing gloves and other personal protective equipment appropriate
to the task, b) most of the organic matter of the spill has been removed with absorbent material, and c)
the surface has been cleaned to remove residual organic matter. A recent study demonstrated that even
strong chlorine solutions (i.e., I: I 0 dilution of chlorine bleach) may fail to totally inactivate high titers
of virus in large quantities of blood, but in the absence of blood these disinfectants can achieve complete
                    1011
viral inactivation.      This evidence supports the need to remove most organic matter from a large spill
before final disinfection of the surface. Additionally, EPA-registered proprietary disinfectant label
claims are based on use on a pre-cleaned surface. 951 · 954

Managing spills of blood, body fluids, or other infectious materials in clinical, public health, and
research laboratories requires more stringent measures because of a) the higher potential risk of disease
transmission associated with large volumes of blood and body fluids and b) high numbers of
microorganisms associated with diagnostic cultures. The use of an intermediate-level gennicide for
routine decontamination in the laboratory is prudent. 954 Recommended practices for managing large
spills of concentrated infectious agents in the laboratory include a) confining the contaminated area, b)
flooding the area with a liquid chemical germicide before cleaning, and c) decontaminating with fresh
germicidal chemical of at least inte1mediate-level disinfectant potency. 1010 A suggested technique when
flooding the spill with germicide is to lay absorbent material down on the spill and apply sufficient
germicide to thoroughly wet both the spill and the absorbent material. 1013 !fusing a solution of
household chlorine bleach, a I: I 0 dilution is recommended for this purpose. EPA-registered germicides
should be used according to the manufacturers' instmctions for use dilution and contact time. Gloves
should be worn during the cleaning and decontamination procedures in both clinical and laboratory
settings. PPE in such a situation may include the use of respiratory protection (e.g., an N95 respirator)
if clean-up procedures are expected to generate infectious aerosols. Protocols for cleaning spills should
be developed and made available on record as pmt of good laboratory practice. 1013 Workers in
laboratories and in patient-care areas of the facility should receive periodic training in environmental-
surface infection-control strategies and procedures as pmt of an overall infection-control and safety
curriculum.

4. Carpeting and Cloth Furnishings
a. Carpeting
Carpeting has been used for more than 30 years in both public and patient-care areas of health-care
facilities. Advantages of carpeting in patient-care areas include a) its noise-limiting characteristics; b)
the "humanizing" effect on health care; and c) its contribution to reductions in falls and resultant
injuries, pmticularly for the elderly. 101 4- 1016 Compared to hard-surface flooring, however, carpeting is
harder to keep clean, especially after spills of blood and body substances. It is also harder to push
equipment with wheels (e.g., wheelchairs, carts, and gurneys) on carpeting.

Several studies have documented the presence of diverse microbial populations, primarily bacteria and
fungi, in carpeting; 111 · 1017- 1024 the variety and number of microorganisms tend to stabilize over time.
                                                                                                              1019
New carpeting quickly becomes colonized, with bacterial growth plateauing after about 4 weeks.
Vacuuming and cleaning the carpeting can temporarily reduce the numbers of bacteria, but these
        .
popu Iattons soon re b oun d an d return to pre-cIeanmg   . leve Is. 1019' 1020· 102' B actena
                                                                                             . I contamma
                                                                                                       . t•wn t en ds
to increase with higher levels ofactivity. ,_ ·  101 1020 1025 Soiled carpeting that is or remains damp or wet
                                                                                                                1026
provides an ideal setting for the proliferation and persistence of gram-negative bacteria and fungi.
Carpeting that remains damp should be removed, ideally within 72 hours.

Despite the evidence of bacterial growth and persistence in carpeting, only limited epidemiologic
evidence demonstrates that carpets influence health-care-associated infection rates in areas housing
                                                                                                                 79

.unmunocompeten t paten t' ts. 10''                                        ~
                                 - · Jo25 · 1027 Th'ts gm'd e I'tne, th ere1ore, . Iudes no recommen dat10ns
                                                                                 me                     .       .
                                                                                                             agatnst
the use of carpeting in these areas. Nonetheless, avoiding the use of carpeting is prudent in areas where
spills are likely to occur (e.g., laboratories, areas around sinks, and janitor closets) and where patients
may be at greater risk of infection from airborne environmental pathogens (e.g., HSCT units, burn units,
ICUs, and 0Rs). 111 · 1028 An outbreak of aspergillosis in an HSCT unit was recently attl'ibuted to carpet
contamination and a pmticular method of carpet cleaning. 111 A window in the unit had been opened
repeatedly during the time of a nearby building fire, which allowed fungal spore intrusion into the unit.
After the window was sealed, the carpeting was cleaned using a "bonnet buffing" machine, which
dispersed Aspergillus spores into the air. 111 Wet vacuuming was instituted, replacing the dry cleaning
method used previously; no additional cases of invasive aspergillosis were identified.

The care setting and the method of carpet cleaning are impmtant factors to consider when attempting to
minimize or prevent production of aerosols and dispersal of carpet microorganisms into the air."· 111
Both vacuuming and shampooing or wet cleaning with equipment can disperse microorganisms to the
air. 111 · 994 Vacuum cleaners should be maintained to minimize dust dispersal in general, and be
                                                                                      986
equipped with HEPA filters, especially for use in high-risk patient-care areas.'· 94•      Some
formulations of carpet-cleaning chemicals, if applied or used improperly, can be dispersed into the air as
                                                                             1029
a fine dust capable of causing respiratory irritation in patients and staff.      Cleaning equipment,
especially those that engage in wet cleaning and extraction, can become contaminated with waterborne
organisms (e.g., Pseudomonas aeruginosa) and serve as a reservoir for these organisms if this
equipment is not properly maintained. Substantial numbers of bacteria can then be transferred to
caJ'Peting during the cleaning process. 1030 Therefore, keeping the carpet cleaning equipment in good
repair and allowing such equipment to dry between uses is prudent.

Carpet cleaning should be performed on a regular basis determined by internal policy. Although spills
of blood and body substances on non-porous surfaces require prompt spot cleaning using standard
cleaning procedures and application of chemical germicides(" similar decontamination approaches to
                                                                                                     1031
blood and body substance spills on carpeting can be problematic from a regulatory perspective.
Most, if not all, modern carpet brands suitable for public facilities can tolerate the activity of a variety of
liquid chemical germicides. However, according to OSHA, carpeting contaminated with blood or other
potentially infectious materials can not be fully decontaminated. 1032 Therefore, facilities electing to use
carpeting for high-activity patient-care areas may choose carpet tiles in areas at high risk for spills.'"·
1032 In the event of contamination with blood or other body substances, carpet tiles can be removed,
discarded, and replaced. OSHA also acknowledges that only minimal direct skin contact occurs with
carpeting, and therefore, employers are expected to make reasonable efforts to clean and sanitize
carpeting using carpet detergent/cleaner products. 1032

Over the last few years, some carpet manufacturers have treated their products with fungicidal and/or
bacte1·icidal chemicals. Although these chemicals may help to reduce the overall numbers of bacteria or
fungi present in carpet, their use does not preclude the routine care and maintenance of the carpeting.
Limited evidence suggests that chemically treated carpet may have helped to keep health-care--
associated aspergillosis rates low in one HSCT unit, 111 but overall, treated carpeting has not been shown
to prevent the incidence of health-care--associated infections in care areas for immunocompetent
patients.

b. Cloth Furnishings
Upholstered furniture and furnishings are becoming increasingly common in patient-care areas. These
furnishings range from simple cloth chairs in patients' rooms to a complete decorating scheme that
gives the interior of the facility more the look of an elegant hotel. 1033 Even though pathogenic
microorganisms have been isolated from the surfaces of cloth chairs, no epidemiologic evidence
suggests that general patient-care areas with cloth furniture pose increased risks of health-care--
80

associated infection compared with areas that contain hard-surfaced furniture. 1034· 1035 Allergens (e.g.,
dog and cat dander) have been detected in or on cloth furniture in clinics and elsewhere in hospitals in
concentrations higher than those found on bed linens. 1034· 1035 These allergens presumably are
transferred from the clothing of visitors. Researchers have therefore suggested that cloth chairs should
be vacuumed regularly to keep the dust and allergen levels to a minimum. This recommendation,
however, has generated concerns that aerosols created from vacuuming could place
immunocompromised patients or patients with preexisting lung disease (e.g., asthma) at risk for
development of health-care-associated, environmental airborne disease. 9· 20• 109• 988 Recovering worn,
upholstered furniture (especially the seat cushion) with covers that are easily cleaned (e.g., vinyl), or
replacing the item is prndent; minimizing the use of upholstered furniture and furnishings in any patient-
care areas where immunosuppressed patients are located (e.g., HSCT units) reduces the likelihood of
disease. 9

5. Flowers and Plants in Patient-Care Areas
Fresh flowers, dried flowers, and potted plants are common items in health-care facilities. In 1974,
clinicians isolated an Erwinia sp. post mortem from a neonate diagnosed with fulminant septicemia,
meningitis, and respirato1y distress syndrome. 1038 Because Erwinia spp. are plant pathogens, plants
brought into the delive1y room were suspected to be the source of the bacteria, although the case report
did not definitively establish a direct link. Several subsequent studies evaluated the numbers and
diversity of microorganisms in the vase water of cut flowers. These studies revealed that high
concentrations of bactel"ia, ranging from I 04-1 0 10 CFU/mL, were often present, especially if the water
was changed infrequently. 515 • 702 · 1039 The major group of microorganisms in flower vase water was
gram-negattve. b actena,     . h p seud omonas aerugmosa
                          . Wit                       .    th e mast ~11·equentIy ISO
                                                                                  . Iate d orgamsm.
                                                                                                .   sis ' 702 · 1039·
1040 P. aeruginosa was also the primaty organism directly isolated from cluysanthemums and other
potted plants. 1041 · 1042 However, flowers in hospitals were not significantly mo1·e contaminated with
bacteria compared with flowers in restaurants or in the home. 702 Additionally, no differences in the
diversity and degree of antibiotic resistance of bacteria have been observed in samples isolated fi·om
hospital flowers versus those obtained from flowers elsewhere. 702

Despite the diversity and large numbers of bacteria associated with flower-vase water and potted plants,
minimal or no evidence indicates that the presence of plants in immunocompetent patient-care areas
poses an increased risk of health-care--associated infection?' In one study involving a limited number
of surgical patients, no correlation was observed between bacterial isolates from flowers in the area and
the incidence and etiology of postoperative infections among the patients. 1040 Similar conclusions were
reached in a study that examined the bacteria found in potted plants. 1042 Nonetheless, some precautions
for general patient-care settings should be implemented, including a) limiting flower and plant care to
staff with no direct patient contact, b) advising health-care staff to wear gloves when handling plants, c)
washing hands after handling plants, d) changing vase water every 2 days and discharging the water into
                                                                                                    702
a sink outside the immediate patient environment, and e) cleaning and disinfecting vases after use.

Some researchers have examined the possibility of adding a chemical germicide to vase water to control
bacterial populations. Certain chemicals (e.g., hydrogen peroxide and chlorhexidine) are well tolerated
by plants. 1040· 1043 · 1044 Use of these chemicals, however, was not evaluated in studies to assess impact on
health-care--associated infection rates. Modem florists now have a variety of products available to add
to vase water to extend the life of cut flowers and to minimize bacterial clouding of the water.

Flowers (fresh and dried) and om amen tal plants, however, may serve as a reservoir of Aspergillus spp.,
and dispersal of conidiospores into the air from this source can occur. 109 Health-care--associated
outbreaks of invasive aspergillosis reinforce the importance of maintaining an environment as fi·ee of
                                                                                                            81

Aspergillus spp. spores as possible for patients with severe, prolonged neutropenia. Potted plants, fresh-
cut flowers, and dried flower arrangements may provide a reservoir for these fungi as well as other
fungal species (e.g., Fusarium spp.). 109' 1045· 1046 Researchers in one study of bacteria and flowers
suggested that flowers and vase water should be avoided in areas providing care to medically at-risk
patients (e.g., oncology patients and transplant patients), although this study did not attempt to correlate
the observations of bacterial populations in the vase water with the incidence of health-care--associated
infections."' Another study using molecular epidemiology techniques demonstrated identical
Aspergillus terreus types among environmental and clinical specimens isolated from infected patients
with hematological malignancies. 1046 Therefore, attempts should be made to exclude flowers and plants
from areas where immunosuppressed patients are be located (e.g., HSCT units).'· 1046

6. Pest Control
Cockroaches, flies and maggots, ants, mosquitoes, spiders, mites, midges, and mice are among the
typical arthropod and vertebrate pest populations found in health-care facilities. Insects can serve as
agents for the mechanical transmission of microorganisms, or as active participants in the disease
transmission process by serving as a vector. 1047- 1049 Arthropods recovered from health-care facilities
have been shown to carry a wide variety of pathogenic microorganisms. 105<>- 1056 Studies have suggested
that the diversity of microorganisms associated with insects reflects the microbial populations p1·esent in
the indoor health-care environment; some pathogens encountered in insects from hospitals were either
absent fi·om or present to a Jesser degree in insects trapped from residential settings. 1057- 1060 Some of
the microbial populations associated with insects in hospitals have demonstrated resistance to
antibiotics. 1048, 1059, to6t-Jo6J

Insect habitats are characterized by warmth, moisture, and availability of food. 1064 Insects forage in and
feed on substrates, including but not limited to food scraps from kitchens/cafeteria, foods in vending
machines, discharges on dressings either in use or discarded, other forms of human detritis, medical
wastes, human wastes, and routine solid waste. 1057- 1061 Cockroaches, in patiicular, have been known to
feed on fixed sputum smears in laboratories. 1065 ' 1066 Both cockroaches and ants are frequently found in
the laundry, central sterile supply departments, and anywhere in the facility where water or moisture is
present (e.g., sink traps, drains and janitor closets). Ants will often find their way into sterile packs of
items as they forage in a warm, moist environment. 1057 Cockroaches and othe1· insects frequent loading
docks and other areas with direct access to the outdoors.

Although insects carry a wide variety of pathogenic microorganisms on their surfaces and in their gut,
the direct association of insects with disease transmission (apa1i from vector transmission) is limited,
especially in health-care settings; the presence of insects in itself likely does not contribute substantially
to health-care-associated disease transmission in developed countries. However, outbreaks of infection
attributed to microorganisms carried by insects may occur because of infestation coupled with breaks in
standard infection-control practices. 1063 Studies have been conducted to examine the role of houseflies
as possible vectors for shigellosis and other forms of diarrheal disease in non-health-care settings. 1046'
1067 When control measures aimed at reducing the fly population density were implemented, a
concomitant reduction in the incidence of diarrheal infections, carriage of Shigella organisms, and
mortality caused by diarrhea among infants and young children was observed.

Myiasis is defined as a parasitosis in which the larvae of any of a variety of flies use living or necrotic
tissue or body substances of the host as a nutritional source. 1068 Larvae from health-care--acquired
myiasis have been observed in nares, wounds, eyes, ears, sinuses, and the external urogenital
structures. 106 ,_ 1071 Patients with this rare condition are typically older adults with underlying medical
conditions (e.g., diabetes, chronic wounds, and alcoholism) who have a decreased capacity to ward off
82

the flies. Persons with underlying conditions who live or travel to tropical regions of the world are
                   1070 1071
especially at risk. '        Cases occur in the summer and early fall months in temperate climates when
                       1071
flies are most active.       An environmental assessment and review of the patient's history are necessary
to verity that the source of the myiasis is health-care-acquired and to identify corrective measures. 1069·
1072
      Simple prevention measures (e.g., installing screens on windows) are important in reducing the
incidence ofmyiasis. 1072

From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from
all indoor environments, including health-care facilities. 1073· 1074 Modern approaches to institutional
pest management usually focus on a) eliminating food sources, indoor habitats, and other conditions that
attract pests; b) excluding pests from the indoor environments; and c) applying pesticides as needed. 1075
Sealing windows in modern health-care facilities helps to minimize insect intrusion. When windows
need to be opened for ventilation, ensuring that screens are in good repair and closing doors to the
outside can help with pest control. Insects should be kept out of all areas of the health-care facility,
especially ORs and any area where immunosuppressed patients are located. A pest-control specialist
with appropriate credentials can provide a regular insect-control program that is tailored to the needs of
the facility and uses approved chemicals and/or physical methods. Industrial hygienists can provide
infonnation on possible adverse reactions of patients and staff to pesticides and suggest alternative
methods for pest control, as needed.

7. Special Pathogen Concerns
a. Antibiotic-Resistant Gram-Positive Cocci
Vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and S.
aureus with intermediate levels of resistance to glycopeptide antibiotics (vancomycin intermediate
resistantS. aureus [VISA] or glycopeptide intermediate resistantS. aureus [GISA]) represent crucial
and growing concerns for infection control. Although the term GISA is technically a more accurate
description of the strains isolated to date (most of which are classified as having intennediate resistance
to both vancomycin and teicoplanin), the tetm "glycopeptide" may not be recognized by many
clinicians. Thus, the label of VISA, which emphasizes a change in minimum inhibitmy concentration
(MICs) to vancomycin, is similar to that ofVRE and is more meaningful to clinicians. 1076 According to
National Nosocomial Infection Surveillance (NNIS) statistics for infections acquired among ICU
patients in the United States in 1999, 52.3% of infections resulting from S. aureus were identified as
MRSA infections, and 25.2% of enterococcal infections were attributed to VRE. These figures reflect a
37% and a 43% increase, respectively, since 1994-1998. 1077

People represent the primmy reservoir of S. aureus. 1078 Although S. aureus has been isolated from a
variety of environmental surfaces (e.g., stethoscopes, floors, charts, furniture, dty mops, and
hydrotherapy tanks), the role of environmental contamination in transmission of this organism in health
care appears to be minimal. 107,._ 1082 S. aureus contamination of surfaces and tanks within bum therapy
units, however, may be a major factor in the transmission of infection among burn patients. 1083

Colonized patients are the principal reservoir ofVRE, and patients who are immunosuppressed (e.g.,
t1·ansplant patients) or otherwise medically at-risk (e.g., ICU patients, cardio-thoracic surgical patients,
patients previously hospitalized for extended periods, and those having received multi-antimicrobial or
                                                                     108
vancomycin therapy) are at greatest risk for VRE colonization. 4- 1087 The mechanisms by which
cross-colonization take place are not well defined, although recent studies have indicated that both
MRSA and VRE may be transmitted either a) directly from patient to patient, b) indirectly by transient
carriage on the hands of health-care workers, 108 8- 1091 or c) by hand transfer of these gram-positive
      ·
organtsms   firom contammate
                          ·    d envn·onmen
                                    ·       t a1sur1aces
                                                   ,       an d patten
                                                                   · t-care eqmpmen
                                                                                 ·     t . Jo84 · 1087· 10n-1o97 In
                                                                                                                            83

one survey, hand carriage ofVRE in workers in a long-term care facility ranged from 13o/.--41 %. 1098
Many of the environmental surfaces found to be contaminated with VRE in outbreak investigations have
been those that are touched frequently by the patient or the health-care worker. 1099 Such high-touch
surfaces include bedrails, doorknobs, bed linens, gowns, overbed tables, blood pressure cuffs, computer
table, bedside tables, and various medical equipment. 22 • 1087· 1094 · 10"· 1100- 1102 Contamination of
environmental surfaces with VRE generally occurs in clinical laboratories and areas where colonized
patients are present, 1087' 1092' 1094 • 1095 ' 1103 but the potential for contamination increases when such patients
               1087
have diarrhea       or have multiple body-site colonization. 1104 Additional factors that can be important
in the dispersion of these pathogens to environmental surfaces are misuse of glove techniques by health-
care workers (especially when cleaning fecal contamination from surfaces) and patient, family, and
visitor hygiene.

Interest in the impmtance of environmental reservoirs of VRE increased when laboratory studies
demonstrated that enterococci can persist in a viable state on dry environmental surfaces for extended
                                     1099
periods oftime (7 days to 4 months) ' 1105 and multiple strains can be identified during extensive
periods of surveillance. 1104 VRE can be recovered from inoculated hands of health-care workers (with
or without gloves) for up to 60 minutes." The presence of either MRSA, VISA, or VRE on
environmental surfaces, however, does not mean that patients in the contaminated areas will become
colonized. Strict adherence to hand hygiene/handwashing and the proper use of barrier precautions help
to minimize the potential for spread of these pathogens. Published recommendations for preventing the
spread of vancomycin resistance address isolation measures, including patient cohorting and
management of patient-care items.' Direct patient-care items (e.g., blood pressure cuffs) should be
disposable whenever possible when used in contact isolation settings for patients with multiply resistant
                  1102
microorganisms.

Careful cleaning of patient rooms and medical equipment contributes substantially to the overall control
ofMRSA, VISA, or VRE transmission. The major focus of a control program for either VRE or MRSA
should be the prevention of hand transfer of these organisms. Routine cleaning and disinfection of the
housekeeping surfaces (e.g., floors and walls) and patient-care surfaces (e.g., bedrails) should be
adequate for inactivation of these organisms. Both MRSA and VRE are susceptible to several EPA-
registered low- and intermediate-level disinfectants (e.g., alcohols, sodium hypochlorite, quaternaty
ammonium compounds, phenolics, and iodophors) at recommended use dilutions for environmental
surface disinfection. 1103 · 110 "- 1109 Additionally, both VRE and vancomycin-sensitive enterococci are
               . . to macttvatton
equa II y sensttJve   .       . . by c h em tea . I germtct
                                                          . 'd es, 1106· 1107· IIo9 an d snm
                                                                                          . 'I ar o bserva t'tons I1ave been
made when comparing the germicidal resistance ofMRSA to that of either methicillin-sensitiveS.
aureus (MSSA) or VISA.ll 10 The use of stronger solutions of disinfectants for inactivation of either
VRE, MRSA, or VISA is not recommended based on the organisms' resistance to antibiotics. 111 0- 1112
VRE from clinical specimens have exhibited some measure of increased tolerance to heat inactivation in
temperature ranges <212'F (5 f!m are efficiently
trapped in the upper respiratory tract and are removed primarily by ciliary action. 1219 Particles :'05 f!m
in diameter reach the lung, but the greatest retention in the alveoli is of pmticles 1-2 f!m in
diameter. 1220- 1222

Box 13. Preliminary concerns for conducting air sampling

     • Consider the possible characteristics and conditions of the aerosol, including size range of particles,
          relative amount of inert material, concentration of microorganisms, and environmental factors.
     • Determine the type of sampling instruments, sampling time, and duration of the sampling program.
       Determine the number of samples to be taken.
       Ensure that adequate equipment and supplies are available.
       Determine the method of assay that will ensure optimal recovery of microorganisms.
       Select a laboratory that will provide proper microbiologic support.
       Ensure that samples can be refrigerated if they cannot be assayed in the laboratory promptly.

Bacteria, fungi, and particulates in air can be identified and quantified with the same methods and
equipment (Table 23). The basic methods include a) impingement in liquids, b) impaction on solid
surfaces, c) sedimentation, d) filtration, e) centrifugation, f) electrostatic precipitation, and g) the1mal
precipitation. 1218 Of these, impingement in liquids, impaction on solid surfaces, and sedimentation (on
                                                                                             289
settle plates) have been used for various air-sampling purposes in health-care settings.

Several instruments are available for smnpling airborne bacteria and fungi (Box 14). Some of the
samplers are self-contained units requiring only a power supply and the appropriate collecting medium,
but most require additional auxiliary equipment (e.g., a vacuum pump and an airflow measuring device
[i.e., a flowmeter or anemometer]). Sedimentation or depositional methods use settle plates and
                                                                                                                                     91

therefore need no special instnnuents or equipment. Selection of an instnunent for air sampling requires
a clear understanding ofthe type ofinfonuation desired and the particular detenuinations that must be
made (Box 14). Infonnationmay be needed regarding a) one particular organism or all organisms that
may be present in the air, b) the concentration of viable particles or of viable organisms, c) the change in
concentration with time, and d) the size distribution of the collected panicles. Before sampling begins,
decisions should be made regarding whether the results are to be qualitative or quantitative. Comparing
quantities of airbome microorganisms to those of outdoor air is also standard operating procedure.
Infection-control professionals, hospital epidemiologists, industrial hygienists, and laborat01y
supervisors, as pmt of a multidisciplinmy temn, should discuss the potential need for microbial air
sampling to detennine if the capacity and expettise to conduct such sampling exists within the facility
and when it is appropriate to enlist the services of an environmental microbiologist consultant.

Tnble 23. Air snmpling methods and exnmples of equipment*
                                                       Coll•quipment
                                                                                                     considN'           snmplers§
                                                         SUl'fllC('       (Limtn,)     ne(';ded+
Impingement in     Air drawn       Viabl~              Buffered             12.5         Yes       Autifoaming          C'bemical
    liquids        through a       organi.'>UlS, and   gelatin,                                    agent maybe          Coq>s. All
                   small jet and   concentration       tryptose                                    needed               Glnso;
                   directed        overtime.           saline,                                     Ambient              !Ulpinger
                   against a       Example use:        peptone,                                    temperuture          {AGI)
                   bqnid surfnce   snmpling water      nutriem                                     and humidity
                                   aerosols to         broth                                       will influence
                                   legionella spp.                                                 length of
                                                                                                   collection lime
 Impaction ou      Air drawn       Viable              Dry S\u-f.1ce,    28 (sieve)      Yes       Available as         Andersen Air
 soUd !inrfat>es   into the-       particles; Yiable   coated             30-800                   sieve                Sampler
                   sampler;        organisms (on       ~1.1rfaces, and                             nnpactors or         (sieve
                                                                           (slit)
                   pnrticle-'>     non~nntrient        agar                                        .slit impactors.     impactor);
                   deposited on    "lurfaces,                                                      Sieve                TDL.
                   a dry surface   limited to                                                      impactors can        Cassella :MJ(.
                                   organisms that                                                  be set up to         2 (slit
                                   resist d1yiug                                                   measure              impnctoH)
                                   and spores);                                                    particle size.
                                   size                                                            Slit impactors
                                   measuremt•nt,                                                   have a rotating
                                   ond                                                             .support st.1ge
                                   conce-nlr<1tion                                                 for agar plates
                                   over tillw.                                                     to allow for-
                                   E.xample use:                                                   IUC.1Sltrement
                                   sampling air for-                                               of
                                   Aspergillus                                                     concentration
                                   spp., fungal                                                    overtime.
                                   spores
Sedimentation      Partide'> and
                   micro-
                                   Viable
                                   particles.
                                                       Nutrient
                                                       media
                                                                             -           No        Slmple and
                                                                                                   inexpensive;
                                                                                                                        Settle plates

                   orgamsms        Example us-es:      (agors) on                                  best !>1.li~ed for
                   seitle onto     ~runpling air for   plt~tes or                                  qualitative
                   surfaces via    bacteria in the     slides                                      sampling;
                   gravity         vlcmity of and                                                  significant
                                   during a                                                        nit-borne
                                   tnedicnl                                                        fi.mgal spores
                                   procedure;                                                      are too
                                   general                                                         buoyan1 to
                                   measurements                                                    settle
                                   ofmicrobi<~l air                                                efficiently for
                                   quality.                                                        collection
                                                                                                   u~ing   this
                                                                                                   method.
92

                                                                  CollN·tion        Rate of    Auxllliary
                                            Suitable for                                                        Points to           P1·ototype
      Method              Principle                                tnE'diA 01'     colledion   equipm(lut
                                            measuring:                                                          tonstder            snmplers§
                                                                    surfnee         (L/min.)    lt(>(>()(>d+
     Filtration          Air drawn                                Paper,              1 50         Yes         Filter must be
                         tltrough a
                                            Viable
                                            parti.d<:ls; viable   cellulose,                                   agitated f1rst
                                                                                                                                         -
                         filter unit;       organisms (on         gla'f~ wool,                                 in rin.w fluid
                         particles          non-nutrient          gelatin foaru.                               to remove and
                         trapped;           S\lrfaces,            and                                          disperse
                         0.2jcmpore         limited to            membrane                                     trapped micro-
                         size               spores and            fillers                                      organisms;
                                            organisms that                                                     rime flnid i~;
                                            resist drying);                                                    assayed; n~ed
                                            concentmtion                                                       more for
                                            overtime.                                                          sampling dust
                                            Example use:                                                       and chemicals.
                                            air sampling for
                                            Asporgillus
                                            spp., fungal
                                            spores. and dust
 Centdfugntion           Aerosols           Viable                Coated glass       40-50         Yes         Calibration is     BiotestRCS
                         subjected to       particles; viable     or plastic                                   difficult and is   Plus
                         centrifugal        organisms (on         slides, and                                  doneon1yby
                         force~             non-nutrient          agar surfac~s                                the: factoty;
                         particles          surface-s,                                                         relative
                         impacted           limited to                                                         comp-arison of
                         onto a $Olid       spores and                                                         airbome
                         surface            organism'> that                                                    contamination
                                            resist drying):                                                    is its general
                                            coneentrntton                                                      use.
                                            over time..
                                            Example- me:
                                            air ~ampllng for
                                            Aspergillus
                                            spp., and
                                            fungal ~-pores
    Electrostarle        Airdrnwn
                         over an
                                            Viable
                                            particles; viable
                                                                  Solid
                                                                  collecting
                                                                                      85           Yes         High volmne
                                                                                                               sampling rat~.
                                                                                                                                         -
    predpitation
                         electro~           organism.<; (on       snrfaces                                     but equipment
                        stati-cally         non-nutrient          (glass, and                                  is complex
                        charged             surfaces.             agar)                                        and must be
                        surfa<:e;           limited to                                                         handled
                        particles           !>pores and                                                        cttrefi!lly; not
                        become              organism<.> that                                                   practical for
                        charged             resist drying);                                                    use in health-
                                            concentration                                                      cttre settings.
                                            overtime
      Thermal
    preeipitntion
                         Air drawn
                         over a
                                            Size
                                            measurements
                                                                  Glass
                                                                  coverslip,
                                                                                   0.003-0.4       Yes         Determine
                                                                                                               partide size              -
                         thennal                                  aud electron                                 by direct
                         gradient;                                micro:o;cope                                 observation;
                         particles                                grid                                         not frequently
                         repelled from                                                                         used because
                         bot surf.1.ce.~.                                                                      ofeomplex
                         setlle on                                                                             adjustments
                         col de!                                                                               and low
                         snrfaces                                                                              sampling
                                                                                                               rates.

*   Material iu dUs t11ble -is compiled from references 289. 1218, 1223. and 1224.
+ Most samplers require a flow meter or anemometer and a vacuum source as auxiliary equipment.
§ Trade names listed are fur identification purposes only <1nd are not intended as endorsements by the U.S. Public Health Servke.
                                                                                                          93

Box 14. Selecting an air sampling device*

The following factors must be considered when choosing an air sampling instrument:

         Viability and type of the organism to be sampled
         Compatibility with the selected method of analysis
         Sensitivity of particles to sampling
         Assumed concentrations and particle size
       • Whether airborne clumps must be broken (i.e., total viable organism count vs. particle count)
       • Volume of air to be sampled and length of time sampler is to be continuously operated
         Background contamination
         Ambient conditions
         Sampler collection efficiency
         Effort and skill required to operate sampler
         Availability and cost of sampler, plus back-up samplers in case of equipment malfunction
       • Availability of auxiliary equipment and utilities (e.g., vacuum pumps, electricity, and water)

*   Material in this box is compiled from reference 1218.

Liquid impinger and solid impactor samplers are the most practical for sampling bacteria, particles, and
fungal spores, because they can sample large volumes of air in relatively short periods oftime. 289 Solid
impactor units are available as either slit" or "sieve" designs. Slit impactors use a rotating disc as
                                                    11

support for the collecting surface, which allows determinations of concentration over time. Sieve
impactors commonly use stages with calibrated holes of different diameters. Some impactor-type
samplers use centrifugal force to impact particles onto agar surfaces. The interior of either device must
be made sterile to avoid inadvertent contamination from the sampler. Results obtained from either
sampling device can be expressed as organisms or pmticles per unit volume of air (CFUhn 3).

Sampling for bacteria requires special attention, because bacteria may be present as individual
organisms, as clumps, or mixed with or adhering to dust o1· covered with a protective coating of dried
organic or inorganic substances. Reports of bacterial concentrations determined by ail' sampling
therefore must indicate whether the results represent individual organisms or particles bearing multiple
cells. Certain types of samplers (e.g., liquid impingers) will completely or partially disintegrate clumps
and large particles; the sampling result will therefore reflect the total number of individual organisms
present in the air.

The task of sizing a bioaerosol is simplified through the use of sieves or slit impactors because these
samplers will separate the particles and microorganisms into size ranges as the sample is collected.
                                                                                                        1225
These samplers must, however, be calibrated first by sampling aerosols under similar use conditions.

The use of settle plates (i.e., the sedimentation or depositional method) is not recommended when
sampling air for fungal spores, because single spores can remain suspended in air indefinitely. 289 Settle
plates have been used mainly to sample for particulates and bacteria either in research studies or during
epidemiologic investigations."'· 1226- 1229 Results of sedimentation sampling are typically expressed as
numbers of viable particles or viable bacteria per unit area per the duration of sampling time (i.e.,
CFU/area/time); this method can not quantifY the volume of air sampled. Because the survival of
microorganisms during air sampling is inversely propmtional to the velocity at which the air is taken
into the sampler, 1215 one advantage of using a settle plate is its reliance on gravity to bring organisms
and particles into contact with its surface, thus enhancing the potential for optimal survival of collected
organisms. This process, however, takes several hours to complete and may be impractical for some
situations.
94

Air samplers are designed to meet differing measurement requirements. Some samplers are better
suited for one fonn of measurement than others. No one type of sampler and assay procedure can be
used to collect and enumerate I 00% of airborne organisms. The sampler and/or sampling method
chosen should, however, have an adequate sampling rate to collect a sufficient number of particles in a
reasonable time period so that a representative sample of air is obtained for biological analysis. Newer
analytical techniques for assaying air samples include PCR methods and enzyme-linked immunosorbent
assays (ELISAs).

3. Water Sampling
A detailed discussion of the principles and practices of water sampling has been published. 945 Water
sampling in health-care settings is used detect waterborne pathogens of clinical significance or to
determine the quality of finished water in a facility's distribution system. Routine testing of the water in
a health-care facility is usually not indicated, but sampling in support of outbreak investigations can
help determine appropriate infection-control measures. Water-quality assessments in dialysis settings
have been discussed in this guideline (see Water, Dialysis Water Quality and Dialysate, and Appendix
C).
Health-care facilities that conduct water sampling should have their samples assayed in a laboratory that
uses established methods arid quality-assurance protocols. Water specimens are not "static specimens"
at ambient temperature; potential changes in both numbers and types of microbial populations can occur
during transport. Consequently, water samples should be sent to the testing laboratory cold (i.e., at
approximately 39.2'F [4'C]) and testing should be done as soon as practical after collection (preferably
within 24 hours).

Because most water sampling in health-care facilities involves the testing of finished water from the
facility's distribution system, a reducing agent (i.e., sodium thiosulfate [Na2 S2 0 3]) needs to be added to
neutralize residual chlorine or other halogen in the collected sample. Ifthe water contains elevated
levels of heavy metals, then a chelating agent should be added to the specimen. The minimum volume
of water to be collected should be sufficient to complete any and all assays indicated; I00 mL is
considered a suitable minimum volume. Sterile collection equipment should always be used.

Sampling from a tap requires flushing of the water line before sample collection. If the tap is a mixing
faucet, attachments (e.g., screens and aerators) must be removed, and hot and then cold water must be
run through the tap before collecting the sample. 945 If the cleanliness of the tap is questionable,
disinfection with 500--600 ppm sodium hypochlorite (I :I 00 v/v dilution of chlorine bleach) and flushing
the tap should precede sample collection.

Microorganisms in finished or treated water often are physically damaged ("stressed") to the point that
growth is limited when assayed under standard conditions. Such situations lead to false-negative
readings and misleading assessments of water quality. Appropriate neutralization of halogens and
chelation of heavy metals are cmcial to the recovery of these organisms. The choice of recovery media
and incubation conditions wiJI also affect the assay. Incubation temperatures should be closer to the
ambient temperature of the water rather than at 98.6°F (37°C), and recovery media should be formulated
to provide appropriate concentrations of nutrients to support organisms exhibiting less than rigorous
growth. 945 High-nutrient content media (e.g., blood agar and tryptic soy agar [TSA]) may actually
inhibit the growth of these damaged organisms. Reduced nutrient media (e.g., diluted peptone and
R2A) are preferable for recovery of these organisms. 945
                                                                                                               95

Use of aerobic, heterotrophic plate counts allows both a qualitative and quantitative measurement for
water quality. If bacterial counts in water are expected to be high in number (e.g., during waterborne
outbreak investigations), assaying small quantities using pour plates or spread plates is appropriate. 945
Membrane filtration is used when low-count specimens are expected and larger sampling volumes are
required (2: I 00 mL ). The sample is filtered through the membrane, and the filter is applied directly
face-up onto the surface of the agar plate and incubated.

Unlike the testing of potable water supplies for coliforms (which uses standardized test and specimen
collection parameters and conditions), water sampling to support epidemiologic investigations of
disease outbreaks may be subjected to modifications dictated by the circumstances present in the
facility. Assay methods for waterborne pathogens may also not be standardized. Therefore, conn·ol or
comparison samples should be included in the experimental design. Any departure from a standard
method should be fully documented and should be considered when interpreting results and developing
strategies. Assay methods specific for clinically significant waterborne pathogens (e.g., Legionella spp.,
Aeromonas spp, Pseudomonas spp., and Acinetobacter spp.) are more complicated and costly compared
with both methods used to detect coli forms and other standard indicators of water quality.

4. Environmental Surface Sampling
Routine environmental-surface sampling (e.g., surveillance cultures) in health-care settings is neither
cost-effective nor warranted."'· 1225 When indicated, surface sampling should be conducted with
multidisciplinaty approval in adherence to carefully considered plans of action and policy (Box 15).

Box 15. Undertaking environmental-surface sampling*

The following factors should be considered before engaging in environmental-surface sampling:

        Background information from the literature and present activities (i.e., preliminary results from an
           epidemiologic investigation)
        Location of surfaces to be sampled
        Method of sample collection and the appropriate equipment for this tasl{
        Number of replicate samples needed and which control or comparison samples are required
        Parameters ofthe sample assay method and whether the sampling will be qualitative,
         quantitative, or both
     • An estimate of the maximum allowable microbial numbers or types on the surface(s) sampled
         (refer to the Spaulding classification for devices and surfaces)
     • Some anticipation of a corrective action plan

* The material in this box is compiled from reference 1214.

Surface sampling is used currently for research, as part of an epidemiologic investigation, or as part of a
comprehensive approach for specific quality assurance purposes. As a research tool, surface sampling
                         . a) potentia
has been use d to determme              . I envtronmenta
                                               .                   . of patI10gens,564 ' 123 0- 1232 b) survtva
                                                         1 reserv01rs                                       . I of
                              1232 1233                                                                1023
microorganisms on surfaces, •            and c) the sources of the environmental contamination.             Some
                                                                               1232
or all of these approaches can also be used during outbreak investigations.         Discussion of surface
sampling of medical devices and instruments is beyond the scope of this document and is deferred to
future guidelines on sterilization and disinfection issues.
                                                                                                  1214
Meaningful results depend on the selection of appropriate sampling and assay techniques.     The
media, reagents, and equipment required for surface sampling are available from any well-equipped
96

microbiology laboratory and laboratory supplier. For quantitative assessment of surface organisms,
non-selective, nutrient-rich agar media and broth (e.g., TSA and brain-heart infusion broth [BHI] with
or without 5% sheep or rabbit blood supplement) are used for the recove1y of aerobic bactelia. Broth
media are used with membrane-filtration teclmiques. Further sample work-up may require the use of
selective media for the isolation and enumeration of specific groups of microorganisms. Examples of
selective media are MacConkey agar (lv1AC [selects for gram-negative bacteria]), Cetrimide agar
(selects for Pseudomonas aemgiuosa), or Sabonraud dextrose- and malt extract agars and broths (select
for fungi). Qualitative detenninatiom of organisms from snrtaces require only the use of selective or
non-selective broth media.

Effective sampling of surfaces requires moisture. either already present on the surface to be sampled or
via moistened swabs, sponges, wipes, agar snrtaces, or membrane filters. 1214• 123'- 1236 Dilution fluids
and rinse fluids include various buffers or general pmpose broth media (Table 24). If disinfectant
residuals are expected on smfaces being sampled, specific neutralizer chemicals should be used in both
the growth media and the dilution or rinse fluids. Lists of the neutralizers, the target disinfectant active
ingredients, and the use concentrations have been published. 1214• 1237 Altematively. instead of adding
neutralizing chemicals to existing culture media (or if the chemical nature of the disinfectant residuals is
unknown), the use of either a) commercially available media including a variety of specific and non-
specific neutralizers orb) double-strength broth media will facilitate optimal recove1y of
microorganisms. 111e inclusion of appropriate control specimens should be included to rule out both
residual antimicrobial activity from surface disinfectants and potential toxicity caused by the presence
of neutralizer chemicals canied over into the assay system. 1214

Table 24. Examples of eluents and diluents for environmental-surface sampling* +
                            Solutions                                                       Couc~utrlltion      in water
Ringer                                                                   %strength
Peplow; water                                                            O.lo/6-LO%
Buffered peptone wotei'                                                  0.067 M phosphnte. 0,43% NaCI, 0.1% peptone
Pho.sphnte-buffered snline                                               0.02 M pho:.phatct 0.9% NnCl
Sodium chloride (NaCl)                                                   0,25%r·-0,9%
Ca lg:on Ringer§                                                         ~-4 strength
111ioo:.ulfate Ringert:!                                                 'A strength
\Vntel'                                                                      -
TI)'Piic soy bro1h (TSB)                                                     -·
Brnin-hentt infusion broth (BHI) supplemented with 0.5%                      -
   beef extract
•   Matenalm tlus tablets compiled from references 1214 and 123K
+ A stufnctnnt (e.g., polysorbate {i.e .. Tween® SO)) may be added to elt1ents and dilueuls. A concentwtion ranging from O.oto/o-0.1% is
    genffillly used, depending on the speclfic appliauion. Foruning may occ\lr dming me.
§ Thi'> soluliotl is used for dissolution of caldulU olginate swabs.
~ This .'>olution isu$ed for ueutrnlization of residual chlorine.

Several methods can be used for collecting enviromnental surface samples (Table 25). Specific step-by-
step discussions of each of the methods have been published. 1214 • 1239 For best results, all methods
should inco1porate aseptic teclmiques. sterile equipment and sterile recovery media.
                                                                                                                                                  97

Table 25. Methods of environmental-surface sampling
                 .
                       Suitable fol'
    .Method           approptillte
                                                Assay              Procf'clnl'al             Points: of               Available
                                                                                                                                     Reference~
                                              technique               notes              lntel'(H'etatiou             staudat'ds
                        suJ'face{s}
Snmplefrila-~e
Moistened            Non-absorbent         Dtlutions;            Assay multiple        Report results per        YES- food          1214, 1239-
swab/rinse           surfaces, comets,     qualitative or        measure'> ilre-as     measured areas or if      industry;          1242
                     crevice.~. devices,   quantitative          or devices wilb       assaying an object,       NO-heath
                     and ins1nm~ents       assays                separate swabs        per t1te entire sample    me
                                                                                       site

Moistened            Large artas and       Dilutions;            Vigorously nth a      Report results per        YES- food          1214, 1239-
sponge/rinse         housekeeping          qnttlitntive or       stffile sponge        uv.msured area            indu.~try;         1242
                     smfaces (e.g..        qmmtitahve            over the surface                                NO-J1ealth
                     floors or walls)      assny.s                                                               care

Moistened            Larg{l areas nnd      Dliutions;            Use a steril{l        Report results pe-r       YES- food          1214, 1239-
wipeJrinse           housekeeping          qualitative or        wipe                  measured area             indmhy;            1242
                     surfaces {e.g.,       quantitati•:e.                                                        NO-health
                     cotmtertops)          assays                                                                biologi<:al
                                                                 concentration is
                                                                 low
Contaitnnl.'ut       Interior surfaces     Dilutions;            Use membrane          Evaluate both the         \'ES ~food and     12!4
                     of containers,        qu;llitative or       filtnuion if rinse    types and number!i        industrial
                     tubes, or bottles     quantitative          volume is l<~rge      of microorgani!>m~        applications for
                                           assays                                                                containers prior
                                                                                                                  :fill
                                                                                                                 to
RODAC"               Pre~·iously           Direct assny          Overgrowth            Provide.'> direct,        NO                 1214, 1237,
                     cleaned mtd                                 occurs ifnsed on      q\lantitati\'e results;                      1239.1243,
                     snnitized flnt,                             heavily               u<>e a minimum of                            1244
                     non--absorbent                              contamitltlted         15 plates per an
                     ~;urfaces:; not                             surfaces; use         average hospital
                     suitable for                                ne\tflaliurs -in      .room
                     irregular surfaces                          the agar if
                                                                 ,~urface
                                                                 disinfectant
                                                                 retsiduals are
                                                             I   present

"* RODAC stands for "replicate organism dlrect agar contact:'

Sample/rinse methods are frequently chosen because of their versatility. However, )hese samplin5
methods are the most prone to errors caused by manipulation of the swab, gauze pad, or sponge. 12 8
Additionally.no microbiocidal or microbiostatic agents should be present in any of these items when
used for sampling. 1238 Each of the rinse methods requires effective elution of microorganisms from the
item used to sample the surface. Thorough mixing of the rinse fluids after elution (e.g .. via manual or
mechanical mixing using a vortex mixer, shaking with or without glass beads, and ultrasonic bath) will
help to remove and sus~end material from the sampling device and break up clumps of organisms for a
more accurate count. 123 In some instances, the item used to sample the surface (e.g., gauze pad and
sponge) may be immersed in the rinse fluids in a sterile bag and subjected to stomaching. 1238 This
technique, however, is suitable only for soft or absorbent items that will not puncnlfe the bag dming the
elution process.

If sampling is conducted as pmt of an epidemiologic investigation of a disease outbreak, identification
of isolates to species level is mandat01y, and characterization beyond the species level is prefened. 1214
\Vhen iute1preting the results of the sampling, the expected degree of microbial contamination
98

associated with the various categories of surfaces in the Spaulding classification must be considered.
Environmental surfaces should be visibly clean; recognized pathogens in numbers sufficient to result in
secondary transfer to other animate or inanimate surfaces should be absent fi·om the surface being
          1214
sampled.       Although the interpretation of a sample with positive microbial growth is self-evident, an
environmental surface sample, especially that obtained from housekeeping surfaces, that shows no
growth does not represent a "sterile" surface. Sensitivities of the sampling and assay methods (i.e., level
of detection) must be taken into account when no-growth samples at·e encountered. Properly collected
control samples will help rule out extraneous contamination of the surface sample.

G. Laundry and Bedding
1. General Information
Laundry in a health-care facility may include bed sheets and blankets, towels, personal clothing, patient
apparel, uniforms, scrub suits, gowns, and drapes for surgical procedures. 1245 Although contaminated
textiles and fabrics in health-care facilities can be a source of substantial numbers of pathogenic
microorganisms, reports of health-care-associated diseases linked to contaminated fabrics are so few in
number that the overall risk of disease transmission during the laundry process likely is negligible.
When the incidence of such events are evaluated in the context of the volume of items laundered in
health-care settings (estimated to be 5 billion pounds annually in the United States),' 246 existing control
measures (e.g., standard precautions) are effective in reducing the risk of disease transmission to
patients and staff. Therefore, use of current control measures should be continued to minimize the
contribution of contaminated laund1y to the incidence of health-care-associated infections. The control
measures described in this section of the guideline are based on principles of hygiene, common sense,
and consensus guidance; they pertain to Iaund1y services utilized by health-care facilities, either in-
house or contract, rather than to laund1y done in the home.

2. Epidemiology and General Aspects of Infection Control
Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances,
including blood, skin, stool, urine, vomitus, and other body tissues and fluids. When textiles are heavily
contaminated with potentially infective body substances, they can contain bacterial loads of I 06-1 08
CFU/1 00 cm 2 of fabric. 1247 Disease transmission attributed to health-care laundry has involved
contaminated fabrics that were handled inappropriately (i.e., the shaking of soiled linens). Bacteria
(Salmonella spp., Bacillus cereus), viruses (hepatitis B virus [HBV]), fungi (Microsporum canis), and
ectoparasites (scabies) presumably have been transmitted from contaminated textiles and fabrics to
workers via a) direct contact or b) aerosols of contaminated lint generated from sorting and handling
contaminated textiles. 124,._. 1252 In these events, however, investigations could not rule out the possibility
that some of these reported infections were acquired from community sources. Through a combination
of soil removal, pathogen removal, and pathogen inactivation, contaminated laundry can be rendered
hygienically clean. Hygienically clean laundty carries negligible risk to health-care workers and
patients, provided that the clean textiles, fabric, and clothing are not inadvertently contaminated before
use.

OSHA defines contaminated laundty as "laundty which has been soiled with blood or other potentially
infectious materials or may contain sharps. " 967 The purpose of the laundry pottion of the standard is to
protect the worker from exposure to potentially infectious materials during collection, handling, and
sotting of contaminated textiles through the use of personal protective equipment, proper work
practices, containment, labeling, hazard communication, and ergonomics.
                                                                                                           99

Expet1s are divided regarding the practice of transporting clothes worn at the workplace to the health-
care worker's home for laundering. Although OSHA regulations prohibit home laundering of items that
are considered personal protective apparel or equipment (e.g., laboratory coats), 967 experts disagree
about whether this regulation extends to uniforms and scrub suits that are not contaminated with blood
or other potentially infectious material. Health-care facility policies on this matter vary and may be
inconsistent with recommendations of professional organizations. 1253 • 1254 Uniforms without blood or
body substance contamination presumably do not differ appreciably from street clothes in the degree
and microbial nature of soilage. Home laundering would be expected to remove this level of soil
adequately. However, if health-care facilities require the use of uniforms, they should either make
provisions to launder them or provide information to the employee regarding infection control and
cleaning guidelines for the item based on the tasks being performed at the facility. Health-care
facilities should address the need to provide this service and should determine the frequency for
laundering these items. In a recent study examining the microbial contamination of medical students'
white coats, the students perceived the coats as "clean" as long as the garments were not visibly
contaminated with body substances, even after weating the coats for several weeks. 1255 The heaviest
bacterial load was found on the sleeves and the pockets of these garments; the organisms most
frequently isolated were Staphylococcus aureus, diphtheroids, and Acinetobacter spp. 1255 Presumably,
the sleeves of the coat may make contact with a patient and potentially serve to transfer environmentally
stable microorganisms among patients. In this study, however, surveillance was not conducted among
patients to detect new infections or colonizations. The students did, however, report that they would
likely replace their coats more frequently and regularly if clean coats were provided. 1255 Apart from
this study, which documents the presence of pathogenic bacteria on health-care facility clothing, reports
of infections attributed to either the contact with such apparel or with home laundering have been
rare. 12s6, 12s7

Laundry services for health-care facilities are provided either in-house (i.e., on-premise laundry [OPL]),
co-operatives (i.e., those entities owned and operated by a group offacilities), or by off-site commercial
laundries. In the latter, the textiles may be owned by the health-care facility, in which case the
processor is paid for laundering only. Alternatively, the textiles may be owned by the processor who is
paid for evety piece laundered on a "rental" fee. The laundty facility in a health-care setting should be
designed for efficiency in providing hygienically clean textiles, fabrics, and apparel for patients and
staff. Guidelines for laundry construction and operation for health-care facilities, including nursing
facilities, have been published. 120• 1258 The design and engineering standards for existing facilities are
                                                                                          120
those cited in the AlA edition in effect during the time of the facility's construction.      A laundry
facility is usually partitioned into two separate areas- a "dit1y" area for receiving and handling the
soiled laundry and a "clean" area for processing the washed items. 1259 To minimize the potential for
recontaminating cleaned laundty with aerosolized contaminated lint, areas receiving contaminated
textiles should be at negative air pressure relative to the clean areas. 1260- 1262 Laundry areas should have
handwashing facilities readily available to workers. Laundry workers should wear appropriate personal
protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles. 967
Laundry equipment should be used and maintained according to the manufacturer's instructions to
prevent microbial contamination of the system. 1250• 1263 Damp textiles should not be left in machines
overnight. 1250

3. Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics
The laundty process starts with the removal of used or contaminated textiles, fabrics, and/or clothing
from the areas where such contamination occurred, including but not limited to patients' rooms,
surgical/operating areas, and laboratories. Handling contaminated laundty with a minimum of agitation
100

can help prevent the generation of potentially contaminated lint aerosols in patient-care areas.' 67 · 1259
Sorting or rinsing contaminated laundry at the location where contamination occurred is prohibited by
         967
OSHA.        Contaminated textiles and fabrics are placed into bags or other appropriate containment in
this location; these bags are then secmely tied or otherwise closed to prevent leakage. 967 Single bags of
sufficient tensile strength are adequate for containing laund1y, but leak-resistant containment is needed
if the laundry is wet and capable of soaking through a cloth bag. 1264 Bags containing contaminated
laundry must be clearly identified with labels, color-coding, or other methods so that health-care
workers handle these items safely, regardless of whether the laundry is transported within the facility or
destined for transport to an off-site laundry service. 967

Typically, contaminated laund1y originating in isolation areas of the hospital is segregated and handled
with special practices; however, few, if any, cases of health-care-associated infection have been linked
                1265
to this source.      Single-blinded studies have demonstrated that laund1y from isolation areas is no
more heavily contaminated with microorganisms than laund1y from elsewhere in the hospital. 1266
Therefore, adherence to standard precautions when handling contaminated laundry in isolation areas and
minimizing agitation of the contaminated items are considered sufficient to prevent the dispersal of
potentially infectious aerosols 6

Contaminated textiles and fabrics in bags can be transpotted by ca1t or chute, 1258• 1262 Laundry chutes
require proper design, maintenance, and use, because the piston-like action of a laundry bag traveling in
the chute can propel airborne microbial contaminants throughout the facility. 1267- 1269 Laund1y chutes
should be maintained under negative air pressure to prevent the spread of microorganisms from floor to
floor. Loose, contaminated pieces of laund1y should not be tossed into chutes, and laund1y bags should
be closed or otherwise secured to prevent the contents from falling out into the chute, 1270 Health-care
facilities should determine the point in the laundry process at which textiles and fabrics should be
sorted, Sorting after washing minimizes the exposme of laund1y workers to infective material in soiled
fabrics, reduces airborne microbial contamination in the laund1y area, and helps to prevent potential
percutaneous injmies to personnel. 1271 Sorting laund1y before washing protects both the machinery and
fabrics fmm hard objects (e.g., needles, syringes, and patients' prope1ty) and reduces the potential for
recontamination of clean textiles. 1272 Sotting laund1y before washing also allows for customization of
laund1y formulas based on the mix of products in the system and types of soils encountered,
Additionally, if work flow allows, increasing the amount of segregation by specific product types will
usually yield the greatest amount of work efficiency during inspection, folding, and pack-making
operations. 1253 Protective apparel for the workers and appropriate ventilation can minimize these
exposures. 967· 125 ,. 1260 Gloves used for the task of sorting laund1y should be of sufficient thickness to
minimize sharps injuries. 967 Employee safety personnel and industrial hygienists can help to determine
the appropriate glove choice.

4. Parameters of the Laundry Process
Fabrics, textiles, and clothing used in health-care settings are disinfected during laundering and
generally rendered free of vegetative pathogens (i.e., hygienically clean), but they are not sterile. 1273
                                                                                   1274
Laundering cycles consist of flush, main wash, bleaching, rinsing, and soming.          Cleaned wet
textiles, fabrics, and clothing are then dried, pressed as needed, and prepared (e.g., folded and packaged)
for distribution back to the facility. Clean linens provided by an off-site laund1y must be packaged prior
to transport to prevent inadve1tent contamination fmm dust and dirt during loading, delivery, and
unloading, Functional packaging of laund1y can be achieved in several ways, including a) placing clean
linen in a hamper lined with a previously unused liner, which is then closed or covered; b) placing clean
linen in a properly cleaned cart and covering the cmt with disposable material or a properly cleaned
reusable textile material that can be seemed to the catt; and c) wrapping individual bundles of clean
                                                                                                        101

textiles in plastic or other suitable material and sealing or taping the bundles.

The antimicrobial action of the laundering process results from a combination of mechanical, thennal,
an d c h emtca ' tors. 1211 · lm· I"' D'l1 ut'ton an d agttatton
           . I 1ac                                       . . m   . wat er remove su bstantta
                                                                                          . I quanttttes
                                                                                                   . . of
microorganisms. Soaps and detergents function to suspend soils and also exhibit some microbiocidal
prope1ties. Hot water provides an effective means of destroying microorganisms. 1277 A temperature of
at least 160°F (7 I"C) for a minimum of 25 minutes is commonly recommended for hot-water washing.'
Water of this temperature can be provided by steam jet or separate booster heater. 120 The use of
chlorine bleach assures an extra margin of safety. 1278· 1279 A total available chlorine residual of 50-150
ppm is usually achieved during the bleach cycle. 1277 Chlorine bleach becomes activated at water
temperatures of 135°F-145°F (57.2°C-62.7°C). The last of the series of rinse cycles is the addition of a
mild acid (i.e., sour) to neutralize any alkalinity in the water supply, soap, or detergent. The rapid shift
in pH from approximately 12 to 5 is an effective means to inactivate some microorganisms. 1247
Effective removal of residual alkali from fabrics is an impmtant measure in reducing the risk for skin
reactions among patients.

Chlorine bleach is an economical, broad-spectrum chemical germicide that enhances the effectiveness
of the laundering process. Chlorine bleach is not, however, an appropriate laundry additive for all
fabrics. Traditionally, bleach was not recommended for laundering flame-retardant fabrics, linens, and
clothing because its use diminished the flame-retardant properties of the treated fabric. 1273 However,
some modern-day flame retardant fabrics can now tolerate chlorine bleach. Flame-retardant fabrics,
whether topically treated or inherently flame retardant, should be thoroughly rinsed during the rinse
cycles, because detergent residues are capable ofsuppmting combustion. Chlorine alternatives (e.g.,
activated oxygen-based laund1y detergents) provide added benefits for fabric and color safety in
addition to antimicrobial activity. Studies comparing the antimicrobial potencies of chlorine bleach and
oxygen-based bleach are needed. Oxygen-based bleach and detergents used in health-care settings
should be registered by EPA to ensure adequate disinfection oflaundry. Health-care workers should
note the cleaning instructions of textiles, fabrics, drapes, and clothing to identify special laundering
requirements and appropriate hygienic cleaning options. 1278

Although hot-water washing is an effective laund1y disinfection method, the cost can be substantial.
Laundries are typically the largest users of hot water in hospitals. They consume 50%-75% of the total
hot water, 1280 representing an average of I Oo/o-15% of the energy used by a hospital. Several studies
have demonstrated that lower water temperatures of 71 °F-77°F (22°C-25°C) can reduce microbial
contamination when the cycling of the washer, the wash detergent, and the amqunt of laund1y additive
are carefully monitored and controlled. 1247· 128 H 285 Low-temperature laundry cycles rely heavily on the
presence of chlorine- or oxygen-activated bleach to reduce the levels of microbial contamination. The
selection of hot- or cold-water laundry cycles may be dictated by state health-care facility licensing
standards or by other regulation. Regardless of whether hot or cold water is used for washing, the
temperatures reached in d1ying and especially during ironing provide additional significant
microbiocidal action. 1247 D1yer temperatures and cycle times are dictated by the materials in the
fabrics. Man-made fibers (i.e., polyester and polyester blends) require shorter times and lower
temperatures.

After washing, cleaned and dried textiles, fabrics, and clothing are pressed, folded, and packaged for
transport, distribution, and storage by methods that ensure their cleanliness until use.' State regulations
and/or accrediting standards may dictate the procedures for this activity. Clean/sterile and contaminated
textiles should be transported from the laund1y to the health-care facility in vehicles (e.g., !Iucks, vans,
and carts) that allow for separation of clean/sterile and contaminated items. Clean/sterile textiles and
contaminated textiles may be transpo1ted in the same vehicle, provided that the use of physical barriers
and/or space separation can be verified to be effective in protecting the clean/sterile items from
102

contamination. Clean, uncovered/unwrapped textiles stored in a clean location for short periods of time
(e.g., uncovered and used within a few hours) have not been demonstrated to contribute to increased
levels of health-care-acquired infection. Such textiles can be stored in convenient places for use during
the provision of care, provided that the textiles can be maintained dry and free from soil and body-
substance contamination.

In the absence of microbiologic standards for laundered textiles, no rationale exists for routine
microbiologic sampling of cleaned health-care textiles and fabrics. 1286 Sampling may be used as part of
an outbreak investigation if epidemiologic evidence suggests that textiles, fabrics, or clothing are a
suspected vehicle for disease transmission. Sampling techniques include aseptically macerating the
fabric into pieces and adding these to broth media or using contact plates (RODAC plates) for direct
                         1286
surface sampling. 1271 '      When evaluating the disinfecting properties of the laundering process
specifically, placing pieces of fabric between two membrane filters may help to minimize the
contribution of the physical removal of microorganisms.""

Washing machines and d1yers in residential-care settings are more likely to be consumer items rather
than the commercial, heavy-duty, large volume units typically found in hospitals and other institutional
health-care settings. Although all washing machines and d1yers in health-care settings must be properly
maintained for performance according to the manufacturer's instructions, questions have been raised
about the need to disinfect washers and d1yers in residential-care settings. Disinfection of the tubs and
tumblers of these machines is unnecessa1y when proper laundty procedures are followed; these
procedures involve a) the physical removal of bulk solids (e.g., feces) before the wash/dty cycle and b)
proper use of temperature, detergent, and laundry additives. Infection has not been linked to laundry
procedures in residential-care facilities, even when consumer versions of detergents and laundty
additives are used.

5. Special Laundry Situations
Some textile items (e.g., surgical drapes and reusable gowns) must be sterilized before use and therefore
require steam autoclaving after laundering.' Although the American Academy of Pediatrics in previous
guidelines recommended autoclaving for linens in neonatal intensive care units (NICUs), studies on the
microbial quality of routinely cleaned NICU linen have not identified any increased risk for infection
among the neonates receiving care. 1288 Consequently, hygienically clean linens are suitable for use in
this setting. 997 The use of sterile linens in burn therapy units remains unresolved.

Coated or laminated fabrics are often used in the manufacture of PPE. When these items become
contaminated with blood or other body substances, the manufacturer's instructions for decontamination
and cleaning take into account the compatibility of the rubber backing with the chemical germicides or
detergents used in the process. The directions for decontaminating these items should be followed as
indicated; the item should be discarded when the backing develops surface cracks.

Dry cleaning, a cleaning process that utilizes organic solvents (e.g., perchloroethylene) for soil removal,
is an alternative means of cleaning fabrics that might be damaged in conventional laundering and
detergent washing. Several studies, however, have shown that dry cleaning alone is relatively
. f~1ecttve
me       . .m re ducmg
                    . t he numb ers o f bactena. an d vtruses
                                                       .                 . t e d I'mens; 1289· 1290 mtcro
                                                              on cont aruma                          . b'Ia I
populations are significantly reduced only when d1y-cleaned articles are heat pressed. Dry cleaning
should therefore not be considered a routine option for health-care facility laundry and should be
                                                                                                              1291
reserved for those circumstances in which fabrics can not be safely cleaned with water and detergent.
                                                                                                        103

6. Surgical Gowns, Drapes, and Disposable Fabrics
An issue of recent concern involves the use of disposable (i.e., single use) versus reusable (i.e., multiple
use) surgical attire and fabrics in health-care settings. 1292 Regardless of the material used to
manufacture gowns and drapes, these items must be resistant to liquid and microbial penetration.'·"',_
1297
      Surgical gowns and drapes must be registered with FDA to demonstrate their safety and
effectiveness. Repellency and pore size of the fabric contribute to gown performance, but performance
capability can be influenced by the item's design and construction. 1298• 1299 Reinforced gowns (i.e.,
gowns with double-layered fabric) generally are more resistant to liquid strike-through. 1300 • 1301
Reinforced gowns may, however, be less comfortable. Guidelines for selection and use of barrier
materials for surgical gowns and drapes have been published. 1302 When selecting a barrier product,
                                                                                        967
repellency level and type ofbanier should be compatible for the exposure expected.           However, data
are limited regarding the association between gown or drape characteristics and risk for surgical site
infections.'· 1303 Health-care facilities must ensure optimal protection of patients and health-care
workers. Not all fabric items in health care lend themselves to single-use. Facilities exploring options
for gowns and drapes should consider the expense of disposable items and the impact on the facility's
waste-management costs once these items are discarded. Costs associated with the use of durable goods
involve the fabric or textile items; staff expenses to collect, sort, clean, and package the laundry; and
                                                                                                       1305
energy costs to operate the laundry if on-site or the costs to contract with an outside service. 1304•

7. Antimicrobial-Impregnated Articles and Consumer Items Bearing
Antimicrobial Labeling
Manufacturers are increasingly incorporating antibacterial or antimicrobial chemicals into consumer and
health-care items. Some consumer products bearing labels that indicate treatment with antimicrobial
chemicals have included pens, cutting boards, toys, household cleaners, hand lotions, cat litter, soaps,
cotton swabs, toothbrushes, and cosmetics. The "antibacterial" label on household cleaning products, in
particular, gives consumers the impression that the products perform "better" than comparable products
without this labeling, when in fact all household cleaners have antibacterial properties.

In the health-care setting, treated items may include children's pajamas, mattresses, and bed linens with
label claims of antimicrobial properties. These claims require careful evaluation to determine whether
they pertain to the use of antimicrobial chemicals as preservatives for the fabric or other components or
whether they imply a health claim. 1306• 1307 No evidence is available to suggest that use of these
products will make consumers and patients healthier or prevent disease. No data support the use of
these items as patt of a sound infection-control strategy, and therefore, the additional expense of
replacing a facility's bedding and sheets with these treated products is unwarranted.

EPA has reaffirmed its position that manufacturers who make public health claims for articles
containing antimicrobial chemicals must provide evidence to supp01t those claims as part of the
registration process. 1308 Current EPA regulations outlined in the Treated Articles Exemption of the
Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) require manufacturers to register both the
antimicrobial chemical used in or on the product and the finished product itself if a public health claim
is maintained for the item. The exemption applies to the use of antimicrobial chemicals for the purpose
of preserving the integrity of the product's raw material(s). The U.S. Federal Trade Commission (FTC)
                                                                              1309
is evaluating manufacturer advertising of products with antimicrobial claims.
104

8. Standard Mattresses, Pillows, and Air-Fluidized Beds
Standard mattresses and pillows can become contaminated with body substances during patient care if
the integrity of the covers of these items is compromised. The practice of sticking needles into the
mattress should be avoided. A mattress cover is generally a fitted, protective material, the purpose of
which is to prevent the mattress from becoming contaminated with body fluids and substances. A linen
sheet placed on the mattress is not considered a mattress cover. Patches for tears and holes in mattress
covers do not provide an impermeable surface over the mattress. Mattress covers should be replaced
when torn; the mattress should be replaced if it is visibly stained. Wet mattresses, in particular, can be a
substantial environmental source of microorganisms. Infections and colonizations caused by
Acinetobacter spp., MRSA, and Pseudomonas aeruginosa have been described, especially among burn
patients. 131 0- 1315 In these reports, the removal of wet mattresses was an effective infection-control
measure. Efforts were made to ensure that pads and covers were cleaned and disinfected between
patients using disinfectant products compatible with mattress-cover materials to ensure that these covers
remained impermeable to fluids. 131 0- 1314 Pillows and their covers should be easily cleanable, preferably
in a hot water laundty cycle. 1315 These should be laundered between patients or if contaminated with
body substances.

Air-fluidized beds are used for the care of patients immobilized for extended periods of time because of
therapy or injuty (e.g., pain, decubitus ulcers, and burns). 1316 These specialized beds consist of a base
unit filled with microsphere beads fluidized by warm, dry air flowing upward from a diffuser located at
the bottom of the unit. A porous, polyester filter sheet separates the patient from direct contact with the
beads but allows body fluids to pass through to the beads. Moist beads aggregate into clumps which
settle to the bottom where they are removed as part of routine bed maintenance.

Because the beads become contaminated with the patient's body substances, concerns have been raised
about the potential for these beds to serve as an environmental source of pathogens. Certain pathogens
(e.g., Enterococcus spp., Serratia marcescens, Staphylococcus aureus, and Streptococcusfecalis) have
been recovered either from the microsphere beads or the polyester sheet after cleaning. 1317• 1318 Reports
of cross-contamination of patients, however, are few. 1318 Nevertheless, routine maintenance and
between-patient decontamination procedures can minimize potential risks to patients. Regular removal
of bead clumps, coupled with the warm, dty air of the bed, can help to minimize bacterial growth in the
unit. 131 .,_ 1321 Beads are decontaminated between patients by high heat (ll3°F-194°F [45°C-90°C],
depending on the manufacturer's specifications) for at least I hour; this procedure is patticularly
important for the inactivation of Enterococcus spp. which are relatively resistant to heat. 1322 • 1323 The
polyester filter sheet requires regular changing and thorough cleaning and disinfection, especially
between patients. 1317' 1318• 1322• 1323

Microbial contamination of the air space in the immediate vicinity of a properly maintained air-fluidized
bed is similar to that found in air around conventional bedding, despite the air flow out of the base unit
and around the patient. 1320• 1324 • 1325 An operational air-fluidized bed can, however, interfere with proper
                                                                   1326
pressure differentials, especially in negative-pressure rooms;          the effect varies with the location of
the bed relative to the room's configuration and supply and exhaust vent locations. Use of an air-
fluidized bed in a negative-pressure room requires consultation with a facility engineer to determine
appropriate placement of the bed.
                                                                                                                                            105

H. Animals in Health-Care Facilities
1. Genenll Information
Animals in health-eme facilities traditionally have been limited to laboratories and research areas.
However, their presence in patient-care areas is now more tl·equent, both in acute-care and long:-tenn
care settings. prompting consideration for the potential transmission of zoonotic pathogens tl·om animals
to humans in these settings. Although dogs and cats may be conunorily encmmtered in health-care
settings. other animals (e.g .. fish, birds, non-human primates, rabbits, rodents, and reptiles) also can be
present as research, resident, or service animals. These animals can serve as sources of zoonotic
pathogens that could potentially infect patients and health-care workers (Table 26).u27- 1340 Animals
potentially can serve as reservoirs for antibiotic-resistant microorganisms, which can be introduced to
the health-care setting while the animal is present. VRE have been isolated from both fann animals and
pets, 1341 aud a cat in a geriatric care center was fOlmd to be colonized with MRSA. 1342

Table 26. Examples of diseases nssociatecl witll zoonotic transmission*+
           Infectious disease               Cats        Doos             Fish   Birds      Rabbits      Rtomiasi.<;                           +            +                                                                +
Cryptospotidiosls                             +
Giardiasis                                    +           +                                                                 +
T oxocariasis                                 +           +                                                                 +
Toxoplasmosis                                 +           +                                                                 +
p.,;;;;;                                      ·-·-..-. ·-      ---· ·-                                f----
Blastomycosis                                             +
Dermatophytosis                                           +                                   +                             +             +

* Material in this table is adapted from reference 1331 and used with penuission of the publisher (Lippi.ncott William'.i and Wilkins).
+· l11is table doe-s not include veclorbome disea!<>t>S.
§ Reptiles include lizards, snakes, and Miles. Rodents include ham-.krs, mice, and rats.
4jf The+ symbol indicates that the pathogen ass-ociated whlt the infection has been isolated from animals and Is considered to pose potential
     risk to humans.
106

Zoonoses can be transmitted from animals to humans either directly or indirectly via bites, scratches,
aerosols, ectoparasites, accidental ingestion, or contact with contaminated soil, food, water, or
                     1331
unpasteurized milk. ' 1332 • 134 .,_. 1345 Colonization and hand transferral of pathogens acquired from pets
in health-care workers' homes represent potential sources and modes of transmission of zoonotic
pathogens in health-care settings. An outbreak of infections caused by a yeast (Ma/assezia
pachydermatis) among newborns was traced to transfer of the yeast fi·om the hands of health-care
workers with pet dogs at home. 1346 In addition, an outbreak of ringworm in a NICU caused by
Microsporum canis was associated with a nurse and her cat, 1347 and an outbreak of Rhodococcus
(Gordona) bronchia/is sternal SS!s after coronary-artery bypass surge1y was traced to a colonized nurse
whose dogs were culture-positive for the organism. 1348 In the latter outbreak, whether the dogs were
the sole source of the organism and whether other environmental reservoirs contributed to the outbreak
are unknown. Nonetheless, limited data indicate that outbreaks of infectious disease have occurred as a
result of contact with animals in areas housing immunocompetent patients. However, the low frequency
of outbreaks may result from a) the relatively limited presence of the animals in health-care facilities
and b) the immunocompetency ofthe patients involved in the encounters. Formal scientific studies to
evaluate potential risks of transmission of zoonoses in health-care settings outside of the laboratmy are
lacking.

2. Animal-Assisted Activities, Animal-Assisted Therapy, and Resident
Animals
Animal-Assisted Activities (AAA) are those programs that enhance the patients' quality of life. These
programs allow patients to visit animals in either a common, central location in the facility or in
individual patient rooms. A group session with the animals enhances opportunities for ambulatory
                                                                                                   1351
patients and facility residents to interact with caregivers, family members, and volunteers. 1349-
Alternatively, allowing the animals access to individual rooms provides the same opportunity to non-
ambulatory patients and patients for whom privacy or dignity issues are a consideration. The decision
to allow this access to patients' rooms should be made on a case-by-case basis, with the consultation and
consent of the attending physician and nursing staff.

Animal-Assisted Therapy (AAT) is a goal-directed intervention that incorporates an animal into the
                                                           1330
treatment process provided by a credentialed therapist. • 1331 The concept for AAT arose from the
observation that some patients with pets at home recover fi·om surgical and medical procedures more
rapidly than patients without pets. 1352 • 1353 Contact with animals is considered beneficial for enhancing
wellness in certain patient populations (e.g., children, the elderly, and extended-care hospitalized
patients). 1349• 1354-1 357 However, evidence supporting this benefit is largely derived fi·om anecdotal
                                                            1357 1359
reports an d o b servatwns ·        ' I amma
                              of patient  . I.mteractmns.
                                                      '         -      G ut'deI'mes '101' establ'ts h'mg AAT
                                                                  1360
programs are available for facilities considering this option.

The incorporation of non-human primates into an AAA or AAT program is not encouraged because of
                                                                                                       1361
concerns regarding potential disease transmission from and unpredictable behavior of these animals. '
1362
      Animals participating in either AAA or AA T sessions should be in good health and up-to-date with
recommended immunizations and prophylactic medications (e.g., heartwmm prevention) as determined
by a licensed veterinarian based on local needs and recommendations. Regular re-evaluation of the
animal's health and behavior status is essential. 1360 Animals should be routinely screened for enteric
parasites and/or have evidence of a recently completed anti helminthic regimen. 1363 They should also be
ft·ee of ectoparasites (e.g., fleas and ticks) and should have no sutures, open wounds, or obvious
dermatologic lesions that could be associated with bacterial, fungal, or viral infections or parasitic
infestations. Incorporating young animals (i.e., those aged ): Lassa feY~!' vims; Mnrburg vims; monkeypox virus; So"th Americnn hemorrhagic fever
                            villiS(:S (Juuiu, Machupo, Sabia, FlexaL Ommmito); tick-bome encephalitis- complex (flavi)
         Virus('s
                            vintses (Central E\tropeaa tick-bome encephalitis, Fnr Eastern tick-borne encephalitis [Russian
                            ~>pring- and summer encephalitis, Kyasnaur Forest disease. Omsk hemonhagic fever]); variola
                            maj01· virus (srnallpox virus): and variola minor virus (ala»trim.)
      Exclusions,           Vaccine strain of Junin virus (Candid. #1)
         Bat'f('ria         Rickettsia prowaze/..."ii, R. rickettsii, Yersiuia pestis
          Fungi             Coccidioides posadasii
                            Abrin: couo!oxins: diacetm••')'scitvenol; ricin; saxitoxin; Shiga-like ribo»ome inactivating
          To:dus          I proteins; tetrodotoxin

                            The following toxin'> (in purified f(mn or iu combinntions of pme nnd impur¢ fonm) if the
                            aggt'egate amotmt under the control of n principnl investigator does not, at any time, exceed the
       Exclusions~          amount specified: 100 mg of abrin; 100 mg of conotoxins; I ,000 mg of diacetoxyscilvenol; 100
                            mg of ricin; 100 mg of saxitoxin: 100 mg of Shiga-like ribosome inactivating proteins: or 100
                            mg of tetrodotoxin
                               Select agent viral nucleic acids (synthetic or natumlly-derived, contiguous or fmgmented. in
                                  host chromosomes or iu expt'es<..ion vectors) that crm encode infectious andror replkation
   Genetic !~lemPufs,             competent fonm of any of the select agent viruses:
 t'ffombinnnt nudt>k        • Nuclei<; acids (s-ynthetic or tmhu-ally-derived) that encode for !he functional fonn(s) of any of
ndds, aud rpcombinnnt             the toxins listed in this table if the nucleic acids: a) are in a vector or host chromosome:
       organisms,                 b) can be expres'>ed in vivo or in vih·o; or c) at·e iu a vector or host dtromosomc and can be
                                  expressed iu vivo or illl'ifro;
                            • Vitmes; bacteria, fnuoi, and toxins listed in this table that have been genetically modified.
Hlglt consequence livestock pathogens and toxiuslse!ect agents (overlap agents) (42 CFR Part 7-1 §73.S mtd
[!.~DA ref(ulatlou 9 CFR Par/121)
                                Eastem equine encephalitis virus: Nipah and Hendra complex vin1ses; Rift Valley fever vims;
          Virttst's
                                Venezuelan equine encephalitis virus
                                MP·12 vuccine strain of Rif! Valley fever vims; TC·83 vaccine strain of Venezudau equine
       Exdusions~
                                encephalith virus
                                Bacillus anthmcis; Brucella abortus, B. melitensis, B. suis; Btwkhofdm·ia mollei (fonnerly
         Bnrtet·in              Pseudomonas 111(1/lei). B. pseudomallei (formerly P, pseudomallei); botulinum neurotoxin-
                              . producing species of Clostridium,' Coxiella bumeh'i; Francisella tularensis
           FuuW                 Cocchlioides immitis
                                Botulinum neurotoxins; Clostridium perfringens ~psilon toxin; Shigatoxiu; .staphylococcal
          Toxins
                                enterotoxins: T~2 toxin
                                The following toxins (in purified fonn or in combinations of pure and impw·e fonns) if the
                                aggregate- amotult under the control of a principal investigator does not, at any time, exceed the
                                amount specified: 0,5 mg of bohtlinnm neurotoxins; 100 mg of Clostridium peifNngeus epsilon
                                toxin; 100 mg of Shigatoxin; 5 mg of stnphylococcal enterotoxins; or 1,000 mg ofT-2 toxin
       Exclusions,
116

High cousequence livestock pathogens and loxlnshe!ecl agents (ow?rlap agents) (4.2 CFR .Part 73 §73.5 and
USDA reeulatlou 9 CFR Partllll (contluuedl
                                    • Select agent viral nuclei acids (:>.ynthetic or uaturally derived. contiguow; or fragmented. in
                                        host chromosomes or in expression wctors) thntC!'\11 encode infectious and/or replication
   Genetic elements,                    competent form<.. of any of the select agent vin1s¢s;
  l'l~combiuant uudeie              • Nucleic acid'> (synthetic or naturally derived) thai encode for the fnuctionnl fonu(s) of nny of
acids, and l'ecombiuant                 the toxins listed in this table if the nucleic acids: a) are in a vector or b"st chromosome;
        orgnnisms~                      b) can be expressed in vivo or iu vitro; or c) are in a vector or host chromosome and can be
                                        expressed in vivo Ol' in vin·o;
                                    • Viruses, bacterin, funei, and ioxins listed in thi~ !~ble that have been g:eneticallv modified

* Material in this table iscoutpiled from references 1412. 1413, and 1424. Reference 1424 also contaitt~ lists of select agents tbal include
    plant pathogens and pathogeru affecting livestock
+ 42 CFR 73 §§73.4 and 73 . .5 do not indude any ~lee! agent or toxin tbat is in its naturally-oc":urring enviroument. provided it has not beeu
   intentionally introduced, cultivated, collected, or otherwise extracted from it'> nan~rnl source. 1l1ese ~ctions also do not indude non-viable
   select agent organism<> or nonf\mctional toxim;. This Jist of select agt'llls is current ns of3 40 states. Ce1tain recommendations have two categmy ratings (e.g., Categories TA and TC or
Categories IB and !C), indicating the recommendation is evidence-based as well as a standard or
regulation.

B. Rating Categories
Recommendations are rated according to the following categories:

    •   Category lA. Strongly recommended for implementation and strongly supported by well-
        designed experimental, clinical, or epidemiologic studies.
    •   Category lB. Strongly recommended for implementation and suppoJted by ceJtain
        experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
    •   Category IC. Required by state or federal regulation, or representing an established association
        standard. (Note: Abbreviations for governing agencies and regulatmy citations are listed, where
        appropriate. Recommendations fi'Om regulations adopted at state levels are also noted.
        Recommendations from ATA guidelines cite the appropriate sections ofthe standard).
    •   Category II. Suggested for implementation and supported by suggestive clinical or
        epidemiologic studies, or a theoretical rationale.
    •   Unresolved Issue. No recommendation is offered. No consensus or insufficient evidence
        exists regarding efficacy.
118

C. Recommendations-Air
I.    Air-Handling Systems in Health-Care Facilities
      A.   Use AlA guidelines as minimum standards where state or local regulations are not in place
           for design and construction of ventilation systems in new or renovated health-care facilities.
           Ensure that existing structures continue to meet the specifications in effect at the time of
           construction. 120 Category IC (AlA: l.l.A, 5.4)
      B.   Monitor ventilation systems in accordance with engineers' and manufacturers'
           recommendations to ensure preventive engineering, optimal performance for removal of
                                                            18     106
           particulates, and elimination of excess moisture. • 35 ' • 120• 220• 222 • 333 • 336 Category IB, IC
            (AIA: 7.2, 7.31.0, 8.31.0, 9.3l.D, 10.31.0, 11.31.0, EPA guidance}
            I.     Ensure that heating, ventilation, air conditioning (HVAC) filters are properly installed
                   and maintained to prevent air leakages and dust overloads. 17• 18 • 106• 222 Category IB
            2.     Monitor areas with special ventilation requirements (e.g., All or PE) for ACH,
                   filtration, and pressure differentials.Z 1• 120 • 249• 250• 273-275 • 277 • 33 3-344 Category IB, IC
                    (AlA: 7.2.C7, 7.2.06)
                    a.     Develop and implement a maintenance schedule for ACH, pressure
                           differentials, and filtration efficiencies using facility-specific data as part of the
                           multidisciplinary risk assessment. Take into account the age and reliability of
                           the system.
                   b.      Document these parameters, especially the pressure differentials.
            3.     Engineer humidity controls into the HV AC system and monitor the controls to ensure
                   proper moisture removal. 120 Category IC (AlA: 7.31.09)
                   a.      Locate duct humidifiers upstream from the final filters.
                   b.      Incorporate a water-removal mechanism into the system.
                   c.      Locate all duct takeoffs sufficiently down-stream from the humidifier so that
                           moisture is completely absorbed.
            4.     IncoqJorate steam humidifiers, if possible, to reduce potential for microbial
                   proliferation within the system, and avoid use of cool mist humidifiers. Category II
            5.     Ensure that air intakes and exhaust outlets are located properly in construction of new
                   facilities and renovation of existing facilities.'· 12 ° Categmy IC (AlA: 7.31.03, 8.31.03,
                   9.31.03, 10.31.03, 11.31.03)
                   a.     Locate exhaust outlets >25 ft. from air-intake systems.
                   b.     Locate outdoor air intakes 2:6 ft. above ground or 2:3 ft. above roof! eve!.
                   c.     Locate exhaust outlets from contaminated areas above roof level to minimize
                          recirculation of exhausted air.
            6.     Maintain air intakes and inspect filters periodically to ensure proper operation.'· 120 • 249•
                   250 27 275 277
                      ' 3- ,       Category IC (AlA: 7.31.08)
            7.     Bag dust-filled filters immediately upon removal to prevent dispersion of dust and
                   fungal spores during transport within the facility. 106• 221 Category IB
                   a.     Seal or close the bag containing the discarded filter.
                   b.     Discard spent filters as regular solid waste, regardless of the area from which
                          they were removed. 221
            8.     Remove bird roosts and nests near air intakes to prevent mites and fungal spores from
                   entering the ventilation system.'· 98• 119 Category IB
            9.     Prevent dust accumulation by cleaning air-duct grilles in accordance with facility-
                   specific procedures and schedules when rooms are not occupied by patients. 21 ,. 120' 249•
                   250 27 275 277
                      • 3- ·       Category IC, II (AlA: 7.31.01 0)
                                                                                                            119

     I 0.       Periodically measure output to monitor system function; clean ventilation ducts as
                part of routine HVAC maintenance to ensure optimum performance."'· 263· 264
                Category II (AlA: 7.31 DlO)
C.   Use portable, industrial-grade HEPA filter units capable of filtration rates in the range of
                        3
     300--800 ft /min. to augment removal of respirable particles as needed. 219 Category II
      I.        Select portable HEPA filters that can recirculate all or nearly all ofthe room air and
                provide the equivalent of?:l2 ACH.' Category II
     2.         Poliable HEPA filter units previously placed in construction zones can be used later
                in patient-care areas, provided all internal and external surfaces are cleaned, and the
                filter's performance verified by appropriate particle testing. Category II
     3.         Situate portable HEPA units with the advice of facility engineers to ensure that all
                room air is filtered.' Category II
     4.         Ensure that fresh-air requirements for the area are met. 214· 219 Category II
D.   Follow appropriate procedures for use of areas with through-the-wall ventilation units. 120
     Category IC (AlA: 8.3\.Dl, 8.3\.DB, 9.31.D23, l0.31.Dl8, Il.3l.Dl5)
     I.         Do not use such a1·eas as PE rooms. 12° Category IC (AlA: 7.2.D3)
     2.         Do not use a room with a through-the-wall ventilation unit as an All room unless it
                can be demonstrated that all required All engineering controls required are met. 4• 120
                Category IC (AlA: 7.2.C3)
E.   Conduct an infection-control risk assessment (!CRA) and provide an adequate number of
     All and PE rooms (if required) or other areas to meet the needs of the patient population.'· 6•
     9, 1s, 19, 69, 94, 120, 142,331-334, 336--JJs Categmy lA, IC (AIA: ?.z.c, 7.2. 0 )
F.   When UVGI is used as a supplemental engineering control, install fixtures I) on the wall
     near the ceiling or suspended from the ceiling as an upper air unit; 2) in the air-return duct
     of an All room; or 3) in designated enclosed areas or booths for sputum induction.'
     Category//
G.   Seal windows in buildings with centralized HVAC systems and especially with PE areas."·
     111 ' 12° Category IB, IC (AlA: 7.2.D3)
H.   Keep emergency doors and exits from PE rooms closed except dming an emergency; equip
     emergency doors and exits with alarms. Categmy II
I.   Develop a contingency plan for backup capacity in the event of a general power failure. 713
     Category IC (Joint Commission on Accreditation ofHealthcare Organizations IJCAHO]: Environment of Care [ECJ
     1.4)
     I.       Emphasize restoration of proper air quality and ventilation conditions in All rooms,
              PE rooms, operating rooms, emergency depattments, and intensive care units. 120 • 713
              Categmy IC (AlA: 1.5.AI; JCAHO: Ec 1.4)
     2.       Deploy infection-control procedures to protect occupants until power and systems
              functions are restored_6· 120· 713 Category IC (AlA: 5.1, 5.2; JCAHo: EC 1.4)
J.   Do not shut down HVAC systems in patient-care areas except for maintenance, repair,
     testing of emergency backup capacity, or new construction. 120· 206 Categmy IB, IC (AlA:
     5.1, 5.2.B, C)
     I.       Coordinate HVAC system maintenance with infection-control staffto allow for
              relocation ofimmunocompromised patients ifnecessary. 12          °    Category IC (AlA: 5.1,
              5.2)
     2.       Provide backup emergency power and air-handling and pressurization systems to
              maintain filtration, constant ACH, and pressure differentials in PE rooms, All moms,
              operating rooms, and other critical-care areas!· 120· 278 Catego1y IC (AlA: 1.5, 5.1, 5.2)
     3.       For areas not served by installed emergency ventilation and backup systems, 11se
              pmiable units and monitor ventilation parameters and patients in those areas. 219
              Categmy II
     4.       Coordinate system startups with infection-control staff to protect patients in PE rooms
              from bursts of fungal spores!· 35 ' 120· 278 Category IC (AlA: 5.1, 5.2)
120

            5.     Allow sufficient time for ACH to clean the air once the system is operational
                   (Appendix B, Table B.! )_4· 12°    Category lC (AlA: 5.1, 5.2)
      K.    HVAC systems serving offices and administration areas may be shut down for energy
            conservation purposes, but the shutdown must not alter or adversely affect pressure
            differentials maintained in laboratories or critical-care areas with specific ventilation
            requirements (i.e., PE rooms, All rooms, operating rooms). Category II
      L.    Whenever possible, avoid inactivating or shutting down the entire HVAC system at one
            time, especially in acute-care facilities. Category II
      M.    Whenever feasible, design and install fixed backup ventilation systems for new or renovated
            constJUction for PE rooms, All rooms, operating rooms, and other critical care areas
            identified by ICRA. 12 °  Category IC (AlA: 1.5.A1)

II.   Construction, Renovation, Remediation, Repair, and Demolition
      A.   Establish a multidisciplinmy team that includes infection-control staff to coordinate
           demolition, construction, and renovation projects and consider proactive preventive
           measures at the inception; produce and maintain summary statements of the team's
           activities. I?, 19, zo, 97, 109, tzo. 249, zso, 273-277 Categmy IB, IC (AIA: 5.1)
      B.   Educate both the construction team and the health-care staff in immunocompromised
           patient-care areas regarding the airborne infection risks associated with construction
           projects, dispersal of fungal spores during such activities, and methods to control the
           dissemination of fungal spores. 3 · 249' 250' 273-277· 142 &- 1432 Category IB
      C.   Incorporate mandatory adherence agreements for infection control into constJUction
           contracts, with penalties for noncompliance and mechanisms to ensure timely correction of
           problems.'· 12 ~ 249• 27,_277 Category IC (AlA: 5.1)
      D.   Establish and maintain surveillance for airborne environmental disease (e.g., aspergillosis)
           as appropriate during construction, renovation, repair, and demolition activities to ensure
           the health and safety of immunocompromised patients.'· 64• 65• 79 Category IB
           I.     Using active surveillance, monitor for airborne fungal infections in
                  immunocompromised patients.'· 9• 64 • 65 Category IB
           2.     Periodically review the facility's microbiologic, histopathologic, and postmortem data
                  to identifY additional cases.'· 9• 64' 65 Category IB
           3.     If cases of aspergillosis or other health-care-associated airborne fungal infections
                  occur, aggressively pursue the diagnosis with tissue biopsies and cultures as feasible.'·
                  64, 65, 79, 249, 273-277      Category IB
      E.   Implement infection-control measures relevant to construction, renovation, maintenance,
           demolition, and repair. 96• 97 • 120• 276• 277 Category IB, IC (AlA: 5.1, 5.2)
            I.    Before the project gets underway, perform an ICRA to define the scope of the project
                  and the need for barrier measures. 96• 97• 120' 249' 27,_277      Category IB, IC (AlA: 5.1)
                  a.        Determine if immunocompromised patients may be at risk for exposure to
                                                                                                        277
                            fungal spores from dust generated during the project. 20• 109• 27,_275 •
                                                                                             20 109 27 275 277
                  b.        Develop a contingency plan to prevent such exposut·es. · • 3- ·
           2.     Implement infection-control measures for external demolition and construction
                  activities. 50• 249• 273--277· 283 Category IB
                  a.        Determine if the facility can operate temporarily on recirculated air; if feasible,
                            seal off adjacent air intakes.
                  b.        If this is not possible or practical, check the low-efficiency (roughing) filter
                            banks frequently and replace as needed to avoid buildup of pmticulates.
                  c.        Seal windows and reduce wherever possible other sources of outside air
                            intrusion (e.g., open doors in stairwells and corridors), especially in PE areas.
           3.     Avoid damaging the underground water distribution system (i.e., buried pipes) to
                  prevent soil and dust contamination of the water. 120• 305 Category IB, IC (AlA: 5.1)
                                                                                               121

4.   Implement infectionwcontrol measures for internal consttuction activities? 0· 49· 97· 120 •
     249 27 277
        • ,_       Category IB, IC (AlA: 5.1, 5.2)
     a.      Construct barriers to prevent dust from construction areas from entering
             patient-care areas; ensure that barriers are impermeable to fungal spores and in
             compliance with local fire codes. zo, 49, 97, 120, 284, 3\2,713, 1431
     b.      Block and seal off return air vents if rigid barriers are used for containment 120•
             276, 277

     c.     Implement dust control measures on surfaces and by diverting pedestrian traffic
            away from work zones. 20' 49• 97• 120
     d.     Relocate patients whose rooms are adjacent to work zones, depending upon
            their immune status, the scope ofthe project, the potential for generation of
            dust or water aerosols, and the methods used to control these aerosols. 49• 120• 281
5.   Perform those engineering and work-site related infection-control measures as needed
     for internal construction, repairs, and renovations: 20· 49• 97• 109• 120• 312 Category IB, IC
     (AlA: 5.1, 5.2)
     a.      Ensure proper operation of the air-handling system in the affected area after
             erection of barriers and before the room or area is set to negative pressure. 49• 69•
             276 278
                '     Category IB
     b.      Create and maintain negative air pressure in work zones adjacent to patient-care
             areas and ensure that required engineering controls are maintained?0• 49• 97• 109• 120•
             312

     c.      Monitor negative air flow inside rigid barriers. 120' 281
     d.      Monitor barriers and ensure the integrity of the construction barriers; repair
             gaps or breaks in barrier joints. 120 • 284 • 307' 312
     e.      Seal windows in work zones if practical; use window chutes for disposal of
             large pieces of debris as needed, but ensure that the negative pressure
             differential for the area is maintained. 20• 120• 273
     f.      Direct pedestrian traffic from construction zones away from patient-care areas
             to minimize the dispersion of dust. 20, 49, 97, 109, Ill, 120, 273--277
     g.      Provide constmction crews with I) designated entrances, corridors, and
             elevators whenever practical; 2) essential services [e.g., toilet facilities], and
             convenience services [e.g., vending machines]; 3) protective clothing [e.g.,
             coveralls, footgear, and headgear] for travel to patient-care areas; and 4) a space
             or anteroom for changing clothing and storing equipment. 120• 249• 27,_277
     h.      Clean work zones and their entrances daily by I) wet-wiping tools and tool
             ca1is before their removal from the work zone; 2) placing mats with tacky
             surfaces inside the entrance; and 3) covering debris and securing this covering
             before removing debris from the work zone. 120• 249• 273--277
     i.      In patient-care areas, for major repairs that include removal of ceiling tiles and
             disruption of the space above the false ceiling, use plastic sheets or
             prefabricated plastic units to contain dust; use a negative pressure system
             within this enclosure to remove dust; and either pass air through an industrial
             grade, pmiable HEPA filter capable of filtration rates ranging from 300-800
             fe/min., or exhaust air directly to the outside. 49· 276• 277• 281 • 309
     j.      Upon completion of the project, clean the work zone according to facility
             procedures, and install barrier curtains to contain dust and debris before
             removal of rigid barriers. 20• 97• 120• 249• 27 3--277
     k.      Flush the water system to clear sediment from pipes to minimize waterborne
             microorganism proliferation. 120· 305
     I.      Restore appmpriate ACH, humidity, and pressure differential; clean or replace
                                                          106 221
             air filters; dispose of spent filters."· • • 278
122

       F.    Use airborne-patticle sampling as a tool to evaluate barrier integrity."· 10 ° Category II
       G.    Commission the HV AC system for newly constructed health-care facilities and renovated
             spaces before occupancy and use, with emphasis on ensuring proper ventilation for
             operating rooms, All rooms, and PE areas. 100• 120• 288• 304 Category IC (AlA: 5.1: ASHRAE: 1-
             1996)
       H.    No recommendation is offered on routine microbiologic air sampling before, during, or
             after construction or before or during occupancy of areas housing immunocompromised
             patients.I7,20,49,97, 109,272,1433        Unresolved issue
       T.    If a case of health-care-acquired aspergillosis or other opportunistic environmental airborne
             fungal disease occurs during or immediately after construction, implement appropriate
             follow-up measures. 20• 55 • 62• 77• 94 • 95 Category IB
             I.     Review pressure differential monitoring documentation to verifY that pressure
                    differentials in the construction zone and in PE rooms were appropriate for their
                    settings. 94 • 95 • 12° Category IB, IC (AlA: 5.1)
             2.     Implement corrective engineering measures to restore proper pressure differentials as
                    needed. 94 • •  °
                                    95 12
                                               Category IB, IC (AlA: 5.1)
             3.     Conduct a prospective search for additional cases and intensifY retrospective
                    epidemiologic review of the hospital's medical and laboratory records.'· 20• 62• 63• 10'1
                    CategoryiB
             4.     If there is no evidence of ongoing transmission, continue routine maintenance in the
                    area to prevent health-care-acquired fungal disease.'· 55 Category IB
       J.    If there is epidemiologic evidence of ongoing transmission of fungal disease, conduct an
             environmental assessment to determine and eliminate the source. 3• 96• 97• 109• 111 • 115 • 249 • 273---277
             CategoryiB
             1.     Collect environmental samples fi·om potential sources of airborne fungal sp,ores,
                                                                                           3 18 44 8 49 97 106
                    preferably using a high-volume air sampler rather than settle plates. • • • • • • •
                    111, 112, 115, 249,254, 273-277, zn, 312 Category IB
             2.     If either an environmental source of airborne fungi or an engineering problem with
                    filtration or pressure differentials is identified, promptly perform corrective measures
                    to eliminate the sow·ce and route of entty. 96• 97 Category IB
             3.     Use an EPA-registered anti-fungal biocide (e.g., coppet'8-quinolinolate) for
                    decontaminating structural materials. 50· 277• 312 • 329 Category IB
             4.     If an environmental source of airbome fungi is not identified, review infection control
                    measures, including engineering controls, to identify potential areas for correction or
                    improvement. 73 • 117 Category IB
             5.     If possible, perform molecular subtyping of Aspergillus spp. isolated fi·om patients
                    and the environment to establish strain identities.'"· 29,_296 Category II
       K.    !fair-supply systems to high-risk areas (e.g., PE rooms) are not optimal, use portable,
             industrial-grade HEPA filters on a temporary basis until rooms with optimal air-handling
             systems become available.'· 120' 27,_277 Category II

III.   Infection-Control and Ventilation Requirements for PE Rooms
       A.    Minimize exposures of severely immunocompromised patients (e.g., solid organ transplant
             patients or allogeneic neutt·openic patients) to activities that might cause aerosolization of
             fungal spores (e.g., vacuuming or disruption of ceiling tiles).'· 20• 109• 272 Category IB
       B.    Minimize the length of time that immunocompromised patients in PE are outside their
                                                                       283
             rooms for diagnostic procedures and other activities.'·         Category IB
       C.    Provide respiratory protection for severely immunocompromised patients when they must
             leave PE for diagnostic studies and other activities; consult the most recent revision of
             CDC's Guidelines for Prevention of Health-Care-Associated Pneumonia for information
             regarding the appropriate type of respiratmy protection.'· 9 Category II
                                                                                                        123

      D.    Incorporate ventilation engineering specifications and dust-controlling pmcesses into the
            planning and constmction of new PE units. Category IB, IC
                                                                                               20 9 104
            I.    Install central or point-of-use HEPA filters for supply (incoming) air.'· 18• · 44 • 9- •
                                    1432 1434
                  120. "'· 316-318,     ·     Category IB, IC (AlA: 5.1, 5.2, 7.2.0)
            2.    Ensure that moms are well sealed by 1) pmperly constmcting windows, doors, and
                  intake and exhaust ports; 2) maintaining ceilings that are smooth and free of fissures,
                  open joints, and crevices; 3) sealing walls above and below the ceiling, and 4)
                  monitoring for leakage and making necessary repairs.'· 111 · 120· 317•
                                                                                         318
                                                                                             Category IB,
                  IC    (AlA: 7.2.D3)
                                                                      120
            3.    Ventilate the mom to maintain :;:12 ACH.'· '· ' 241 · 317 • 318 Categ01y IC (AlA: 7.2.0)
            4.    Locate air supply and exhaust grilles so that clean, filtered air enters fi·om one side of
                  the room, flows across the patient's bed, and exits from the opposite side of the
                  room. 3• 120• 317 • 318 Category IC (AlA: 7.31.01)
            5.    Maintain positive room air pressure (?:2.5 Pa [0.01-inch water gauge]) in relation to
                  the corridor. 3· 35 · 120 · 317· 318 Category IB, IC (AlA: Table7.2)
            6.    Maintain airflow patterns and monitor these on a daily basis by using petmanently
                  installed visual means of detecting airflow in new or renovated construction, or using
                  other visual methods (e.g., flutter strips, or smoke tubes) in existing PE units.
                  Document the monitoring results. 120' 273 Category IC (AlA: 7.2.06)
            7.    Install self-closing devices on all room exit doors in protective environments. 120
                  Category IC       (AlA: 7.2.04)
      E.    Do not use laminar air flow systems in newly constructed PE moms. 316' 318 Category II
      F.    Take measures to protect immunocompromised patients who would benefit fmm a PE room
            and who also have an airborne infectious disease (e.g., acute VZV infection or
            tuberculosis).
            1.    Ensure that the patient's room is designed to maintain positive pressure.
            2.    Use an anteroom to ensure appropriate air balance relationships and provide
                  independent exhaust of contaminated air to the outside, or place a HEPA filter in the
                  exhaust duct if the return air must be recirculated. 120· 317 Category IC (AlA: 7.2.Dl,
                  A7.2.D)
            3.    !fan anteroom is not available, place the patient in All and use pmtable, industrial-
                  grade HEPA filters to enhance filtration of spores in the room. 219 Category II
      G.    Maintain backup ventilation equipment (e.g., portable units for fans or filters) for
            emergency provision of ventilation requirements for PE areas and take immediate steps to
            restore the fixed ventilation system function.'· 120' 278 Category IC (AlA: 5.1)

IV.   Infection-Control and Ventilation Requirements for All Rooms
      A.    Incorporate ce1tain specifications into the planning, and constmction or renovation of AII
            units.<· 107· 120· 317• 318 Category IB, IC
            I.     Maintain continuous negative air pressure (2.5 Pa [0.0 l-inch water gauge]) in relation
                   to the air pressure in the corridor; monitor air pressure periodically, preferably daily,
                   with audible manometers or smoke tubes at the door (for existing All rooms) or with
                   a permanently installed visual monitoring mechanism. Document the results of
                   monitoring. 120· 317• 318 Categoty IB, IC (AlA: 7.2.C7, Table 7.2)
            2.     Ensure that rooms are well-sealed by properly constmcting windows, doors, and air-
                   intake and exhaust pmts; when monitoring indicates air leakage, locate the leak and
                   make necessary repairs."'· 317• 318 Category IB, IC (AlA: 7.2.c3)
            3.     Install self-closing devices on all AT! room exit doors. 120 Category IC (AlA: 7.2.C4)
            4.     Provide ventilation to ensure 2:12 ACH for renovated rooms and new rooms, and 2:6
                   ACH for existing AT! rooms. 4· 107· 12° Categmy IC (AlA: Table 7 2)
124

            5.    Direct exhaust air to the outside, away from air-intake and populated areas. If this is
                   not practical, air from the room can be recirculated after passing through a HEPA
                             °
                   filter.'· 12    Category IC (AlA: Table 7.2)
      B.    Where supplemental engineering c~ntrols for air cleaning are indicated fi·om a risk
            assessment of the All area, install UVGI units in the exhaust air ducts of the HVAC system
            to supplement HEPA filtration or install UVGI fixtures on or near the ceiling to irradiate
            upper room air.' Category II
      C.    Implement environmental infection-control measures for persons with known or suspected
            airborne infectious diseases.
            I.    Use All rooms for patients with or suspected of having an airborne infection who also
                   require cough-inducing procedures, or use an enclosed booth that is engineered to
                   provide I) 2:12 ACH; 2) air supply and exhaust rate sufficient to maintain a 2.5 Pa
                  [0.01-inch water gauge] negative pressure difference with respect to all surrounding
                  spaces with an exhaust rate of2:50 ft3/min.; and 3) air exhausted directly outside away
                  from air intakes and traffic or exhausted after HEPA filtration prior to recirculation.'·
                   120. 348-350   Category IB, IC (AlA: 7.15.E, 7.31.023, 9. 10, Table 7.2)
            2.    Although airborne spread of viral hemoJThagic fever (VHF) has not been documented
                  in a health-care setting, prudence dictates placing a VHF patient in an All room,
                   preferably with an anteroom to reduce the risk of occupational exposure to
                  aerosolized infectious material in blood, vomitus, liquid stool, and respiratmy
                  secretions present in large amounts during the end stage of a patient's illness?02- 204
                  Category II
                  a.        !fan anteroom is not available, use portable, industrial-grade HEPA filters in
                            the patient's room to provide additional ACH equivalents for removing
                            airborne particulates.
                   b.       Ensure that health-care workers wear face shields or goggles with appropriate
                            respirators when entering the rooms of VHF patients with prominent cough,
                            vomiting, diarrhea, or hemorrhage. 203
            3.    Place smallpox patients in negative pressure rooms at the onset of their illness,
                   preferably using a room with an anteroom if available. 6 Category II
      D.    No recommendation is offered regarding negative pressure or isolation rooms for patients
            with Pneumocystis carinii pneumonia. 126 • 131 ' 132 Unresolved issue
      E.    Maintain back-up ventilation equipment (e.g., portable units for fans or filters) for
            emergency provision of ventilation requirements for All rooms and take immediate steps to
            restore the fixed ventilation system function.'· 120' 278 Category IC (AlA: 5.1)

V,    Infection-Control and Ventilation Requirements for Operating Rooms
      A.    Implement environmental infection-control and ventilation measures for operating rooms.
            1.   Maintain positive-pressure ventilation with respect to corridors and adjacent areas.'·
                 120 356
                    •    Category IB, IC (AlA: Table 7.2)
                                                                                    358
            2.   Maintain 2:15 ACH, of which 2:3 ACH should be fresh air. 120· 357•     Category IC
                  (AlA: Table 7.2)
            3.   Filter all recirculated and fresh air through the appropriate filters, providing 90%
                                                                   120 362
                  efficiency (dust-spot testing) at a minimum. '           Category IC (AlA: Table 7.3)
            4.    In rooms not engineered for horizontal laminar airflow, introduce air at the ceiling
                  and exhaust air near the floor. 120' 357 ' 359 Categ01y IC (AlA: 7.3l.D4)
            5.    Do not use UV lights to prevent surgical-site infections. 356• 364-370 Category IB
            6.   Keep operating room doors closed except for the passage of equipment, personnel,
                 and patients, and limit entry to essential personnel. 351 · 352 Category IB
                                                                                                        347
      B.    Follow precautionary procedures for TB patients who also require emergency surgeiy.'· '
            371
                 Category IB, IC
                                                                                                                       125

             1.    Use an N95 respirator approved by the National Institute for Occupational Safety and
                   Health (NIOSH) without exhalation valves in the operating room. 347 • 372 Category
                   JC    {Occupational Safety and Health Administration [OSHA]; 29 Code of Federal Regulations [CFR]
                   1910.134,139)
             2.    Intubate the patient in either the All room or the operating room; if intubating the
                   patient in the operating room, do not allow the doors to open until 99% of the
                   airborne contaminants are removed (Appendix B, Table B.l). 4 • 358 Category IB
            3.     When anesthetizing a patient with confirmed or suspected TB, place a bacterial filter
                   between the anesthesia circuit and patient's airway to prevent contamination of
                   anesthesia equipment or discharge of tubercle bacilli into the ambient air. 371 • 373
                   Category IE
            4.     Extubate and allow the patient to recover in an All room.'· 358 Category IB
            5.     If the patient has to be extubated in the operating room, allow adequate time for ACH
                   to clean 99% of airborne particles from the air (Appendix B, Table B.!) because
                   extubation is a cough-producing procedure.'· 358 Category IB
      C.    Use portable, industrial-grade HEPA filters temporarily for supplemental air cleaning
            during intubation and extubation for infectious TB patients who require surgety.'· 219• 358
            Category II
            1.     Position the units appropriately so that all room air passes through the filter; obtain
                   engineering consultation to determine the appropriate placement of the unit.'
                   Category II
            2.     Switch the portable unit off during the surgical procedure. Category II
            3.     Provide fi·esh air as per ventilation standards for operating rooms; portable units do
                   not meet the requirements for the number offi-esh ACH. 120 • 215 • 219 Category II
      D.    If possible, schedule infectious TB patients as the last surgical cases of the day to maximize
            the time available for removal of airborne contamination. Category II
      E.    No t•ecommendation is offered for perfmming orthopedic implant operations in rooms
            supplied with laminar airflow. 362 ' 364 Unresolved issue
      F.    Maintain backup ventilation equipment (e.g., portable units for fans or filters) for
            emergency provision of ventilation requirements for operating rooms, and take immediate
            steps to restore the fixed ventilation system function."· 120• 278•372 Category IB, IC (AlA:
            5.1)

VI. Other Potential Infectious Aerosol Hazards in Health-Care Facilities
     A.   In settings where surgical lasers are used, wear appropriate personal protective equipment,
           including N95 or N I 00 respirators, to minimize exposure to laser plumes. 347• 378• 389
          Category JC (OSHA; 29 CFR 1910.134,139)
     B.   Use central wall suction units with in-line filters to evacuate minimal laser plumes.'"· 382• 386•
          389
                 Category II
     C.   Use a mechanical smoke evacuation system with a high-efficiency filter to manage the
          generation of large amounts of laser plume, when ablating tissue infected with human
          papilloma virus (HPV) or performing procedures on a patient with extrapulmonary TB.'· 382'
          38 392
             '-     Category II

D. Recommendations-Water
I.    Controlling the Spread ofWaterbome Microoganisms
      A.   Practice hand hygiene to prevent the hand transfer of waterborne pathogens, and use barrier
           precautions (e.g., gloves) as defined by other guidelines. 6• 464• 577• 586• 592• 1364 Category IA
126

       B.    Eliminate contaminated water or fluid environmental reservoirs (e.g., in equipment or
             solutions) wherever possible.'64 • 465 Category IB
       C.    Clean and disinfect sinks and wash basins on a regular basis by using an EPA-registered
             product as set by facility policies. Category II
       D.    Evaluate for possible environmental sources (e.g., potable water) of specimen
             contamination when waterborne microorganisms (e.g., NTM) of unlikely clinical
             importance are isolated from clinical cultures (e.g., specimens collected aseptically from
             sterile sites or, if post-procedural, colonization occurs after use of tap water in patient
             care). 607.6 10-612 Categ01y IB
       E.    A void placing decorative fountains and fish tanks in patient-care areas; ensure disinfection
             and fountain maintenance if decorative fountains are used in the public areas of the health-
             care facility. 664 Category IB

II.    Routine Prevention of Waterbome Microbial Contamination Within the Distribution
       System
       A.   Maintain hot water temperature at the return at the highest temperature allowable by state
            regulations or codes, preferably 2:124 °F (2:51 °C), and maintain cold water temperature at
            <68°F ( <20°C). 3• 661 Category IC (SJuJes; ASHRAE: 12:2000)
       B.   If the hot water temperature can be maintained at 2:124°F (2:51 °C), explore engineering
            options (e.g., install preset thermostatic valves in point-of-use fixtures) to help minimize the
            risk of scalding. 661 Category II
       C.   When state regulations or codes do not allow hot water temperatures above the range of
            105°F-!20°F (40.6°C-49°C) for hospitals o1· 95°F-Il0°F (35°C-43.3°C) for nursing care
            facilities or when buildings cannot be retrofitted for thermostatic mixing valves, follow
            either of these alternative preventive measures to minimize the growth of Legionella spp. in
            water systems. Category II
            1.      Periodically increase the hot water temperature to 2: 150°F (2:66°C) at the point of
                   use. 661 Category II
            2.      Alternatively, chlorinate the water and then flush it through the system. 661 • 710· 711
                    Category II
       D.   Maintain constant recirculation in hot-wate1· distribution systems serving patient-care
            areas. 12°    Category JC (AlA: 7.3J.E3)

III.   Remediation Strategies for Distribution System Repair or Emergencies
       A.  Whenever possible, disconnect the ice machine before planned water disruptions.
           Category II
       B.  Prepare a contingency plan to estimate water demands for the entire facility in advance of
           significant water disruptions (i.e., those expected to result in extensive and heavy microbial
                                                                                                  719
           or chemical contamination of the potable water), sewage intrusion, or flooding. 713 •
           Category IC (JCAHO: EC 1.4)
       C.  When a significant water disruption or an emergency occurs, adhere to any advisory to boil
           water issued by the municipal water utility. 642 Cutegory IB, IC (Municipal order)
           1.     Alert patients, families, staff, and visitors not to consume water from drinking
                  fountains, ice, or drinks made from municipal tap water, while the advismy is in
                  effect, unless the water has been disinfected (e.g., by bringing to a rolling boil for 2:1
                  minute). 642 Categ01y IB, IC (Municipal oo·der)
           2.     After the advismy is lifted, run faucets and drinking fountains at full flow for 2:5
                  minutes, or use high-temperature water flushing or chlorination. 642• 661 Category IC,
                   II    (Municipal order; ASHRAE 12:2000)
       D.    Maintain a high level of surveillance for waterborne disease among patients after a boil
             water adviso1y is lifted. Category II
                                                                                                 127

E.   Corrective decontamination of the hot water system might be necessary after a disruption in
     service or a cross-connection with sewer lines has occurred.
     I.    Decontaminate the system when the fewest occupants are present in the building (e.g.,
           nights or weekends).'· 661 Categmy IC (ASHRAE: 12:2000)
     2.    !fusing high-temperature decontamination, raise the hot-water temperature to 160°F-
           1700F (71 °C-77°C) and maintain that level while progressively flushing each outlet
           around the system for ?:5 minutes.'· 661 Category IC (ASHRAE: 12:2000)
     3.    !fusing chlorination, add enough chlorine, preferably overnight, to achieve a free
           chlorine residual of;o:2 mg!L (2:2 ppm) throughout the system. 661  Category IC
           (ASHRAE: 12:2000)
           a.       Flush each outlet until chlorine odor is detected.
           b.       Maintain the elevated chlorine concentration in the system for 2:2 hrs (but ::;24
                    hrs).
     4.     Use a very thorough flushing of the water system instead of chlorination if a highly
            chlorine-resistant microorganism (e.g., Cryptosporidium spp.) is suspected as the
            water contaminant.       Category II
F.   Flush and restart equipment and fixtures according to manufacturers' instructions.
     Category II
G.   Change the pretreatment filter and disinfect the dialysis water system with an EPA-
     registered product to prevent colonization of the reverse osmosis membrane and
     downstream microbial contamination. 721 Category II
H.   Run water softeners through a regeneration cycle to restore their capacity and function.
     Category II
I.   If the facility has a watet~holding reservoir or water-storage tank, consult the fucility
     engineer or local health department to determine whether this equipment needs to be
     drained, disinfected with an EPA-registered product, and refilled. Category II
J.   Implement facility management procedures to manage a sewage system failure or flooding
     (e.g., arranging with other health-care facilities for temporary transfer of patients or
     provision of services), and establish communications with the local municipal water utility
     and the local health department to ensure that advisories are received in a timely manner
     upon release. 713 ' 719 Category IC (JCAHO: EC 1.4; Municipal order)
K.   Implement infection-control measures during sewage intrusion, flooding, or other water-
     related emergencies.
     1.     Relocate patients and clean or sterilize supplies from affected areas. Category II
     2.     If hands are not visibly soiled or contaminated with proteinaceous material, include
            an alcohol-based hand rub in the hand hygiene process I) before performing invasive
             procedures; 2) before and after each patient contact; and 3) whenever hand hygiene is
            indicated. 1364 Category II
     3.     If hands are visibly soiled or contaminated with proteinaceous material, use soap and
            bottled water for handwashing. 1364 Category II
     4.     If the potable water system is not affected by flooding or sewage contamination,
            process surgical instruments for sterilization according to standard procedures.
            Category II
     5.     Contact the manufacturer of the automated endoscope reprocessor (AER) for specific
            instructions on the use of this equipment during a water advisoty. Category II
L.   Remediate the facility after sewage intrusion, flooding, or other water-related emergencies.
     I.     Close off affected areas during cleanup procedures. Category II
     2.     Ensure that the sewage system is fully functional before beginning remediation so
            contaminated solids and standing water can be removed. Category II
128

             3.   If hard-surface equipment, floors, and walls remain in good repair, ensure that these
                  are dry within 72 hours; clean with detergent according to standard cleaning
                  procedures. Category II
            4.    Clean wood furniture and materials (if stiJJ in good repair); allow them to dry
                  thoroughly before restoring varnish or other surface coatings. Category II
            5.    Contain dust and debris during remediation and repair as outlined in air
                  recommendations (Air: II G 4, 5). Category II
      M.    Regardless of the original source of water damage (e.g., flooding versus water leaks from
            point-of-use fixtures or roofs), remove wet, absorbent structural items (e.g., carpeting,
            wallboard, and wallpaper) and cloth fumishings if they cannot be easily and thoroughly
            cleaned and dried within 72 hours (e.g., moisture content:S20% as determined by moisture
            meter readings); replace with new materials as soon as the underlying structure is declared
            by the facility engineer to be thoroughly dry. 18• 266 • 278 · 1026 Category IB

IV.   Additional Engineering Measures as Indicated by Epidemiologic Investigation for
      Controlling Waterborne, Health-Care-Associated Legionnaires Disease
      A.   When using a pulse or one-time decontamination method, superheat the water by flushing
           each outlet for 2:5 minutes with water at J60°F-170'F (71 °C-77'C) or hyperchlorinate the
           system by flushing all outlets for2:5 minutes with water containing2:2 mg/L (2:2 ppm) free
           residual chlmine using a chlorine-based product registered by the EPA for water treatment
           (e.g., sodium hypochlorite [chlorine bleach]). 661 • 711 • 714 • 724 • 764 • 766 Categoty IB (ASHRAE:
             12:2000)
      B.    After a pulse treatment, maintain both the heated water temperature at the return and the
            cold water temperature as per the recommendation (Water: IIA) wherever practical and
            permitted by state codes, or chlorinate heated water to achieve 1-2 mg/L (1-2 ppm) free
            residual chlorine at the tap using a chlorine-based product registered by the EPA for water
                                                                     661
            treatment (e.g., sodium hypochlorite [bleach]). 26 • 437• • 709• 726• 727 Category IC (Stat";
            ASHRAE: 12:2000)
      C.    Explore engineering or educational options (e.g., install preset thermostatic mixing valves
            in point-of-use fixtures or post warning signs at each outlet) to minimize the risk of scalding
            for patients, visitors, and staff. Category II
      D.    No recommendation is offered for treating water in the facility's distribution system with
            chlorine dioxide, heavy-metal ions (e.g., copper or silver), monochloramine, ozone, or UV
            light. 72&--746 Unresolved issue

V.    General Infection-Control Strategies for Preventing Legionnaires Disease
      A.   Conduct an infection-control risk assessment of the facility to determine if patients at risk or
           severely immunocompromised patients are present. 3• 431 • 432 Category IB
      B.   Implement general strategies for detecting and preventing Legionnaires disease in facilities
           that do not provide care for severely immunocompromised patients (i.e., facilities that do
           not have HSCT or solid organ transplant programs). 3• 431 • 432 Category IB
           1.     Establish a surveillance process to detect health-care-associated Legionnaires
                  disease. 3• 431 • 43 ' CategoryiB
           2.     Inform health-care personnel (e.g., infection control, physicians, patient-care staff,
                  and engineering) regarding the potential for Legionnaires disease to occur and
                 measures to prevent and control health-care-associated legionellosis. 437• 759
                  Category IE
           3.     Establish mechanisms to provide clinicians with labmatory tests (e.g., culture, urine
                  antigen, direct fluorescence assay [DFA], and serology) for the diagnosis of
                  Legionnaires disease. 3• 431 Categoty IB
                                                                                                             129

C.   Maintain a high index of suspicion for health-care-associated Legionnaires disease, and
     perform laboratory diagnostic tests for legionellosis on suspected cases, especially in
     patients at risk who do not require a PE for care (e.g., patients receiving systemic steroids;
     patients aged 2:65 years; or patients with chronic underlying disease [e.g., diabetes mellitus,
     congestive heart failure, or chronic obstructive lung disease]). 3• 395 • 417• 423--425• 432• 435 • 437• 453
     Category/A
D.   Periodically review the availability and clinicians' use oflaboratory diagnostic tests for
     Legionnaires disease in the facility; if clinicians' use of the tests on patients with diagnosed
     or suspected pneumonia is limited, implement measures (e.g., an educational campaign) to
     enhance clinicians' use of the test(s). 453 Category IB
E.   If one case of laboratory-confirmed, health-care-associated Legionnaires disease is
     identified, or if two or more cases of laboratory-suspected, health-care-associated
     Legionnaires disease occur during a 6-month period, certain activities should be initiated. 405 •
     408,431,453,739,759      Category IB
     I.     Report the cases to the state and local health departments where required.                Category
            IC     (States)
     2.     If the facility does not treat severely immunocompromised patients, conduct an
            epidemiologic investigation, including retrospective review of microbiologic,
            serologic, and postmortem data to look for previously unidentified cases of health-
            care-associated Legionnaires disease, and begin intensive prospective surveillance for
            additional cases_3·405, 408,431,453,739,759 Category IB
     3.     If no evidence of continued health-care-associated transmission exists, continue
            intensive prospective surveillance for 2:2 months after the initiation of surveillance.'·
            40S,40S,43J,   4sJ. 739,759   Category IB
F.   If there is evidence of continued health-care-associated transmission (i.e., an outbreak),
                                                                                           410 455
     conduct an environmental assessment to determine the source of Legionella spp. 40,_ •
     Category IB
                                                                                       1209
     I.   Collect water samples from potential aerosolized water sources (Appendix C).
          Category IB
     2.   Save and subtype isolates of Legionella spp. obtained from patients and the
          environment.40J-..4JO, 453,763,764 Category IB
     3.     If a source is identified, promptly institute water system decontamination measures
            per recommendations (see Water IV). 766' 767 Category IB
     4.     If Legionella spp. are detected in2:lcultures (e.g., conducted at 2-week intervals
            during 3 months), reassess the control measures, modify them accordingly, and repeat
            the decontamination procedures; consider intensive use of techniques used for initial
                      . .
            decontammatton,    or a com b'matt.on o f superheating
                                                               . an d hyperc hi anna
                                                                                  . t'wn. 3767768
                                                                                           · ·
            CategorylB
G.   If an environmental source is not identified during a Legionnaires disease outbreak,
     continue surveillance for new cases for 2:2 months. Either defer decontamination pending
     identification of the source of Legionella spp., or proceed with decontamination of the
     hospital's water distribution system, with special attention to areas involved in the outbreak.
     Category II
H.   No recommendation is offered regarding routine culturing of water systems in health-care
     facilities that do not have patient-care areas (i.e., PE or transplant units) for persons at high
                                                                         753
     risk for Legion ella spp. infection. 26' 453 ' 707 ' 709' 714• 747•     Unresolved issue
I.   No recommendation is offered regarding the removal of faucet aerators in areas for
     immunocompetent patients. Unresolved issue
J.   Keep adequate records of all infection-control measures and environmental test results for
     potable water systems. Category II
130

VI.   Preventing Legionnaires Disease in Protective Environments and Transplant Units
      A.   When implementing strategies for preventing Legionnaires disease among severely
           immunosuppressed patients housed in facilities with HSCT or solid-organ transplant
           programs, incorporate these specific surveillance and epidemiologic measures in addition to
           the steps previously outlined (Water: V and Appendix C).
            I.    Maintain a high index of suspicion for legionellosis in transplant patients even when
                  environmental surveillance cultures do not yield legionellae. 430• 431 Category IB
           2.     If a case occurs in a severely immunocompromised patient, or if severely
                  immunocompromised patients are present in high-risk areas ofthe hospital (e.g., PE
                  or transplant units) and cases are identified elsewhere in the facility, conduct a
                  combined epidemiologic and environmental investigation to determine the source of
                  Legionella spp. 431 • 767 Category IB
      B.   Implement culture strategies and potable water and fixture treatment measures in addition to
           those previously outlined (Water: V). Category II
           I.     Depending on state regulations on potable water temperature in public buildings, 725
                  hospitals housing patients at risk for health-care-associated legionellosis should either
                  maintain heated water with a minimum return temperature of?:124°F [2:51 oq and
                  cold water at <68°F [<20°C]), or chlorinate heated water to achieve 1-2 mg/L (1-2
                  ppm) of free residual chlorine at the tap."· 441 • 661 ' 70,_711 • 726 • 727 Category II
           2.     Periodic culturing for legionellae in potable water samples from HSCT or solid-organ
                  transplant units can be performed as part of a comprehensive strategy to prevent
                  Legionnaires disease in these units. 9' 431 ' 710• 769 Category II
           3.     No recommendation is offered regarding the optimal methodology (i.e., frequency
                  or number of sites) for environmental surveillance cultures in HSCT or solid organ
                  transplant units. Unresolved issue
           4.     In areas with patients at risk, when Legionel/a spp. are not detectable in unit water,
                  remove, clean, and disinfect shower heads and tap aerators monthly by using a
                  chlorine-based, EPA-registered product. !fan EPA-registered chlorine disinfectant is
                                                                                                                 745
                  not available, use a chlorine bleach solution (500--615 ppm [I: 100 v/v dilution]). 661 •
                  Category!!
      C.   If Legion ella spp. are determined to be present in the water of a transplant unit, implement
           ceJiain measures until Legionella spp. are no longer detected by culture.
                                                                                                            767
           I.     Decontaminate the water supply as outlined previously (Water: IV) 3 • 9• 661 • 766•
                  CategoryiB
           2.     Do not use water from the faucets in patient-care rooms to avoid creating infectious
                  aerosols.'· 412 Category IB
                                                                                                     412
           3.     Restrict severely immunocompromised patients from taking showers. 9'                     Category
                  IB
           4.     Use water that is not contaminated with Legionella spp. for HSCT patients' sponge
                  baths:·"' Category IB
           5.     Provide patients with sterile water for tooth brushing, drinking, and for flushing
                  nasogastric tubing during Jegionellosis outbreaks.'· 412 Category IB
      D.   Do not use large-volume room air humidifiers that create aerosols (e.g., by Venturi
           principle, ultrasound, or spinning disk) unless they are subjected to high-level disinfection
           and filled only with sterile water.'·'· 402' 455 Category IB

VII. Cooling Towers and Evaporative Condensers
     A.   When planning construction of new health-care facilities, locate cooling towers so that the
          drift is directed away from the air-intake system, and design the towers to minimize the
          volume of aerosol drift. 404 · 661 • 786 Category JC (ASHRAE: 12:2ooo)
                                                                                                                 131

      B.     Implement infection-control procedures for operational cooling towers.' 04 · 661 • 784
             Category IC (ASHRAE: 12:2000)
             I,   Install drift eliminators.'04 ' 661 ' 784 Category IC (ASHRAE: 12:2ooo)
             2.   Use an effective EPA-registered biocide on a regular basis, 661 Category IC
                    (ASHRAE: 12:2000)
             3.    Maintain towers according to manufacturers' recommendations, and keep detailed
                   maintenance and infection control records, including environmental test results from
                   legionellosis outbreak investigations. 661 Category IC (ASHRAE: 12:2ooo)
      C.     If cooling towers or evaporative condensers are implicated in health-care-associated
             legionellosis, decontaminate the cooling-tower system, 404• 405 • 786· 787 Category IB

VIII. Dialysis Water Quality and Dialysate
      A.   Adhere to current AAMI standards for quality assurance performance of devices and
           equipment used to treat, store, and distribute water in hemodialysis centers (both acute and
           maintenance [chronic) settings) and for the preparation of concentrates and dialysate. 31 ' 32 '
           666--668, 789, 791, 800, 807, 809, 1454, 1455 Category JA, /C (AAMI: ANSIIAAMI RD5: 1992, ANSIIAAMI RD
             47:1993)
      B.     No recommendation is offered regarding whether more stringent requirements for water
             quality should be imposed in hemofiltration and hemodiafiltration. Unresolved issue
      C.     Conduct microbiological testing specific to water in dialysis settings.'"· 791 • 792 · 834• 835
             Category IA, IC (AAMI: ANS!IAAMI RD 5: 1992, ANS1/AAM1 RD 47: 1993, ANSI/AAMI RD 62:2001)
             I.    Perform bacteriologic assays of water and dialysis fluids at least once a month and
                   during outbreaks using standard quantitative methods. 792· 834• 835 Category IA, IC
                    (AAMI: ANSI/AAM1 RD 62:2001)
                    a,    Assay for heterotrophic, mesophilic bacteria (e.g., Pseudomonas spp).
                    b.    Do not use nutrient-J"ich media (e.g., blood agar or chocolate agar).
             2.     In conjunction with microbiological testing, perform endotoxin testing on product
                    water used to reprocess dialyzers for multiple use. 789• 791 • 806• 811 • 816 • 829 Category IA,
                    /C    (AAM1: ANS!IAAM1 RD 5:1992, ANSI/AAMl RD 47:1993)
             3.     Ensure that water does not exceed the limits for microbial counts and endotoxin
                                                        789 791 80
                    concentrations outlined in Table 18. · ·         °
                                                                    Category IA, IC (AAMI: ANS11AAM1 RD
                    5:1992, ANS1/AAM1 RD 47:1993)
      D.     Disinfect water distribution systems in dialysis settings on a regular schedule. Monthly
             disinfection is recommended, 66 6-66 '· 792 · 80 ° Category IA, IC (AAM1: ANST/AAM1 RD62:2001)
      E.     Whenever practical, design and engineer water systems in dialysis settings to avoid
             incorporating joints, dead-end pipes, and unused branches and taps that can harbor
                                    °
             bacteria. 666-668• 792• 80 Category IA, IC (AAMI: ANS11AAM1 RD62:2001)
       F.    When storage tanks are used in dialysis systems, they should be routinely drained,
             disinfected with an EPA-registered product, and fitted with an ultrafilter or pyrogenic filter
             (membrane filter with a pore size sufficient to remove small pmticles and molecules 2:1
             kilodalton) installed in the water line distal to the storage tank. 792 Category IC (AAMI:
             ANSl/AAMI RD62:2001)

IX.   Ice Machines and Ice
      A.   Do not handle ice directly by hand, and wash hands before obtaining ice. Categmy II
      B.   U se a smooth~sur1ace~  . scoop to d'1spense 1ce.
                                   tee                    . 680· 863 Category II
           I,     Keep the ice scoop on a chain shmt enough the scoop cannot touch the floor, or keep
                  the scoop on a clean, hard surface when not in use.' 80• 863 Categmy II
           2.     Do not store the ice scoop in the ice bin. Category II
      C.   Do not store pharmaceuticals or medical solutions on ice intended for consumption; use
           sterile ice to keep medical solutions cold, or use equipment specifically manufactured for
           this purpose. 600• 863 Category IB
132

      D.    Machines that dispense ice are preferred to those that require ice to be removed from bins or
            chests with a scoop. 687• 869 Category II
      E.    Limit access to ice-storage chests, and keep the container doors closed except when
            removing ice. 863 Category II
      F.    Clean, disinfect, and maintain ice-storage chests on a regular basis. Category II
            I.     Follow the manufacturer's instructions for cleaning. Category II
            2.     Use an EPA-registered disinfectant suitable for use on ice machines, dispensers, or
                   storage chests in accordance with label instructions.    Category II
            3.     If instructions and EPA-registered disinfectants suitable fot· use on ice machines are
                   not available, use a general cleaning/disinfecting regimen as outlined in Box 12. 863
                   Category II
            4.     Flush and clean the ice machines and dispensers if they have not been disconnected
                   before anticipated lengthy water disruptions. Category II
      G.    Install proper air gaps where the condensate lines meet the waste lines. Category II
      H.    Conduct microbiologic sampling of ice, ice chests, and ice-making machines and dispensers
            where indicated during an epidemiologic investigation. 861- 863 Category IB

X,    Hydrotherapy Tanks and Pools
      A.  Drain and clean hydrotherapy equipment (e.g., Hubbard tanks, tubs, whirlpools, whirlpool
          spas, or birthing tanks) after each patient's use, and disinfect equipment surfaces and
           components by using an EPA-registered product in accordance with the manufacturer's
           instructions. Category II
      B.   In the absence of an EPA-registered product for water treatment, add sodium hypochlorite
          to the water:
           I.    Maintain a 15-ppm chlorine residual in the water of small hydrotherapy tanks,
                 Hubbard tanks, and tubs. 889 Category II
          2.     Maintain a 2-5 ppm chlorine residual in the water of whirlpools and whirlpool
                  spas. 905 Category II
           3.     If the pH of the municipal water is in the basic range (e.g., when chloramine is used
                  as the primary drinking water disinfectant in the community), consult the facility
                  engineer regarding the possible need to adjust the pH ofthe water to a more acid level
                  before disinfection, to enhance the biocidal activity of chlorine. 894 Category II
      C.  Clean and disinfect hydrotherapy equipment after using tub liners. Category II
      D.  Clean and disinfect inflatable tubs unless they are single-use equipment.       Category II
      E.  No recommendation is offered regarding the use of antiseptic chemicals (e.g., chloramine-
          T) in the water during hydrotherapy sessions. Unresolved issue
      F.  Conduct a risk assessment of patients prior to their use of large hydrotherapy pools,
          defening patients with draining wounds or fecal incontinence from pool use until their
          condition resolves. Category II
      G.  For large hydrotherapy pools, use pH and chlorine residual levels appropriate for an indoor
          pool as provided by local and state health agencies. Categ01y IC (States)
      H.  No recommendation is offered regarding the use in health care of whirlpools or spa
          equipment manufactured for home or recreational use. Unresolved issue

XI.   Miscellaneous Medical Equipment Connected to Water Systems
      A.   Clean, disinfect, and maintain AER equipment according to the manufacturer's instructions
           and relevant scientific literature to prevent inadvettent contamination of endoscopes and
           bronchoscopes wtt. h wat erborne mJCroorgamsms.
                                                .         .   911 - 915 Category IB
           l.    To rinse disinfected endoscopes and bronchoscopes, use water of the highest quality
                 practical for the system's engineering and design (e.g., sterile water or
                                                                                                                    133

                  bacteriologically-filtered water [water filtered through O.l-0.2-ftm filters]). 912 · 914 · 915 ·
                  918
                         Category IB
          2.      Dry the intemal channels of the reprocessed endoscope or bronchoscope using a
                  proven method (e.g., 70% alcohol followed by forced-air treatment) to lessen the
                  potential for the proliferation of waterborne microorganisms and to help prevent
                  biofilm formation. 671 · 921 · 923 • 925 · 928 Category IB
     B.   Use water that meets nationally recognized standards set by the EPA for drinking water
          (<500 CFU/mL for heterotrophic plate count) for routine dental treatment output water. 935·
          936 943 944
             • •         Category IB, IC (EPA: 40 CFR 1 Part 141, Subpart G).
     C.   Take precautions to prevent waterborne contamination of dental unit water lines and
          instruments.
          I.      A Iter each patient, discharge water and air for a minimum of 20-30 seconds from any
                  dental device connected to the dental wate1· system that enters the patient's mouth
                  (e.g., handpieces, ultrasonic scalers, and air/water syringe). 936' 937 Category II
          2.      Consult with dental water-line manufacturers to I) determine suitable methods and
                  equipment to obtain the recommended water quality; and 2) determine appropriate
                  methods for monitoring the water to ensure quality is maintained'"· 946 Category II
          3.      Consult with the dental unit manufacturer on the need for periodic maintenance of
                  anti-retraction mechanisms. 937• 946 Category IB

E. Recommendations-Environmental Services
I.   Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas
     A.   Select EPA-registered disinfectants, if available, and use them in accordance with the
          manufacturer's instructions?· 974• 983      Category JB, IC       (EPA: 7 United States   Code[USC] § 136 et
          seq)
     B.   Do not use high-level disinfectants/liquid chemical sterilants for disinfection of either
          noncritical instrument/devices or any environmental surfaces; such use is counter to label
          instructions for these toxic chemicals. 951 · 952 · 961- 964 Category IB, IC (FDA: 21 CFR &01.5,
          807.87.e)
     C.   Follow manufacturers' instructions for cleaning and maintaining noncritical medical
          equipment. Categ01y II
     D.   In the absence of a manufacturer's cleaning instructions, follow certain procedures.
          1.     Clean noncritical medical equipment surfaces with a detergent/disinfectant. This may
                 be followed with an application of an EPA-registered hospital disinfectant with or
                 without a tuberculocidal claim (depending on the nature of the surface and the degree
                 of contamination), in accordance with disinfectant label instructions.'" Category II
          2.     Do not use alcohol to disinfect large environmental surfaces. 951 Category II
          3.    Use barrier protective coverings as appropriate for noncritical equipment surfaces that
                 are I) touched frequently with gloved hands during the delivery of patient care; 2)
                 likely to become contaminated with blood or body substances; or 3) difficult to clean
                 (e.g., computer keyboards). 936 Category II
     E.   Keep housekeeping surfaces (e.g., floors, walls, and tabletops) visibly clean on a regular
          basis and clean up spills promptly. 954 Category II
          I.     Use a one-step process and an EPA-registered hospital disinfectant/detergent
                 designed for general housekeeping purposes in patient-care areas when I) uncertainty
                 exists as to the nature of the soil on these surfaces [e.g., blood or body fluid
                 contamination versus routine dust or dirt]; or 2) uncertainty exists regarding the
                                                                                                 983 986 987
                 presence or absence of multi-drug resistant organisms on such surfaces. 952• • •
                 Category!!
134

            2.     Detergent and water are adequate for cleaning surfaces in nonpatient-care areas (e.g.,
                   administrative offices). Category II
            3.      Clean and disinfect high-touch surfaces (e.g., doorknobs, bed rails, light switches, and
                   surfaces in and around toilets in patients' rooms) on a more frequent schedule than
                   minimal touch housekeeping surfaces. Category II
            4.      Clean walls, blinds, and window curtains in patient-care areas when they are visibly
                    dusty or soiled. 2• 971 • 972' 982 Category II
      F.    Do not perform disinfectant fogging in patient-care areas.'· 976 Category IB
      G.    Avoid large-surface cleaning methods that produce mists or aemsols or disperse dust in
            patient~care areas. 9 · • •
                                      20 109 272
                                                     Category IB
      H.    Follow proper procedures for effective use of mops, cloths, and solutions. Category II
            I.     Prepare cleaning solutions daily or as needed, and replace with fresh solution
                   frequently according to facility policies and procedures. 986• 987 Category II
            2.     Change the mop head at the beginning of the day and also as required by facility
                   policy, or after cleaning up large spi11s of blood or other body substances. Category
                   II
            3.     Clean mops and cloths after use and allow to dry before reuse; or use single-use,
                                                             °
                   disposable mop heads and cloths. 971 ' 98 ,_ 99 Category II
      I.    After the last surgical pmcedure of the day or night, wet vacuum or mop operating room
            floors with a single-use mop and an EPA-registered hospital disinfectant.'       Category IB
      J.    Do not use mats with tacky surfaces at the entrance to operating rooms or infection-control
            suites. 7    Category IB
      K.    Use appropriate dusting methods for patient-care areas designated for immunocompromised
            patients (e.g., HSCT patients): 9• 94 • 986 Category IB
            I.     Wet-dust horizontal surfaces daily by moistening a cloth with a small amount of an
                                                                      94
                   EPA-registered hospital detergent/disinfectant.'· • 986 Category IB
            2.     Avoid dusting methods that disperse dust (e.g., feather-dusting). 94 Category IB
      L.    Keep vacuums in good repair, and equip vacuums with HEPA filters for use in areas with
            patients at risk.'· 94 • 986 • 994 Category IB
      M.    Close the doors of immunocompromised patients' rooms when vacuuming, waxing, or
            buffing corridor floors to minimize exposure to airborne dust.'· 94 · 994 Category IB
      N.    When performing low- or intermediate-level disinfection of environmental surfaces in
            nurseries and neonatal units, avoid unnecessary exposure of neonates to disinfectant
            residues on environmental surfaces by using EPA-registered disinfectants in accordance
            with manufacturers' instructions and safety advisories.'"· 99,_997 Category IB, IC (EPA: 7
            USC § 136 et seq.) ,
            1.   Do not use phenolics or any other chemical germicide to disinfect bassinets or
                 incubators during an infant's stay.'"· 99 ,_997 Category IB
            2.   Rinse disinfectant-treated surfaces, especially those treated with phenolics, with
                 water.'9,_997 Category IB
      0.    When using phenolic disinfectants in neonatal units, prepare solutions to correct
            concentrations in accordance with manufacturers' instructions, or use premixed
            formulations.' 74 • 99,_997 Categmy IB, IC (EPA: 7USC § 136elseq.)

II.   Cleaning Spills of Blood and Body Substances
      A.   Promptly clean and decontaminate spills of blood or other potentially infectious
           materials.'"· 99,_ 1004 Categmy IB, IC (OSHA: 29 CFR 1910.1030 §d.4.ii.A)
      B.   Follow proper procedures for site decontamination of spi11s of blood or blood-containing
           body fluids. 967 • 99,_ 1004 Category IC (OSHA: 29 CFR 1910.1030 § d.4.ii.A)
           1.    Use protective gloves and other PPE appropriate for this task.'67 Category IC
                    (OSHA: 29 CFR 1910.1030 § d.3.i, ii)
                                                                                                               135

              2.    If the spill contains large amounts of blood or body fluids, clean the visible matter
                    with disposable absorbent material, and discard the contaminated materials in
                    appropriate, labeled containment.'67• 1002 ' 1003 ' 1010• 1012 Category IC (OSHA: 29 CFR
                    !910.1030 § d.4.iii.B)
              3.   Swab the area with a cloth or paper towels moderately wetted with disinfectant, and
                                                   1010
                   allow the surface to dry. 967 •      Category IC (OSHA: 29 CFR 1910.1030 § d.4.ii.A)
       C.    Use EPA-registered hospital disinfectants labeled tuberculocidal or registered germicides on
             the EPA Lists D and E (products with specific label claims for HIV or hepatitis B virus
             [HBV]) in accordance with label instmctions to decontaminate spills of blood and other
             body tluids. 967 • 1007 • 1010 Category /C (OSHA 29 CFR 1910.1030 § d.4.iLA memorandum 2/28/97;
             compliance document CPL 2·2.440 [11/99])
       D.    An EPA-registered sodium hypochlorite product is preferred, but if such products are not
             available, generic versions of sodium hypochlorite solutions (e.g., household chlorine
             bleach) may be used.
             I.    Use a I: I 00 dilution (500-615 ppm available chlorine) to decontaminate nonporous
                   surfaces after cleaning a spill of either blood or body fluids in patient-care
                   settings. 1010' 1011 Category II
             2.    !fa spill involves large amounts of blood or body fluids, or if a blood or culture spill
                   occurs in the laboratory, use a 1: I 0 dilution (5,000-6,150 ppm available chlorine) for
                   the first application of germicide before cleaning. 954 • 1010 Category II

III.   Carpeting and Cloth Fumishings
       A.   Vacuum carpeting in public areas of health-care facilities and in general patient-care areas
            regularly with well-maintained equipment designed to minimize dust dispersion.'"
            Category II
       B.   Periodically perform a thorough, deep cleaning of carpeting as determined by facility policy
            by using a method that minimizes the production of aerosols and leaves little or no
            residue 111    Category II
       C.   Avoid use of carpeting in high-traffic zones in patient-care areas or where spills are likely
            (e.g., burn therapy units, operating rooms, laboratories, and intensive care units). 111 • 1023 • 1028
            Category IB
       D.   Follow proper procedures for managing spills on carpeting.
                                                                                 1011
            I.     Spot-clean blood or body substance spills promptly. 967• 1010• ' 1032 Category IC
                    {OSHA: 29 CFR 1910.1030 § d.4.ii.A, interpretation)
             2.    If a spill occurs on carpet tiles, replace any tiles contaminated by blood and body
                   fluids or body substances. 1032 Category IC (OSHA 29 CFR 1910.1030 § d.4.ii interpretation)
       E.    Thoroughly dry wet carpeting to prevent the growth of fungi; replace carpeting that remains
             wet after 72 hours.'· 1026 Category IB
       F.    No recommendation is offered regarding the routine use of fungicidal or bactericidal
             treatments for carpeting in public areas of a health-care fucility or in general patient-care
             areas. Unresolved issue
       G.    Do not use carpeting in hallways and patient rooms in areas housing immunosuppressed
             patients (e.g., PE areas). 9· 111 CategoryiB
       H.    Avoid the use of upholstered furniture and furnishings in high-risk patient-care areas and in
             areas with increased potential for body substance contamination (e.g., pediatrics units).'
             Category II
       I.    No recommendation is offered regarding whether upholstered furniture and fumishings
             should be avoided in general patient-care areas. Unresolved issue
       J.    Maintain upholstered furniture in good repair. Category II
              I.   Maintain the surface integrity of the upholstery by repairing tears and holes.
                   Category II
136

            2.     If upholstered furniture in a patient's room requires cleaning to remove visible soil or
                   body substance contamination, move that item to a maintenance area where it can be
                   adequately cleaned with a process appropriate for the type of upholstery and the
                   nature of the soil. Category II

IV.   Flowers and Plants in Patient-Care Areas
      A.   Flowers and potted plants need not be restricted from areas for immunocompetent
           patients.m, 702, 1040,I042 Category II
      B.    Designate care and maintenance of flowers and potted plants to staff not directly involved
            with patient care. 702 Category II
      C.    If plant or flower care by patient-care staff is unavoidable, instmct the staff to wear gloves
            when handling the plants and flowers and perform hand hygiene after glove removal. 702
            Category II
      D.    Do not allow fresh or dried flowers, or potted plants in patient-care areas for
            immunosuppressed patients.'· 109· 515 · 1046 Category II

V.    Pest Control
      A.    Develop pest-control strategies, with emphasis on kitchens, cafeterias, laundries, central
            sterile supply areas, operating rooms, loading docks, construction activities, and other areas
            prone to infestations. 1050' 1072' 1075 Category II
      B.    Install screens on all windows that open to the outside; keep screens in good repair. 1072
            Category IB
      C.    Contract for routine pest control service by a credentialed pest-control specialist who will
            tailor the application to the needs of a health-care facility. 1075 Category II
      D.    Place laboratory specimens (e.g., fixed sputum smears) in covered containers for overnight
                     1065
            storage. · 1066 Category II

VI.   Special Pathogens
      A.   Use appropriate hand hygiene, PPE (e.g., gloves), and isolation precautions during cleaning
                                                       1130
           and disinfecting procedures. 5· 952 · · 1364 Category IB
      B.   Use standard cleaning and disinfection protocols to control environmental contamination
           with antibiotic-resistant gram-positive cocci (e.g., methicillin-resistant Staphylococcus
           aureus, vancomycin intermediate-resistant Staphylococcus aureus, or vancomycin-resistant
           Enterococcus [VRE] ). 5· 111 '- 1118 Categ01y IB
            I.      Pay close attention to cleaning and disinfection of high-touch surfaces in patient-care
                    areas (e.g., bed rails, carts, bedside commodes, bedrails, doorknobs, or faucet
                    handles).'· 111 '- 1118 Category IB
           2.       Ensure compliance by housekeeping staff with cleaning and disi11fection procedures.'·
                    111 '- 1118 Category IB
           3.       Use EPA-registered hospital disinfectants appropriate for the surface to be disinfected
                    (e.g., either low- or intermediate-level disinfection) as specified by the manufacturers'
                    instructions. 974 • ll06-IIIO, 1118 Category JB, IC (EPA: 7USC § J36etseq.)
           4.       When contact precautions are indicated for patient care, use disposable patient-care
                    items (e.g., blood pressure cuffs) whenever possible to minimize cross-contamination
                    with multiple-resistant microorganisms. 1102 Category IB
           5.       Follow these same surface cleaning and disinfecting measures for managing the
                    environment ofVRSA patients. 11 10· 111 '- 1118 Category II
      C.   Environmental-surface culturing can be used to verify the efficacy of hospital policies and
           procedures before and afte1· cleaning and disinfecting rooms that house patients with VRE.'·
           1084, JOB?, toss, 1092,1096   Category II
                                                                                                137

     I.      Obtain prior approval from infection-control staff and the clinical laboratory before
             performing environmental surface culturing. Category II
     2.      Infection-control staff, with clinical laboratory consultation, must supervise all
             environmental culturing. Category II
D.   Thoroughly clean and disinfect environmental and medical equipment surfaces on a regular
     basis using EPA-registered disinfectants in accordance with manufacturers' instructions.'"·
     974 1130 1143
        •    •        Category IB, JC (EPA: 7 usc§ 136 etseq.)
E.   Advise families, visitors, and patients about the importance of hand hygiene to minimize the
     spread of body substance contamination (e.g., respiratmy secretions or fecal matter) to
     surfaces. 952 Category II
F.   Do not use high-level disinfectants (i.e., liquid chemical sterilants) on environmental
     surfaces; such use is inconsistent with label instructions and because of the toxicity of the
     chemicals.'· 951 • 952 · 964 Category IC (FDA: 21 CFR &01.5, &07.&7.e)
G.   Because no EPA-registered products are specific for inactivating Clostridium difficile
     spores, use hypochlorite-based products for disinfection of environmental surfaces in those
     patient-care areas where surveillance and epidemiology indicate ongoing transmission of C.
     dijficile.'"· Jt3o, 1141    Category II
H.   No recommendation is offered regarding the use of specific EPA-registered hospital
     disinfectants with respect to environmental control of C. dijficile. Unresolved issue
I.   Apply standard cleaning and disinfection procedures to control environmental
     contamination with respiratmy and enteric viruses in pediatric-care units and care areas for
     immunocompromised patients.'"· 1158 Categmy IC (EPA: 1 usc§ 136 el seq.)
J.   Clean surfaces that have been contaminated with body substances; perform low- to
     intermediate-level disinfection on cleaned surfaces with an EPA-registered disinfectant in
     accordance with the manufacturer's instructions.'"· 974 • 1158 Category JC (OSHA: 29 CFR
     1910.1030 § d.4.ii.A; EPA: 7 USC § 136 et seq.)
K.   Use disposable barrier coverings as appropriate to minimize surface contamination.
     Category II
L.   Develop and maintain cleaning and disinfection procedures to control environmental
     contamination with agents ofCreutzfeldt-Jakob disease (CJD), for which no EPA-registered
     product exists. Categmy II
     1.   In the absence of contamination with central nervous system tissue, extraordinary
           measures (e.g., use of2N sodium hydroxide [NaOH] or applying full-strength sodium
           hypochlorite) are not needed for routine cleaning or terminal disinfection of a room
           housing a confirmed or suspected CJD patient.'"· 1199 Category II
     2.    After removing gross tissue from the surface, use either IN NaOH or a sodium
           hypochlorite solution containing approximately I 0,000-20,000 ppm available
           chlorine (dilutions of I :5 to I :3 v/v, respectively, of U.S. household chlorine bleach;
           contact the manufacturers of commercially available sodium hypochlorite products
           for advice) to decontaminate operating room or autopsy surfaces with central nervous
          system or cerebral spinal fluid contamination from a diagnosed or suspected CJD
           patient.9st, tt7o, I Iss, Jt9t, IJ97~1199, 1201 Category II
           a.     The contact time for the chemical used during this process should be 30 min-I
                     hour.l191, 1197. 1201

             b.    Blot up the chemical with absorbent material and rinse the treated surface
                   thoroughly with water.
             c.    Discard the used, absorbent material into appropriate waste containment.
     3.      Use disposable, impervious covers to minimize body substance contamination to
             autopsy tables and surfaces. 1197 ' 1201 Category IB
138

      M.    Use standard procedures for containment, cleaning, and decontamination of blood spills on
            surfaces as previously described (Environmental Services: JI). 967 Categ01y IC (OSHA: 29
            CFR 191Q 1030 ~d4.ii.A)
            I.     Wear PPE appropriate for a surface decontamination and cleaning task 967• 1199
                   Category IC (OSHA 29 CFR 1910.1030 §d.3.i, ii)
            2.    Discard used PPE by using routine disposal procedures or decontaminate reusable
                   PPE as appropriate!"· 1199 Category IC (OSHA 29 CPR 1910.1030 §d.3.viii)

F. Recommendations-Environmental Sampling
I.    General Information
      A.    Do not conduct random, undirected microbiologic sampling of air, water, and
            environmental surfaces in health-care facilities.'· 1214 Category IB
      B.    When indicated, conduct microbiologic sampling as pmt of an epidemiologic investigation
            or during assessment of hazardous environmental conditions to detect contamination and
            verity abatement of a hazard.'· 1214 Category IB
      C.    Limit microbiologic sampling for quality assurance purposes to I) biological monitoring of
            sterilization processes; 2) monthly cultures of water and dialysate in hemodialysis units; and
            3) short-term evaluation of the impact of infection-control measures or changes in infection-
            control protocols.'· 1214 Category IB

II.   Air, Water, and Environmental-Surface Sampling
      A.    When conducting any form of environmental sampling, identify existing comparative
                                                                                                      1238
           standards and fully document depa1tures from standard methods. 945 • 1214 • 1223 • 1224•
            Category II
      B.   Select a high-volume air sampling device if anticipated levels of microbial airborne
           contamination are expected to be low. 290 · 1218• 1223 • 1224 Category II
      C.   Do not use settle plates to quantity the concentration of airborne fungal spores 290
            Category II
      D.   When sampling water, choose growth media and incubation conditions that will facilitate
           the recovery of waterborne organisms. 945 Category II
      E.   When using a sample/rinse method for sampling an environmental surface, develop and
           document a procedure for manipulating the swab, gauze, or sponge in a reproducible
           manner so that results are comparable. 1238 Category II
      F.   When environmental samples and patient specimens are available for comparison, pe1'form
           the laboratory analysis on the recovered microorganisms down to the species level at a
           minimum and beyond the species level if possible. 1214 Category II

G. Recommendations-Laundry and Bedding
I.    Employer Responsibilities
      A.  Employers must launder workers' personal protective garments or uniforms that are
                                                                             967
          contaminated with blood or other potentially infectious materials.     Category IC (OSHA:
           29 CFR 1910.1030 § d.3.iv)
                                                                                                         139

II.    Laundry Facilities and Equipment
       A.  Maintain the receiving area for contaminated textiles at negative pressure compared with
           the clean areas of the laund1y in accordance with AlA construction standards in effect
           during the time of facility construction.'"· 1261H 262 C11tegory IC (AlA: 7.23.BI,B2)
       B.  Ensure that laundry areas have handwashing facilities and products and appropriate PPE
           available for workers. 120· 967 Category IC (AlA: 7.23.04; osHA: 29 CFR 1910.1030 § d.2.i;;)
       C.  Use and maintain laundry equipment according to manufacturers' instructions. 1250• 1263
           Category II
       D.  Do not leave damp textiles or fabrics in machines overnight. 125 °   Category II
       E.  Disinfection of washing and d1ying machines in residential care is not needed as long as
           gross soil is removed before washing and proper washing and drying procedures are used.
           Category II

III.   Routine Handling of Contaminated Laundry
       A.   Handle contaminated textiles and fabrics with minimum agitation to avoid contamination of
            air, surfaces, and persons. 6• 967 • 1258 · 1259 Categmy IC (OSHA: 29 CFR 1910.1030 § d.4.iv)
       B,   Bag or otherwise contain contaminated textiles and fabrics at the point ofuse. 967
            Category IC (OSHA: 29 CFR 1910.1030 § d.4.;v)
            l,     Do not sort or prerinse contaminated textiles or fabrics in patient-care areas."67
                   Category IC (OSHA: 29 CFR 1910.1030 §d.4.iv)
            2.     Use leak-resistant containment for textiles and fabrics contaminated with blood or
                   body substances. 967• 1258 Category IC (OSHA: 29 erR 1910.1030 § d.4jv)
            3.     Identity bags or containers for contaminated.textiles with labels, color coding, or
                   other alternative means of communication as appropriate.'" Category IC (OSHA:
                   29 CFR 1910.1030 § d.4.;v)
       C.   Covers are not needed on contaminated textile hampers in patient-care areas. Category II
       D.   If laundry chutes are used, ensure that they are properly designed, maintained, and used in a
            manner to minimize dispersion of aerosols from contaminated laundry .1253• 1267- 1270
            Category IC (AAMl: ANSI/AAMl ST65:2000)
            1,     Ensure that laund1y bags are closed before tossing the filled bag into the chute.
                   Category II
            2.     Do not place loose items in the chute. Category II
       E.   Establish a facility policy to determine when textiles or fabrics should be smted in the
            laund1y facility (i.e., before or after washing). 1271 · 1272 Category II

IV.    Laundry Process
       A.  If hot-water laund1y cycles are used, wash with detergent in water 2: 160°F (2:71 °C) for 2:25
           minutes.'· 12° Category IC (AlA: 7.3l.E3)
       B,  No recommendation is offered regarding a hot-water temperature setting and cycle
           duration for items laundered in residence-style health-care facilities. Unresolved issue
       C,  Follow fabric-care instmctions and special laundering requirements for items used in the
           facility, 1278 Category/J
       D,  Choose chemicals suitable for low-temperature washing at proper use concentration if low-
           temperature (<160°F [<71 oc]) laundry cycles are used. 1247• 1281- 1285 Category II
       E,  Package, transport, and store clean textiles and fabrics by methods that will ensure their
           cleanliness and protect them fi·om dust and soil during interfacility loading, transpmt, and
           unloading. 2 Category II

V.     Microbiologic Sampling of Textiles
                                                                                    1286
       A.   Do not conduct routine microbiological sampling of clean textiles. 2'          Category IB
140

      B.    Use microbiological sampling during outbreak investigations if epidemiologic evidence
            suggests a role for health-care textiles and clothing in disease transmission."" Category
            IB

VI.   Special Laundry Situations
      A.   Use sterilized textiles, surgical drapes, and gowns for situations requiring sterility in patient
           care. 7 Category IB
      B.   Use hygienically clean textiles (i.e., laundered, but not sterilized) in neonatal intensive care
           units:"· 1288 Category IB
      C.   Follow manufacturers' recommendations for cleaning fabric products including those with
           coated or laminated surfaces. Category II
      D.   Do not use dry cleaning for routine laundering in health-care facilities. 128"- 1291 Category
           II
      E.   Use caution when considering the use of antimicrobial mattresses, textiles, and clothing as
           replacements for standard bedding and other fabric items; EPA has not approved public
           health claims asserting protection against human pathogens for treated articles. 1306
           Category II
      F.   No recommendation is offered regarding using disposable fabrics and textiles versus
           durable goods. Unresolved issue

VII. Mattresses and Pillows
     A.   Keep mattresses dry; discard them if they become and remain wet or stained, particularly in
          burn units. 131 ll- 1315 Category IB
     B.   Clean and disinfect mattress covers using EPA-registered disinfectants, if available, that are
          compatible with the cover materials to prevent the development of tears, cracks, or holes in
          the cover. 131 ll- 1315 Category IB
     C.   Maintain the integrity of mattress and pillow covers. Category II
          I.     Replace mattress and pillow covers if they become torn or otherwise in need of repair.
                 Category II
          2.    Do not stick needles into the mattress through the cover. Category II
     D.   Clean and disinfect moisture-resistant mattress covers between patients using an EPA-
          registered product, if available. 131 ll- 1315 Category IB
     E.   !fusing a mattress cover completely made of fabric, change these covers and launder
          between patients. 131 1)- 1315 Category IB
     F.   Launder pillow covers and washable pillows in the hot-water cycle between patients or
          when they become contaminated with body substances. 1315 Category IB

VIII. Air-Fluidized Beds
      A.   Follow manufacturers' instructions for bed maintenance and decontamination. Category
           II
      B.   Change the polyester filter sheet at least weekly or as indicated by the manufacturer. 1317• 1318•
            1322 1323
                •     Category II
      C.   Clean and disinfect the polyester filter sheet thoroughly, especially between patients, using
           an EPA-registered product, ifavailable. 1317• 1318• 1322• 1323 CategoryiB
      D.   Consult the facility engineer to determine the proper location of air-fluidized beds in
           negative-pressure rooms. 1326 Category II
                                                                                                        141

H. Recommendations-Animals in Health-Care Facilities
I.     General Infection-Control Measures for Animal Encounters
       A.   Minimize contact with animal saliva, dander, urine, and feces. 136 ,_ 1367 Category II
       B.   Practice hand hygiene after any animal contact.'· 1364 Category IB
            I.    Wash hands with soap and water, especially if hands are visibly soiled. 1364
                  CategoryiB
           2.     Use either soap and water or alcohol-based hand mbs when hands are not visibly
                  soiled. 1364 Category IB

II.    Animal-Assisted Activities, Animal-Assisted Therapy, and Resident Animal Programs
       A.  Avoid selection of nonhuman primates and reptiles in animal-assisted activities, animal-
           assisted therapy, or resident animal programs. 1360- 1362 Category IB
       B.  Enroll animals that are fully vaccinated for zoonotic diseases and that are healthy, clean,
           well-groomed, and negative for enteric parasites or otherwise have completed recent
                                                                                      °
           antihelminthic treatment under the regular care of a veterinarian. 1349• 136    Category II
       C.  Enroll animals that are trained with the assistance or under the direction of individuals who
                                            °
           are experienced in this field. 136   Category II
       D.  Ensure that animals are handled by persons trained in providing activities or therapies
           safely, and who know the animals' health status and behavior traits. 1349• 136 °  Category II
       E. Take prompt action when an incident of biting or scratching by an animal occurs during an
           animal-assisted activity or therapy.
            I.    Remove the animal permanently from these programs. 136      °   Category II
           2.     Repott the incident promptly to appropriate authorities (e.g., infection-control staff,
                  animal program coordinator, or local animal control). 136  °  Category II
           3.     Promptly clean and treat scratches, bites, or other accidental breaks in the skin.
                  Category II
       F.  Perform an ICRA and work actively with the animal handler prior to conducting an animal-
           assisted activity or therapy to determine if the session should be held in a public area of the
           facility or in individual patient rooms.
                                                    1349 136
                                                        •   ° Category II
       G.  Take precautions to mitigate allergic responses to animals. Category II
                                                                                                       1360
            I.    Minimize shedding of animal dander by bathing animals <24 hours before a visit.
                  Category II
           2.     Groom amma . Is to remove Ioose hatr . betore
                                                             c      . ' or usmg
                                                                 a vtstt,     .               . I cape. 1358
                                                                                 a th erapy amma
                  Category!!
       H.   Use routine cleaning protocols for housekeeping surfaces after therapy sessions.
           Category II
       I.  Restrict resident animals, including fish in fish tanks, from access to or placement in
           patient-care areas, food preparation areas, dining areas, laundry, central sterile supply areas,
           sterile and clean supply storage areas, medication preparation areas, operating rooms,
           isolation areas, and PE areas. Category II
       J.  Establish a facility policy for regular cleaning of fish tanks, rodent cages, bird cages, and
           any other animal dwellings and assign this cleaning task to a nonpatient-care staff member;
           avoid splashing tank water or contaminating environmental surfaces with animal bedding.
           Category II

III.   Protective Measures for Immunocompromised Patients
       A.    Advise patients to avoid contact with animal feces and body fluids such as saliva, urine, or
             solid litter box material.' Category II
142

      B.    Promptly clean and treat scratches, bites, or other wounds that break the skin.' Category
            II
      C.                                                                         °
            Advise patients to avoid direct or indirect contact with reptiles. 134  Category IB
      D.    Conduct a case-by-case assessment to determine if animal-assisted activities or animal-
            assisted therapy programs are appropriate for immunocompromised patients. 1349 Category
            II
      E.    No recommendation is offered regarding permitting pet visits to terminally ill
            immunosuppressed patients outside their PE units. Unresolved issue

IV.   Service Animals
      A.    Avoid providing access to nonhuman primates and reptiles as service animals. 1340· 1362
            Category IB
      B.    Allow service animals access to the facility in accordance with the Americans with
            Disabilities Act of 1990, unless the presence of the animal creates a direct threat to other
            persons or a fundamental alteration in the nature of services. 1366· 1376 Category IC (U.s.
            Department of Justice: 28 CFR § 36.302)
      C.    When a decision must be made regarding a service animal's access to any particular area of
            the health-care facility, evaluate the service animal, the patient, and the health-care situation
            on a case-by-case basis to determine whether significant risk ofhann exists and whether
            reasonable modifications in policies and procedures will mitigate this 1·isk. 1376   Category
            IC (Justice: 28 CPR § 36.208 and App.B)
      D.    If a patient must be separated from his or her service animal while in the health-care facility
             I) ascertain from the person what arrangements have been made for supervision or care of
            the animal during this period of separation; and 2) make appropriate arrangements to
            address the patient's needs in the absence of the service animal. Category II

V.    Animals as Patients in Human Health-Care Facilities
      A.  Develop health-care facility policies to address the treatment of animals in human health-
          care facilities.
          I.     Use the multidisciplinary team approach to policy development, including public
                 media relations in order to disclose and discuss these activities. Category II
          2.     Exhaust all veterinary facility, equipment, and instrument options before undertaking
                 the procedure. Category II
          3.     Ensure that the care of the animal is supervised by a licensed veterinarian.
                    Category II
      B.    When animals are treated in human health-care facilities, avoid treating animals in
            operating rooms or other patient-care areas where invasive procedures are performed (e.g.,
            cardiac catheterization laboratories, or invasive nuclear medicine areas). Category II
      C.    Schedule the animal procedure for the last case of the day for the area, at a time when
            human patients are not scheduled to be in the vicinity. Category II
      D.    Adhere strictly to standard precautions. Category II
      E.    Clean and disinfect environmental surfaces thoroughly using an EPA-registered product in
            the room after the animal is removed. Category II
      F.    Allow sufficient ACH to clean the air and help remove airborne dander, microorganisms,
            and allergens [Appendix B, Table B.!.]). Category II
      G.    Clean and disinfect using EPA-registered products or sterilize equipment that has been in
            contact with animals, or use disposable equipment. Category II
      H.    If reusable medical or surgical instruments are used in an animal procedme, restrict future
            use of these instruments to animals only. Category II
                                                                                                                            143

VI.    Research Animals in Health-Care Facilities
       A.   Use animals obtained fi·om quality stock, or quarantine incoming animals to detect zoonotic
            diseases. Category II
       B.   Treat sick animals or remove them from the facility. Category II
       C.   Provide prophylactic vaccinations, as available, to animal handlers and contacts at high risk.
            Category II
       D.   Ensure proper ventilation through appropriate facility design and location. 1395 Category
            IC (U.S. Department of Agriculture [USDA]: 7 USC 2131)
            I.    Keep animal rooms at negative pressure relative to corridors. 1395 Category IC
                   (USDA: 7 USC 2131)
            2.    Prevent air in animal rooms from recirculating elsewhere in the health-care
                  facility. 1395 CategoryiC (USDA:7USC2131)
       E.   Keep doors to animal research rooms closed. Category II
       F.   Restrict access to animal facilities to essential personnel. Category II
       G.   Establish employee occupational health programs specific to the animal research facility,
            and coordinate management of postexposure procedures specific for zoonoses with
            occupational health clinics in the health-care facility. 1013 • 1378 Category IC (U.S. Dcpartmenl
            of Health and Human Services [DHHS}: BMBL; OSHA: 29 CFR 1910.1 030.132-139)
                                                                            1013
       H.   Document standard operating procedures for the unit.         Category IC (DliHS: BMBL)
       I.   Conduct routine employee training on worker safety issues relevant to the animal research
            facility (e.g., working safely with animals and animal handling). 1013 • 1393 Category IC
            (DHHS: BMBL; OSHA: 29 CFR 1910.1030.132-139)
       J.   Use precautions to prevent the development of animal-induced asthma in animal
            workers. 1013 Category IC (DIIHS: BMBL)

I. Recommendations-Regulated Medical Waste
I.     Categories of Regulated Medical Waste
       A.   Designate the following as major categories of medical waste that require special handling
            and disposal precautions: I) microbiology laboratory wastes [e.g., cultures and stocks of
            microorganisms]; 2) bulk blood, blood products, blood, and bloody body fluid specimens;
            3) pathology and anatomy waste; and 4) sharps [e.g., needles and scalpels].' Category II
       B.   Consult federal, state, and local regulations to determine if other waste items are considered
            regulated medical wastes. 967· 1407' 1408 Category IC (States; Authorities having jurisdiction [AHJ];
            OSHA: 29 CFR 1910.1030 §g.2.1; U.S. Department of Transportation [DOl]: 49 CFR 171-180; U.S. Postal Service: C023.8)

II.    Disposal Plan for Regulated Medical Wastes
       A.   Develop a plan for the collection, handling, predisposal treatment, and terminal disposal of
            regulated medical wastes. 967· 1409 Category IC (S1a1es; AHJ; OSHA: 29 CFR 19101030 §g.2.i;)
       B.   Designate a person or persons to be responsible for establishing, monitoring, reviewing, and
            administering the plan. Category II

III.   Handling, Transporting, and Storing Regulated Medical Wastes
       A.   Inform personnel involved in the handling and disposal of potentially infective waste of the
            possible health and safety hazards; ensure that they are trained in appropriate handling and
            disposal methods. 967 Categmy IC (OSHA: 29 CFR 1910.1030 § g.2.i)
       B.   Manage the handling and disposal of regulated medical wastes generated in isolation areas
            by using the same methods as for regulated medical wastes from other patient-care areas.'
            Category II
       C.   Use proper sharps disposal strategies.'" Category IC (OSHA 29 CFR 1910.1030 § d.4.iii.A)
144

            I.      Use a sharps container capable of maintaining its impermeability after waste
                    treatment to avoid subsequent physical injuries during final disposal. 967 Categmy
                    IC (OSHA; 29 CFR 1910.1030 § d.4.iii.A)
            2.      Place disposable syringes with needles, including sterile sharps that are being
                    discarded, scalpel blades, and other sharp items into puncture-resistant containers
                    located as close as practical to the point ofuse. 967 Category IC (OSHA: 29 CFR
                    1910.1030 § dA.iiLA)
            3.     Do not bend, recap, or break used syringe needles before discarding them into a
                   container. 6• 967· 1415 Category IC (OSHA: 29 CFR 1910 !030 § d.2.vii and§ d.2.vii.A)
      D.    Store regulated medical wastes awaiting treatment in a properly ventilated area that is
            inaccessible to vertebrate pests; use waste containers that prevent the development of
            noxious odors. Category IC (States; AHJ)
      E.    If treatment options are not available at the site where the medical waste is generated,
            transport regulated medical wastes in closed, impervious containers to the on-site treatment
            location or to another facility for treatment as appropriate. Category IC (States; AHJ)

IV.   Treatment and Disposal of Regulated Medical Wastes
      A.   Treat regulated medical wastes by using a method (e.g., steam sterilization, incineration,
           interment, or an alternative treatment technology) approved by the appropriate authority
           having jurisdiction (AHJ) (e.g., states, Indian Health Service [IHS], Veterans Affairs [VA])
           before disposal in a sanitmy landfill. Category IC (States, AHJ)
      B.   Follow precautions for treating microbiological wastes (e.g., amplified cultures and stocks
           of microorganisms). 1013 Categmy IC (DHIIS: BMBL)
           I.     Biosafety leve14 laboratories must inactivate microbiological wastes in the laboratory
                  by using an approved inactivation method (e.g., autoclaving) before transport to and
                  disposal in a sanitaty landfill. 1013 Categmy IC (DHHS; BMBL)
           2.     Biosafety level 3 laboratories must inactivate microbiological wastes in the laboratmy
                  by using an approved inactivation method (e.g., autoclaving) or incinerate them at the
                  facility before transport to and disposal in a sanitary landfill. 1013 Category IC
                  (DHHS; BMBL)
      C.   Biosafety levels I and 2 laboratories should develop strategies to inactivate amplified
           microbial cultures and stocks onsite by using an approved inactivation method (e.g.,
           autoclaving) instead of packaging and shipping untreated wastes to an offsite facility for
           treatment and disposal. 1013 · 14 t9- 1421 Category II
      D.   Laboratories that isolate select agents from clinical specimens must comply with federal
           regulations for the receipt, transfer, management, and appropriate disposal of these
           agents. 1412 Category IC (DHHS: 42 CFR 73 § 73.6)
      E.   Sanitary sewers may be used for the safe disposal of blood, suctioned fluids, ground tissues,
           excretions, and secretions, provided that local sewage discharge requirements are met and
           that the state has declared this to be an acceptable method of disposal. 1414 Category II

V.    Special Precautions for Wastes Generated During Care of Patients with Rare Diseases
      A.   When discarding items contaminated with blood and body fluids from VHF patients,
           contain these regulated medical wastes with minimal agitation during handling.'· 203
           Category II
      B.   Manage properly contained wastes from areas providing care to VHF patients in accordance
                                                                                             2 6 203
           with recommendations for other isolation areas (Regulated Medical Waste: III B). ' '
           Category II
      C.   Decontaminate bulk blood and body fluids from VHF patients using approved inactivation
           methods (e.g., autoclaving or chemical treatment) before disposal. 6' 203 Category IC, II
            {States; AHJ)
                                                                                                                 145

        D.     When discarding regulated medical waste generated during the routine (i.e., non-surgical)
               care of CJD patients, contain these wastes and decontaminate them using approved
               inactivation methods (e.g., autoclaving or incineration), appropriate for the medical waste
               category (e.g., blood, sharps, pathological waste).'·'·' 8• 1199 Ctttegory IC, [[ (States; AID)
        E.     Incinerate medical wastes (e.g., central nervous system tissues or contaminated disposable
               materials) from brain autopsy or biopsy procedures of diagnosed or suspected CJD
                         1197 1201
               patients.     '     Category IB

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        detection of Legionella pneumophila in domestic hot water devices. Curr Microbial 1992;25 :19--25.
1463.   (Box 2) Vickers RM, Stout JE, Yu VL. Failure of a diagnostic monoclonal immunofluorescent reagent
        to detect Legione!la pneumophila in envil·onmental samples. Appl Environ Microbial 1990;56:2912-4.
1464.   (Box 2) Flournoy DJ, Belobraydic KA, Silberg SL, Lawrence CH, Guthrie PJ. False postive Legione!la
        pneumophila direct immunofluorscence monoclonal antibody test caused by Bacillus cereus spores. Diag
        Microbial Infect Dis 1988;9: 123-5.
1465.     (Box 2) Bej AK, Majbubani MH, Atlas RM. Detection of viable Legionella pneumophi/a in water by
        polymerase chain reaction and gene probe methods. Appl Environ Microbial 1991;57:597-600.
1466.   Schulze-Robbecke R, Jung KD, Pullman H, Hundgeburth J. Control of Leglonella pneumophila in a
        hospital hot water system. Zbl Hyg 1990;190:84--100.
1467.   Colbourne JS, Pratt DJ, Smith MG, Fisher-Hoch SP, Harper D. Water fittings as sources of Legionella
        pneumophila in a hospital plumbing system. Lancet 1984; 1:210-3.
1468.   U.S. Environmental Protection Agency. National interim primary drinking water regulations: control of
        trihalomethanes in drinking water: final rules. Federal Register 1979;44:68624--705.
1469.   U.S. Environmental Protection Agency. National interim primary drinking water regulations:
        Trihalomethanes. Federal Register 1983;48:8406-14.
                                                                                                     201

Part IV. Appendices

Appendix A. Glossary of Terms
 Acceptable indoor air quality: air in which there are no known contaminants at harmful
 concentrations as determined by knowledgeble authorities and with which a substantial majotity (2:80%)
 of the people exposed do not express dissatisfaction.
 ACGIH: American Conference of Govemmental Industrial Hygienists.
 Action level: the concentration of a contaminant at which steps should be taken to interrupt the trend
toward higher, unacceptable levels.
 Aerosol: particles of respirable size generated by both humans and environmental sources and that
 have the capability of remaining viable and airborne for extended periods in the indoor environment.
AlA: American Institute of Architects, a professional group responsible for publishing the Guidelines
for Design and Construction ofHospitals and Healthcare Facilities, a consensus document for design
 and consiiuction of health-care facilities endorsed by the U.S. Department of Health and Human
 Services, health-care professionals, and professional organizations.
 Air changes per hour (ACH): the ratio of the volume of air flowing through a space in a certain
period of time (the airflow rate) to the volume of that space (the room volume). This ratio is expressed
 as the number of air changes per hour (ACH).
Air mixing: the degree to which air supplied to a room mixes with the air already in the room, usually
 expressed as a mixing factor. This factor varies from 1 (for perfect mixing) to 10 (for poor mixing). It
 is used as a multiplier to determine the actual airflow required (i.e., the recommended ACH multiplied
by the mixing factor equals the actual ACH required).
Airborne transmission: a means of spreading infection when airborne droplet nuclei (small particle
residue of evaporated droplets :'05 f!m in size containing microorganisms that remain suspended in air
for long periods of time) are inhaled by the susceptible host.
 Air-cleaning system: a device or combination of devices applied to reduce the concentration of
 airbome contaminants (e.g., microorganisms, dusts, fumes, aerosols, other particulate matter, and
gases).
Air conditioning: the process of treating air to meet the requirements of a conditioned space by
controlling its temperature, humidity, cleanliness, and distribution.
 Allogeneic: non-twin, non-self. The term refers to transplanted tissue from a donor closely matched to
a recipient but not related to that person.
Ambient air: the air surrounding an object.
Anemometer: a flow meter which measures the wind force and velocity of air. An anemometer is
 often used as a means of determining the volume of air being drawn into an air sampler.
Anteroom: a small room leading from a corridor into an isolation room. This room can act as an
airlock, preventing the escape of contaminants fi·om the isolation room into the corridor.
 ASHE: American Society for Healthcare Engineering, an association affiliated with the American
 Hospital Association.
ASHRAE: American Society of Heating, Refrigerating, and Air-Conditioning Engineers Inc.
Autologous: self. The term refers to transplanted tissue whose source is the same as the recipient, or
 an identical twin.
 Automated cycler: a machine used during peritoneal dialysis which pumps fluid into and out of the
patient while he/she sleeps.
Biochemical oxygen demand (BOD): a measure of the amount of oxygen removed from aquatic
environments by aerobic microorganisms for their metabolic requirements. Measurement of BOD is
used to determine the level of organic pollution of a stream or lake. The greater the BOD, the greater
202

the degree of water pollution. The term is also referred to as Biological Oxygen Demand (BOD).
Biological oxygen demand (BOD): an indirect measure of the co11centration of biologically
degradable material present in organic wastes (pertaining to water quality). It usually reflects the
amount of oxygen consumed in five days by biological processes breaking down organic waste (BODS).
Biosafety level: a combination of microbiological practices, laboratory facilities, and safety equipment
determined to be sufficient to reduce or prevent occupational exposures of laboratory personnel to the
microbiological agents they work with. There are four biosafety levels based on the hazards associated
with the vat·ious microbiological agents.
BODS: the amount of dissolved oxygen consumed in five days by biological processes breaking down
organic matter.
Bonneting: a floor cleaning method for either carpeted or hard surface floors that uses a circular
motion of a large fibrous disc to lift and remove soil and dust from the surface.
Capped spur: a pipe leading from the water recirculating system to an outlet that has been closed off
("capped"). A capped spur cannot be flushed, and it might not be noticed unless the surrounding wall is
removed.
CFU/m 3 : colony forming units per cubic meter (of air).
Chlamydospores: thick-walled, typically spherical or ovoid resting spores asexually produced by
certain types of fungi fi·om cells of the somatic hyphae.
Chloramines: compounds containing nitrogen, hydrogen, and chlorine. These are formed by the
reaction between hypochlorous acid (HOC!) and ammonia (NH3) and/or organic amines in water. The
formation of chloramines in drinking water treatment extends the disinfecting power of chlorine. The
term is also referred to as Combined Available Chlorine.
Cleaning: the removal of visible soil and organic contamination from a device or surface, using either
the physical action of scrubbing with a surfactant or detergent and water, or an energy-based process
(e.g., ultrasonic cleaners) with appropriate chemical agents.
Coagulation-flocculation: coagulation is the clumping of particles that results in the settling of
impurities. It may be induced by coagulants (e.g., lime, alum, and iron salts). Flocculation in water and
wastewater treatment is the agglomeration or clustering of colloidal and finely-divided suspended matter
after coagulation by gentle stirring by either mechanical or hydraulic means, such that they can be
separated from water or sewage.
Commissioning (a o·oom): testing a system or de'>:ice to ensure that it meets the pre-use specifications
as indicated by the manufacturer or predetermined standard, or air sampling in a room to establish a pre-
occupancy baseline standard of microbial or particulate contamination. The term is also referred to as
benchmarking at 77°F (25°C).
Completely packaged: functionally packaged, as for laundry.
Conidia: asexual spores of fungi borne externally.
Conidiophores: specialized hyphae that bear conidia in fungi.
Conditioned space: that part of a building that is heated or cooled, or both, for the comfott of the
occupants.
Contaminant: an unwanted airborne constituent that may reduce the acceptibility of air.
Convection: the transfer of heat or other atmospheric properties within the atmosphere or in the
airspace of an enclosure by the circulation of cutTents from one region to another, especially by such
motion directed upward.
Cooling tower: a structure engineered to receive accumulated heat from ventilation systems and
equipment and transfer this heat to water, which then releases the stored heat to the atmosphere through
evaporative cooling.
Critical item (medical instrument): a medical instrument or device that contacts notmally sterile
areas of the body or enters the vascular system. There is a high risk of infection from such devices if
they are microbiologically contaminated prior to use. These devices must be sterilized before use.
Dead legs: areas in the water system where water stagnates. A dead leg is a pipe or spur, leading from
the water recirculating system to an outlet that is used infrequently, resulting in inadequate flow of
                                                                                                        203

water from the recirculating system to the outlet. This inadequate flow reduces the perfusion of heat or
chlorine into this part of the water distribution system, thereby adversely affecting the disinfection of the
water system in that area.
Deionization: removal of ions from water by exchange with other ions associated with fixed charges
on a resin bed. Cations are usually removed and ft ions are exchanged; Olf ions are exchanged for
anions.
Detritis: particulate matter produced by or remaining after the wearing away or disintegration of a
substance or tissue.
Dew point: the temperature at which a gas or vapor condenses to form a liquid; the point at which
moisture begins to condense out of the air. At dew point, air is cooled to the point where it is at 100%
relative humidity OJ' saturation.
Dialysate: the aqueous electrolyte solution, usually containing dextrose, used to make a concentration
gradient between the solution and blood in the hemodialyzer (dialyzer).
Dialyzer: a device that consists of two compartments (blood and dialysate) separated by a
semipermeable membrane. A dialyzer is usually referred to as an artificial kidney.
Diffuser: the grille plate that disperses the air stream coming into the conditioned air space.
Direct transmission: involves direct body surface-to-body surface contact and physical transfer of
microorganisms between a susceptible host and an infected/colonized person, or exposure to cloud of
infectious particles within 3 feet of the source; the aerosolized pmticles are >5 11m in size.
Disability: as defined by the Americans with Disabilities Act, a disability is any physical or mental
impairment that substantially limits one or more major life activities, including but not limited to
walking, talking, seeing, breathing, hearing, or caring for oneself.
Disinfection: a generally less lethal process of microbial inactivation (compared to sterilization) that
eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms
(e.g., bacterial spores).
Drain pans: pans that collect water within the HVAC system and remove it from the system.
Condensation results when air and steam come together.
Drift: circulating water lost from the cooling tower in the form as liquid droplets entrained in the
exhaust air stream (i.e., exhaust aerosols from a cooling tower).
Drift eliminators: an assembly of baffles or labyrinth passages through which the air passes prior to its
exit from the cooling tower. The purpose of a drift eliminator is to remove entrained water droplets
from the exhaust air.
Droplets: pmticles of moisture, such as are generated when a person coughs or sneezes, or when water
is converted to a fine mist by a device such as an aerator or shower head. These particles may contain
infectious microorganisms. Intermediate in size between drops and droplet nuclei, these particles tend
to quickly settle out from the air so that any risk of disease transmission is generally limited to persons
in close proximity to the droplet source.
Droplet nuclei: sufficiently small particles (1-5 11m in diameter) that can remain airborne indefinitely
and cause infection when a susceptible person is exposed at or beyond 3 feet of the source of these
particles.
Dual duct system: an HVAC system that consists of parallel ducts that produce a cold air stream in
one and a hot air stream in the other.
Dust: an air suspension of particles (aerosol) of any solid material, usually with pmticle sizes ;SI 00 11m
in diameter.
Dust-spot test: a procedure that uses atmospheric air or a defined dust to measure a filter's ability to
remove pmticles. A photometer is used to measure air samples on either side of the filter, and the
difference is expressed as a percentage of particles removed.
Effective leal8,000 daltons [e.g.,
p2 microglobulin]) are removed from blood.
High-level disinfection: a disinfection process that inactivates vegetative bacteria, mycobacteria, fungi,
and viruses, but not necessarily high numbers of bacterial spores.
                                                                                                     205

Housekeeping surfaces: environmental surfaces (e.g., floors, walls, ceilings, and tabletops) that are not
involved in direct delivery ofpatientcare in health-care facilities.
Hoyer lift: an apparatus that facilitates the repositioning of the non-ambulatory patient from bed to
wheelchair or gurney and subsequently to therapy equipment (immersion tanks).
Hubbard tank: a tank used in hydrotherapy that may accomodate whole-body immersion (e.g., as may
be indicated for burn therapy). Use of a Hubbard tank has been replaced largely by bedside post-lavage
therapy for wound care management.
HVAC: Heating, Ventilation, Air Conditioning.
lato·ogenic: induced in a patient by a physician's activity, manner, or therapy. The term is used
especially in reference to an infectious complication or other adverse outcome of medical treatment.
Impactor: an air-sampling device in which particles and microorganisms are directed onto a solid
surface and retained there for assay.
Impingement: an air-sampling method during which particles and microorganisms are directed into a
liquid and retained there for assay.
Indirect transmission: involves contact of a susceptible host with a contaminated intermediate object,
usually inanimate (a fomite).
Induction unit: the terminal unit of an in-room ventilation system. Induction units take centrally
conditioned air and further moderate its temperature. Induction units are not appropriate for areas with
high exhaust requirements (e.g., research laboratories).
Intermediate-level disinfection: a disinfection process that inactivates vegetative bacteria, most fungi,
mycobacteria, and most viruses (patticularly the enveloped viruses), but does not inactivate bacterial
spores.
Isoform: a possible configuration (tertiary structure) of a protein molecule. With respect to prion
proteins, the molecules with large amounts of a-conformation are the normal isoform of that pa1ticular
protein, whereas those prions with large amounts of P-sheet conformation are the proteins associated
with the development ofspongiform encephalopathy (e.g., Creutzfeldt-Jakob disease [CJD]).
Laminar flow: HEPA-filtered air that is blown into a room at a rate of90 ± I 0 feet/min in a
unidirectional pattern with 100 ACH-400 ACH.
Large enveloped virus: vimses whose particle diameter is >50 nm and whose outer surface is covered
by a lipid-containing structure derived from the membranes of the host cells. Examples of large
enveloped viruses include influenza viruses, herpes simplex viruses, and poxviruses.
Laser plume: the transfer of electromagnetic energy into tissues which results in a release of particles,
gases, and tissue debris.
Lipid-containing viruses: viroses whose particle contains lipid components. The term is generally
synonymous with enveloped viroses whose outer surface is derived from host cell membranes. Lipid-
containing viruses are sensitive to the inactivating effects of liquid chemical germicides.
Lithotriptors: instruments used for crushing caliculi (i.e., calcified stones, and sand) in the bladder or
kidneys.
Low efficiency filter: the prefilter with a particle-removal efficiency of approximately 30% through
which incoming air first passes. See also Prefilter.
Low-level disinfection: a disinfection process that will inactivate most vegetative bacteria, some fungi,
and some viruses, but cannot be relied upon to inactivate resistant microorganisms (e.g., mycobacteria
or bacterial spores).
Mal5% of water samples total coliform-positive in a month.
PPE: Personal Protective Equipment.
ppm: parts per million. The term is a measure of concentration in solution. Chlorine bleaches
(undiluted) that are available in the U.S. (5.25%-6.15% sodium hypochlorite) contain approximately
50,000-61,500 parts per million of free and available chlorine.
Prefilter: the first filter for incoming fresh air in a HVAC system. This filter is approximately 30%
efficient in removing particles from the air. See also Low-Efficiency Filter.
Pl'ion: a class of agent associated with the transmission of diseases knowns as transmissible
spongiform encephalopathies (TSEs). Prions are considered to consist of protein only, and the abnormal
isoform of this protein is thought to be the agent that causes diseases such as Creutzfeldt-Jakob disease
(CJD), kum, scrapie, bovine spongiform encephalopathy (BSE), and the human version ofBSE which is
variant CJD (vCJD).
Product water: water produced by a water treatment system or individual component of that system.
Protective envil'onment: a special care area, usually in a hospital, designed to prevent transmission of
opportunistic airborne pathogens to severely immunosuppressed patients.
Pseudoepidemic (pseudo-outbreak): a cluster of positive microbiologic cultures in the absence of
clinical disease. A pseudoepidemic usually results from contamination of the laboratory apparatus and
process used to recover microorganisms.
Pyrogenic: an endotoxin burden such that a patient would receive 2:5 endotoxin units (EU) per
kilogram of body weight per hour, thereby causing a febrile response. In dialysis this usually refers to
water or dialysate having endotoxin concentrations of2:5 EU/mL.
Rani< order: a strategy for assessing overall indoor air quality and filter performance by comparing
airborne particle counts from lowest to highest (i.e., from the best filtered air spaces to those with the
least filtration).
RAPD: a method of genotyping microorganisms by randomly amplified polymorphic DNA. This is
one version of the polymerase chain reaction method.
Recirculated air: air removed from the conditioned space and intended for reuse as supply air.
Relative humidity: the ratio of the amount of water vapor in the atmosphere to the amount necessary
for saturation at the same temperature. Relative humidity is expressed in terms of percent and measures
the percentage of saturation. At 100% relative humidity, the air is saturated. The relative humidity
decreases when the temperature is increased without changing the amount of moisture in the air.
Reprocessing (of medical instruments): the procedures or steps taken to make a medical instrument
safe for use on the next patient. Reprocessing encompasses both cleaning and the final or terminal step
(i.e., sterilization or disinfection) which is determined by the intended use ofthe instmment according to
the Spaulding classification.
Residuals: the presence and concentration of a chemical in media (e.g., water) or on a surface after the
chemical has been added.
Reservoir: a nonclinical source of infection.
Respirable particles: those particles that penetrate into and are deposited in the nonciliated portion of
the lung. Particles> 10 1.11n in diameter are not respirable.
Return air: air removed from a space to be then recirculated.
Reverse osmosis (RO): an advanced method of water or wastewater treatment that relies on a semi-
permeable membrane to separate waters from pollutants. An external force is used to reverse the
normal osmotic process resulting in the solvent moving from a solution of higher concentration to one
of lower concentration.
Riser: water piping that connects the circulating water supply line, from the level of the base of the
tower or supply header, to the tower's distribution system.
208

RODAC: Replicate Organism Direct Agar Contact. This term refers to a nutrient agar plate whose
convex agar surface is directly pressed onto an environmental surface for the purpose of microbiologic
sampling of(hat surface.
Room-air HEPA recirculation systems and units: devices (eitheo· fixed or portable) that remove
airborne contaminants by recirculating air through a HEPA filter.
Routine sampling: envimnmental sampling conducted without a specific, intended purpose and with
no action plan dependent on the results obtained.
Sanitizer: an agent that reduces microbial contamination to safe levels as judged by public health
standards or requirements.
Saprophytic: a naturally-occurring microbial contaminant.
Sedimentation: the act or process of depositing sediment from suspension in water. The term also
refers to the process whereby solids settle out of wastewater by gravity during treatment.
Semicritical devices: medical devices that come into contact with mucous membranes or non-intact
skin.
Seo·vice animal: any animal individually trained to do work or perform tasks for the benefit of a person
with a disability.
Shedding: the generation and dispersion of particles and spores by sources within the patient area,
through activities such as patient movement and airflow over surfaces.
Single-pass ventilation: ventilation in which 100% of the air supplied to an area is exhausted to the
outside.
Small, non-enveloped viruses: viruses whose paoticle diameter is <50 nm and whose outer surface is
the protein of the paoticle itself and not that of host cell membrane components. Examples of small,
non-enveloped viruses are polioviruses and hepatitis A virus.
Spaulding Classification: the categorization of inanimate medical device surfaces in the medical
environment as proposed in 1972 by Dr. Earle Spaulding. Surfaces are divided into three general
categories, based on the theoretical risk of infection if the surfaces are contaminated at time of use. The
categories are "critical," "semicritical," and "noncritical."
Specific humidity: the mass of water vapor per unit mass of moist air. It is expressed as grains of
water per pound of doy air, or pounds of water per pound of doy air. The specific humidity changes as
moisture is added or removed. However, temperature changes do not change the specific humidity
unless the air is cooled below the dew point.
Splatter: visible drops of liquid or body fluid that are expelled forcibly into the air and settle out
quickly, as distinguished from pmticles of an aerosol which remain airborne indefinitely.
Steady state: the usual state of an area.
Sterilization: the use of a physical or chemical procedure to destroy all microbial life, including large
numbers of highly-resistant bacterial endospores.
Stop valve: a valve that regulates the flow of fluid through a pipe. The term may also refer to a faucet.
Substitution fluid: fluid that is used for fluid management of patients receiving hemodiafiltration.
This fluid can be prepared on-line at the machine through a seoies ofultmfilters or with the use of sterile
peritoneal dialysis fluid.
Supply air: air that is delivered to the conditioned space and used for ventilation, heating, cooling,
humidification, or dehumidification.
Tensile strength: the resistance of a material to a force tending to tear it apaot, measured as the
maximum tension the material can withstand without tearing.
Therapy animal: an animal (usually a personal pet) that, with their owners or handlers, provide
supervised, goal-directed intervention to clients in hospitals, nursing homes, special-population schools,
and other treatment sites.
Thermophilic: capable of growing in environments warmer than body temperature.
Thermotolerant: capable of withstanding high temperature conditions.
TLV®: an exposure level under which most people can work consistently for 8 hours a day, day after
day, without adverse effects. The term is used by the ACGJH to designate degree of exposure to
                                                                                                        209

contaminants. TL V® can be expressed as approximate milligrams of particulate per cubic meter of air
(mg/m 3 ). TLVs® are listed as either an 8-hour TWA (time weighted average) or a 15-minute STEL
(short term exposure limit).
TLV-TWA: Threshold Limit Value-Time Weighted Average. The term refers to the time-weighted
average concentration for a normal 8-hour workday and a 40-hour workweek to which nearly all
workers may be exposed repeatedly, day after day, without adverse effects. The TLV-TWA for
"particulates (insoluble) not otherwise classified" (PNOC)- (sometimes referred to as nuisance dust)-
are those particulates containing no asbestos and  revised from Table S3-l in referen~e 4 and has been adapted from the fonnuln for the rate of purging airbome
     contaminant~ presented in reference 1435,
+ Shaded entries denote frequently cited ACH for patient~are areas,
§ Values were derived .fi:om the fonuula:

                           t2 - t1 = -[In (C, I C 1) I (Q J V)] x 60. with t1 = 0 and where

                t1 =initial timepoint in minutes                       t2 = final timepoint in minutes
                C 1 =initial concentration of contaminant              C2 =final concentration of contaminant
                c, j cl = 1 - (removal efficiency /I 00)               Q ~ air flow rate in cubic feet/hour
                V =room volume in cubic feet                           Q/V=ACH

-r   Values apply to an empty room with no aerosol~generati.ng source. \Vith a person present rmd generating
aerosol, this tHble would not apply. Other equations are (Jvnilnble that include a constant generating source.
However, certain disease!> (e.g.., infectious tuberculosis) are not likely to be aerosolized at n constant rate. TI1e
times given assume perfect mixing of the air within the space (i.e .. mixing factor= 1). However. perfect mixing
usun11y does not occur. Remo\·al times will be longer in rooms or areas with imperfect mixing or air st500 CFU/mL would indicate a general decrease in water quality.
                                                                                                       1450
A direct correlation between heterotrophic plate count and biofilm levels has been demonstrated.
Therefore, an increase in heterotrophic plate count would suggest a greater rate and extent of biofilm
formation in a health-care facility water system. The water supplied to the facility should also contain
200 CFU/mL as determined by assay on TSA agar for 48 hrs. at 96.8°F (36°C), and
::;2 endotoxin units (EU) per mL. The dialysate at the end of a dialysis treatment should not contain
>2,000 CFU/mL.'1· ''· '"· '"· '"

3. Water Sampling Strategies and Culture Techniques for Detecting
Legionellae

Legion ella spp. are ubiquitous and can be isolated from 20%-40% of freshwater environments,
including man-made water systems. 1457· 1458 In health-care facilities, where legionellae in potable water
rarely result in disease among immunocompromised patients, courses of remedial action are unclear.

Scheduled microbiologic monitoring for legionellae remains controversial because the presence of
legionellae is not necessarily evidence of a potential for causing disease. 1459 CDC recommends
aggressive disinfection measures for cleaning and maintaining devices known to transmit legionellae,
but does not recommend regularly scheduled microbiologic assays for the bacteria. 396 However,
scheduled monitoring of potable water within a hospital might be considered in certain settings where
persons are highly susceptible to illness and mortality from Legionella infection (e.g., hematopoietic
stem cell transplantation units and solid organ transplant units).' Also, after an outbreak of
224

legionellosis, health officials agree monitoring is necessary to identity the source and to evaluate the
efficacy ofbiocides or other prevention measures.

Examination of water samples is the most efficient microbiologic method for identifYing sources of
legionellae and is an integral part of an epidemiologic investigation into health-care-associated
Legionnaires disease. Because of the diversity of plumbing and HVAC systems in health-care facilities,
the number and types of sites to be tested must be determined before collection of water samples. One
environmental sampling protocol that addresses sampling site selection in hospitals might serve as a
prototype for sampling in other institutions. 1209 Any water source that might be aerosolized should be
considered a potential source for transmission of legionellae. The bacteria are rarely found in municipal
water supplies and tend to colonize plumbing systems and point-of-use devices. To colonize,
legionellae usually require a temperature range of 7TF-l 08°F (25°C-42.2°C) and are most commonly
located in hot water systems. 1460 Legionellae do not smvive dtying. Therefore, air-conditioning
equipment condensate, which frequently evaporates, is not a likely source. 1461

Water samples and swabs from point-of-use devices or system surfaces should be collected when
sampling for legionellae (Box C.1). 1437 Swabs of system surfaces allow sampling ofbiofilms, which
fi·equently contain legionellae. When culturing faucet aerators and shower heads, swabs of surface areas
should be collected first; water samples are collected after aerators or shower heads are removed from
their pipes. Collection and culture techniques are outlined (Box C.2). Swabs can be streaked directly
onto buffered charcoal yeast extract agar (BCYE) plates if the pates are available at the collection site.
If the swabs and water samples must be transported back to a Iaboratoty for processing, immersing
individual swabs in sample water minimizes dtying during transit. Place swabs and water samples in
insulated coolers to protect specimens from temperature extremes.

Box C.l. Potential sampling sites for Legionella spp. in health-care facilities*

                • Potable water systems
                      incoming water main, water softener unit, holding tanks, cisterns, water heater tanks
                          (at the inflows and outflows)

                • Potable water outlets, especially those in or near patient rooms
                      faucets or taps, showers

                  Cooling towers and evaporative condensers
                      makeup water (e.g., added to replace water lost because of evaporation, drift, or leakage),
                        basin (i.e., area under the tower for collection of cooled water), sump (i.e., section of basin
                        from which cooled water returns to heat source), heat sources (e.g., chillers)

                • Humidtiers (e.g., nebullizers)
                     bubblers for oxygen, water used for respirat01y therapy equipment

                  Other sources
                     decorative fountains, irrigation equipment, fire sprinkler system (if recently used), whirlpools,
                       spas

*   Material in this box is adapted from reference 1209.
                                                                                                                          225

Box C.2. Procedures for collecting and processing environmental specimens for
Legionella spp. *

     1.   Collect water (!-liter samples, if possible) in sterile, screw-top bottles.
     2. Collect culture swabs ofintemal surfaces of faucets, aerators, and shower heads in a sterile,
        screw-top container (e.g., 50 mL plastic centrifuge tube). Submerge each swab in 5--10 mL of
        sample water taken from the same device from which the sample was obtained.
     3, Transport samples and process in a laboratory proficient at culturing water specimens for
        Legionella spp. as soon as possible after collection.+
     4, Test samples for the presence of Legionella spp. by using semiselective culture media using
        procedures specific to the cultivation and detection of Legionella spp.§1!

* Matel"ial in this table is compiled from references1209, 1437, 1462-1465.
+ Samples may be tnmspo11ed at room temperature but must be protected from temperature extremes. Samples not processed
   within 24 hours of collection should be refrigerated,
§ Detection of Legionella spp. antigen by the direct fluorescent antibody technique is not suitable for environmental samples.
~ Use of polymerase chain reaction for identification of Legionella spp. is not recommended until more data regading the
   sensitivity and specificity of this procedure are available.

4. Procedure for Cleaning Cooling Towers and Related Equipment

I.   Perform these steps prior to chemical disinfection and mechanical cleaning.
     A. Provide protective equipment to workers who perform the disinfection, to prevent their exposure
         to chemicals used for disinfection and aerosolized water containing Legionella spp. Protective
         equipment may include full-length protective clothing, boots, gloves, goggles, and a full- or
         half-face mask that combines a HEPA filter and chemical cartridges to protect against airborne
         chlorine levels of up to 10 mg/L.
     B. Shut off cooling tower.
         1. Shut off the heat source, if possible.
         2. Shut off fans, if present, on the cooling tower/evaporative condenser (CTIEC).
         3. Shut off the system blowdown (i.e., purge) valve.
         4. Shut off the automated blowdown controller, if present, and set the system controller to
             manual.
         5. Keep make-up water valves open.
         6. Close building air-intake vents within at least 30 meters of the CT/EC until after the cleaning
             procedure is complete.
         7. Continue operating pumps for water circulation through the CT/EC.

II. Perform these chemical disinfection procedures.
    A. Add fast-release, chlorine-containing disinfectant in pellet, granular, or liquid form, and follow
        safety instructions on the product label. Use EPA-registered products, if available. Examples
        of disinfectants include sodium hypochlorite (NaOCI) or calcium hypochlorite (Ca[OCI]z),
        calculated to achieve initial free residual chlorine (FRC) of 50 mg/L: either a) 3.0 lbs [1.4 kg]
        industrial grade NaOCI [12%--15% available Cl] per 1,000 gallons ofCTIEC water; b) 10.5lbs
        [4.8 kg] domestic grade NaOCI [3o/o--5% available Cl] per 1,000 gallons ofCT/EC water; or c)
226

           0.6 lb [0.3 kg] Ca[OClh per 1,000 gallons ofCT/EC water. If significant biodeposits are
            present, additional chlorine may be required. If the volume of water in the CT/EC is unknown,
            it can be estimated (in gallons) by multiplying either the recirculation rate in gallons per minute
            by I 0 or the refrigeration capacity in tons by 30. Other appropriate compounds may be
           suggested by a water-treatment specialist.
      B.   Record the type and quality of all chemicals used for disinfection, the exact time the chemicals
            were added to the system, and the time and results ofFRC and pH measurements.
      C.   Add dispersant simultaneously with or within 15 minutes of adding disinfectant. The dispersant
            is best added by first dissolving it in water and adding the solution to a turbulent zone in the
           water system. Automatic-dishwasher compounds are examples of low- or non foaming, silicate-
            based dispersants. Dispersants are added at I 0--25 Jbs (4.5-11.25 kg) per I ,000 gallons of
           CT/EC water.
      D.   After adding disinfectant and dispersant, continue circulating the water through the system.
           Monitor the FRC by using an FRC-measuring device with the DPD method (e.g., a swimming-
            pool test kit), and measure the pH with a pH meter every 15 minutes for 2 hours. Add chlorine
           as needed to maintain the FRC at_::: I 0 mg/L. Because the biocidal effect of chlorine is reduced
           at a higher pH, adjust the pH to 7.5-8.0. The pH may be lowered by using any acid (e.g.,
           nuriatic acid or sulfuric acid used for maintenance of swimming pools) that is compatible with
           the treatment chemicals.
    E.     Two hours after adding disinfectant and dispersant or after the FRC level is stable at_::: I 0 mg!L,
            monitor at 2-hour intervals and maintain the FRC at_:::IO mg!L for 24 hours.
    F.     After the FRC level has been maintained at_::: I 0 mg!L for 24 hours, drain the system. CT/EC
           water may be drained safely into the sanita1y sewer. Municipal water and sewerage authorities
           should be contacted regarding local regulations. If a sanitary sewer is not available, consult
           local or state authorities (e.g., a department of natural resou1·ces or environmental protection)
           regarding disposal of water. If necessary, the drain-off may be dechlorinated by dissipation or
            chemical neutralization with sodium bisulfite.
      G.   Refill the system with water and repeat the procedure outline in steps 2-7 in I-B above.

III. Perform mechanical cleaning.
     A. After water from the second chemical disinfection has been drained, shut down the CT/EC.
     B. Inspect all water-contact areas for sediment, sludge, and scale. Using brushes and/or a low-
         pressure water hose, thoroughly clean all CT/EC water-contact areas, including the basin, sump,
         fill, spray nozzles, and fittings. Replace components as needed.
     C. If possible, clean CT/EC water-contact areas within the chilJers.

IV. Perform these procedures after mechanical cleaning.
    A. FilJ the system with water and add chlorine to achieve an FRC level of I 0 mg!L.
    B. Circulate the water for I hour, then open the blowdown valve and flush the entire system until
       the water is free of turbidity.
    C. Drain the system.
    D. Open any air-intake vents that were closed before cleaning.
    E. FilJ the system with water. The CT/EC may be put back into service using an effective water-
        treatment program.
                                                                                                      227

5. Maintenance Procedures Used to Decrease Survival and Multiplications
of Legionella spp. in Potable-Water Distribution Systems
Wherever allowable by state code, provide water at 2: I 24 op (2:5 I oq at all points in the heated water
system, including the taps. This requires that water in calorifiers (e.g., water heaters) be maintained at
2:I40°F (2:60°C). In the United Kingdom, where maintenance of water temperatures at?:l22°F (2:50°C)
in hospitals has been mandated, installation of blending or mixing valves at or near taps to reduce the
water temperature to _:Sl 09.4°F (S63°C) has been recommended in certain settings to reduce the risk for
scald injury to patients, visitors, and health care workers. 726 However, Legionella spp. can multiply
even in short segments of pipe containing water at this temperature. Increasing the flow rate from the
hot-water-circulation system may help lessen the likelihood of water stagnation and cooling.'"· 1465
Insulation of plumbing to ensure delive1y of cold (<68°F [<20°C]) water to water heaters (and to cold-
water outlets) may diminish the opportunity for bacterial multiplication. 456 Both dead legs and capped
spurs within the plumbing system provide areas of stagnation and cooling to PD.
                    Parasites:                   Endolimax nana; Entamoeba coli                 1059
                    GranHleg:Mive bacteria       Acinetobacter spp.; Campulobacterfetus         1047, 1048, 1050,
                                                  ~ubsp. Jejuni; Chlamydia spp.; Citrobacter    1053-1055, 1060
                                                 ji-mmdii; Enterobacter spp.; Esclum'cltia
                                                  coli; HehcobacUwpylOJ1; Klebsiella spp.;
                                                  Proteus spp.; Pseudomonas aeruginosa,'
                                                  Serratia marcescens · Shigella s1m.
  Houseflies        Gmmvposith·e bacteria        Bacillus spp.; Euterococcusfaecalis,-          1048. 1060
                                                 Micrococcus spp.; Staphylococcus spp.
                                                 (congnl(lse-neg:ntive), S. am·eus;
                                                 Streptococcus spp,, S. viridans
                    Fungi I yen;ts                Candida spp.; Geotriclmm spp.                 1060
                    Parasites                    Endolimax naua,• Entamoeba coli                1060
                    Vimses                       Rotnviruses                                    1049
                    GranNtegatiYe bacteria       Acinetobacter spp.; Esclwrichifl coli;         1057
                                                 Klebsiella spp.,· Neisseria sicca; Proteus
                                                  ">pp.; Provideucia spp./ Pscudomo11as
                                                 aeruginosa, P. jluorescens
       Ants.        Grmu-positive bacteria        Bacillus spp., B. cereus, B. pumilis;         1057
                                                  Clostridium cochlem1um, C welchii;
                                                  Enterococcusfaecalis,· Staphylococcus spp.
                                                  (coag:nlase--negntivc), S. aureus;
                                                  Sn·eptococcus pyrogencs
                    Gnun-negative bacteria       Acinetobacter spp.,· Cittobacterfi'eundii;     1048
                                                  Enterobacteraerogenes; Morganella
      Spiders
                                                 t/101'/!0tlti
                    Gram-positive bacteria        Stavh •lococcus spp. {congulase-negative)      104&
                    Bl'am-negntive bacteria       Acinetobacter spp.,- Burkholderia cepacia,·    1048
                                                  Ellterbacter agglomerans, E. aerogeues,-
~1ites,   midges
                                                  Ha[nia alvei,' Pseudomonas aer11mnosa
                    Gram-positive bacteria        Staphylococcus .<;.pp. (conguht'ie·ne_gntive)  1048
                    Gram·negative bncteria        Acinetobacter calcoaceticus; Enteobacter       1048
                                                  cloacae                                                     ---·-
 !vlosquitoes
                   -o;,;~;}:po<>itiw bacterin    -E:nterococcu-;-s-p}}."; StCi})i~ylococcus ~ 'li!4&
                                                  (coae:ulnse-negative)
                                                                                                       229

Appendix E. Information Resonrces

The following sources of information may be helpful to the reader. Some of these are available at no
charge, while others are available for purchase from the publisher.

Air andWater
    •   Jensen PA, Schafer MP. Sampling and characterization ofbioaerosols. NIOSH Manual of
        Analytical Methods; revised 6/99. www.cdc.gov/niosh/nmam/pdfs/chapter-j.pdf
    •   American Institutes of Architects. Guidelines for Design and Construction ofHospital and
        Health Care Facilities. Washington DC; American Institute of Architects Press; 200 I. AlA,
        1735 New York Avenue, NW, Washington DC 20006. 1-800-AIA-3837 or (202) 626-7541
    •   ASHRAE. Standard 62, and Standard 12-2000. These documents may be purchased from:
        American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc. 1791 Tullie
        Circle, NE, Atlanta GA 30329 1-800-527-4723 or (404) 636-8400.
    •   University of Minnesota websites: www.dehs.umn.edu             Indoor air quality site:
        www.dehs.umn.edu/resources.htm#indoor          Water infiltration and use of the wet test
        (moisture) meter: www.dehs.umn.edu/remangi.html
    •   The CDC website for bioterrorism information contains the interim intervention plan for
        smallpox. The plan discusses infection control issues both for home-based care and hospital-
        based patient management. www.bt.cdc.gov/agent/smallpox/response-plan/index.asp

Environmental Sampling
    •   ISO. Sterilization of medical devices- microbiological methods, Part l. ISO standard 11737-
        1. Paramus NJ; International Organization for Standardization; 1995.

Animals in Health-Care Facilities
    •   Service animal information with respect to the Americans with Disabilities Act. Contact the
        U.S. Department ofJustice ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383
        (TDD), or visit the ADA website at: www.usdoj.gov/crt/ada/adahom l.htm

Regulated Medical Waste
    •   U.S. Environmental Protection Agency. This is the Internet address on their Internet web site
        that will link to any state for information about medical waste rules and regulations at the state
        level: www.epa.gov/epaoswer/other/medical/stregs.htm

General Resources
    •   APIC Text of!nfection Control and Epidemiology. Association for Professionals in Infection
        Control and Epidemiology, Inc. Washington DC; 2000. (Two binder volumes, or CD-ROM)
    •   Abrutyn E, Goldmann DA, Scheckler WE. Saunders Infection Control Reference Service, 2"d
        Edition. Philadelphia PA; WB Saunders; 2000.
    •   ECRI publications are available on a variety ofhealthcare topics. Contact ECRI at (610) 825-
        6000. CRI, 5200 Butler Pike, Plymouth Meeting, PA 19462-1298.
230

Appendix F. Areas of Future Research
Air
   Standardize the methodology and interpretation of microbiologic air sampling (e.g., determine action
    levels or minimum infectious dose for aspergillosis, and evaluate the significance of airborne
    bacteria and fungi in the surgical field and the impact on postoperative SSI).
   Develop new molecular typing methods to better define the epidemiology of health-care-associated
   outbreaks of aspergillosis and to associate isolates recovered from both clinical and environmental
      sources.
   Develop new methods for the diagnosis of aspergillosis that can lead reliably to early recognition of
   infection.
   Assess the value of laminar flow technology for surgeries other than for joint replacement surgery.
   Determine ifpatticulate sampling can be routinely performed in lieu of microbiologic sampling for
   purposes such as determining air quality of clean environments (e.g., operating rooms, HSCT units).

Water
  Evaluate new methods of water treatment, both in the facility and at the water utility (e.g., ozone,
   chlorine dioxide, copper/silver/monochloramine) and perform cost-benefit analyses of treatment in
   preventing health-care-associated legionellosis.
  Evaluate the role ofbiofilms in overall water quality and determine the impact of water treatments
   for the control of biofilm in distribution systems.
  Determine if the use of ultrapure fluids in dialysis is feasible and warranted, and determine the action
   level for the final bath.
  Develop quality assurance protocols and validated methods for sampling filtered rinse water used
  with AERs and determine acceptable microbiologic quality of AER rinse water.

Environmental Services
   Evaluate the innate resistance of microorganisms to the action of chemical germicides, and
    determine what, if any, linkage there may be between antibiotic resistance and resistance to
    disinfectants.

Laundry and Bedding
   Evaluate the microbial inactivation capabilities of new laundry detergents, bleach substitutes, other
    laund1y additives, and new laundry technologies.

Animals in Health-Care Facilities
  Conduct surveillance to monitor incidence of infections among patients in facilities that use animal
   programs, and conduct investigations to determine new infection control strategies to prevent these
   infections.
  Evaluate the epidemiologic impact of performing procedures on animals (e.g., surge1y or imaging) in
   human health-care facilities.

Regulated Medical Waste
   Determine the efficiency of current medical waste treatment technologies to inactivate emerging
    pathogens that may be present in medical waste (e.g., SARS-coV).
   Explore options to enable health-care facilities to reinstate the capacity to inactivate microbiological
    cultures and stocks on-site.
                                                                                                                                                                           231

Index-Parts I and IV
                                                                                            blood .. 12, 64, 69, 75, 77-79, 86, 87, 98, 99, 102, 113, 116
                                                                                            bloodborne pathogens ............................................. 73, 116
A                                                                                           boil water advisory ................................................... 51,52

AAMI standards ,................................. 59, 60, 62, 222, 223
Acinetobocter spp ............................ l1, 20, 43, 44. 99, 104                      c
aerators ................................ 47, 48, 94, 220--222,224, 225
aerosols ... l2, 27, 41, 47, 56, 59, 67, 75, 76, 78, 80, 85, 89,                            calibrated loop .............................................................. 222
    90, 98, 106, Ill, 113, 114                                                              carpet cleaning ................................................................ 79
AlA guidelines ............................. 17, 18, 19, 25, 37, 39, 99                     carpet tiles ....................................................................... 79
All rooms ................................................................. 35--37          carpeting .................................................. 22, 25, 52, 78, 79
airchangesperhour(ACH) ....... 6, 12, 16, 18,31,111,210                                     cats ......................................................... l05, 106, 108, I 09
air conditioners ........................................................... 8, 22          chain of infection ........................................................ 4, 87
air conditioning systems ............................... 13, 20, 57, 59                     chemical ge1micides ................................ 73, 74, 77, 80, 84
air filtration ................................................................... 111      chloramine/chloramine" T ............................................... 68
air intakes ............................................................... 31, 226         chlorine .................................... 46, 50, 53, 69, 84, 221, 226
air sampling ............................... 26, 29, 89, 90, 91, 93,210                     chlorine bleach ........................................................ 78, 101
airbomc infection isolation (AU) ................................ 6, 19                     chlorine residual ............................ 50, 68, 69, 94, 101,221
airbmne transmission ...................................................... 12              cleaning .. 68, 70--72, 74, 78, 80, 83, 85, 86, 107, 109, 112,
air~ fluidized beds .......................................................... 104              225
alcohol" based hand rubs ................................................. 53               cleaning cloths ................................................................ 75
alkaline glutaraldehyde ................................................... 70              cleaning solutions ..................................................... 75, 76
allergens ............................................................ 17, 80, 107          Clostridium difjicile .................................................... 5, 84
American Institute of Architects (AlA) .......................... 13                        cloth chairs ...................................................................... 79
Americans with Disabilities Act.. ......................... 108, 110                        cockroaches .................................................................... 81
amplified stocks and cultures ................................ l 14, l 15                   coliform bacteria ........................................................... 221
Animal Assisted Activities ................................... 106, l 07                    colonization ...................... .42-44, 68, 70, 83, 99, 106,227
Animal Assisted Therapy ..................................... I 06, I 07                    colony counts ................................................................ 211
anin1al bites ................................................................... 107       coinlnissioning .......................................................... 29, 89
anin1al handler .............................................................. 107          construction ..... 7, 13, 14, 21, 23, 26, 27, 29, 31, 37, 76,89
anilnal patient ............................................................... II 0        constmction workers ........................................... 24, 26,31
Animal Welfare Act., .................................................... 112               contact precautions ......................................................... 85
anterooms ................................................ 12, 25, 33, 3&--38               contact time ................................................ 74, 84, 88, 221
ants ................................................................................. 81   contaminants .......................................... l4, 18, 19, 59,210
ASHRAE ............................................................ 13, 47,49               contaminated fabrics ....................................... 98, 101, 102
aspergillosis ............................... ?, 8, 16, 19, 21, 35, 79,80                   contingency plans ..................................................... 21, 50
Aspergillusfumigatus ............................................. 7, 8, 29                 continuous chlorination ................................................ 227
Aspergillus spp .......................... 5, 7, 20, 21, 28, 32, 34,81                      cooling tower .......................... .41, 53, 55, 57-59, 220, 225
auto1nated cyclers ........................................................... 65           copper/silver ions ............................................................ 54
automated endoscope reprocessor....................... 50, 69, 70                           copper"8"quinolinolate .................................................... 35
autopsy suites/rooms ................................................. 12, 87               Creutzfeldt~Jakob disease ....................................... 86, 116
                                                                                            Cr;ptosporidium parvum ................................................ 46

B
                                                                                            D
bacterial spores ................................................... 73, 84, 89
bank offilters .................................................................. l4        dead legs ........................................................... 59, 64, 221
barrier ............................................................................. 34    decorative fountains .......................................... 47, 49, 224
barrier precautions/protection ......................... 74, 109, 116                       demolition ..................................................... 23, 25, 26, 29
barriers ................................................................ 27, 31, 33        dental unit water lines ..................................................... 71
bassinets .......................................................................... 76     detergent/disinfectant.. .............................................. 74-76
biolilms .................................. 46, 54, 64, 71, 220--222, 224                   dialysate .................................................................... 59-62
biosafety level ............................................................... 114         dialysis machines ............................................................ 64
bioteJTorism ............................................................ 89, 114           dialysis water ................................................................ 222
bird droppings ....................................................... 9, 20, 22            dialyzer., ......................................................................... 62
birthing tanks ............................................................ 67,69           dialyzer membranes ........................................................ 61
232

dialyzer reprocessing ...................................................... 59              floors ............................................................. 25, 75, 82, 83
dioctylphthalate (DOP) particle test.. .............................. 15                     flowers ............................................................................ 80
direct contact. ....................... 6, 41, 67, 85, 86, 98, 108, 111                      flush titnes ....................................................................... 51
direct threat ................................................................... 109        flutter strips ......................................................... 20, 34, 36
disinfectant fogging ........................................................ 75             fomites ................................................................ 3, 4, 7, 85
disinfectant residuals ...................................................... 96             Food and Dmg Administration (FDA) .............. 69, 73, 103
disinfectants ...................................................... 21, 76,225              free residual chlorine ................................ 51, 54, 225-227
disinfecting ........................ 71, 74, 80, 83, 85, 86, 112, 226                       fungal spores ... 8, 15, 16, 19-21,26-28,31,34,38,79, 89,
disinfection ................................................... 63, 64, 68, 70                  93
dispersant ...................................................................... 226        fungi .................................................................................. 8
disposal (of medical waste) ........................................... ll3                  furniture .............................................................. 52, 79, 82
distribution system .................................................. 94,221
dogs ...................................................... 105, 106, 108, 109
dl'ift eliminators ................... ,,,,,,,,,,,,,,,,,,,, ....................... 58       G
drinking water ................................................................. 71
droplet nuclei .............................................. 6, 7, 10, 12, 89
                                                                                             gram-negative bacteria ... II, 41, 42, 48, 50, 60, 63, 64, 221
droplets ..................................................... 6, 55, 85, 86, 89
                                                                                             gram~positive bacteria ............................................... 11, 84
dry cleaning .................................................................. 102
drying .............................................................................. ll
dual-duct system ............................................................. 20
duct cleaning ................................................................... 21         H
ductwork ................................................................... 20, 22
dust .................................... &, 20, 24, 27, 30, 32, 74, 79, 93                  hand hygiene ............................................. 25, 71, 107, 109
dust-spot test ................................................................... l5        hand transferral.. ........................ 3, 44, 65,82-84, 106,221
                                                                                             handwashing ......................................... 25, 80, 84, 99, 107
                                                                                             hantavhuses .................................................................... 12
E                                                                                            hematopoietic stem cell transplant .................................... 6
                                                                                             hemodiafiltration ............................................................. 62
                                                                                             hemodialysis ......................................... 59, 60, 62, 64, 223
education ........................................................................ 24
                                                                                             hemodialysis patients ........................................................ 7
electrical generators ........................................................ 53
                                                                                             hen1ofiltration ................................................................. 62
emergency ....................................................................... 53
                                                                                             HEPA filtration/ftlters ........ 6, 12, 14, 15, 17, 31, 32, 36,76
endotoxin .................................................... 60--62, 64, 223
                                                                                             hepatitis B vilus .................................................. 40, 73, 98
engineering controls ........................................................ 36
                                                                                             heterotrophic plate counts ............. 51, 62, 66, 95, 221-223
enteric viruses ................................................................. 85
                                                                                             high~ flux membranes ............................. ~ ........................ 61
environmental cultures .............................................. 83, 88
                                                                                             high-level disinfectants ..................................... ,............. 73
Environmental Protection Agency (EPA) .... 21,73-75,77,
                                                                                             high-level disinfection ........................................ 60, 69, 72
    103,227                                                                                  high-temperature flushing ............................................... 50
environmental sampling ............................................ 88, 95
                                                                                             high~touch surfaces ............................................. 75,83-85
environmental surfaces ... 11, 44, 71, 72, 74, 82-86, 88, 98,
                                                                                             holding tank .................................................................... 47
    107                                                                                      hospital disinfectant ........................................................ 73
environmental surveillance ....................................... 54, 55
                                                                                             hot water system ....................................................... 51, 54
EPA registration .................................................. 73, 76, 83
                                                                                             hot water tanks ................................................ 53, 220--222
EPA-registered gennicides ........................... 75, 78, 85, 86                         hot \Vater temperature ..................................................... 49
evaporative condensers ....................................... 41, 57-59                     housekeeping surfaces ........................ 3, 64, 72, 74-77, 83
exclusion (of a service animal) ..................................... 109
                                                                                             HSCT patients ............................................................. 6, 37
exotic anin1als ............................................................... 110          HSCT units ........................................... II, 26, 79, 80, 107
                                                                                             Hubbard tanks ................................................................. 68
                                                                                             human hcalth~care facilities .................................. 110, 111
F                                                                                            human immunodeficiency virus ...................................... 73
                                                                                             humidifiers .......................................................... 17, 23,41
fan-coil units .................................................................. 18         humidity ............................................ 13, 14, 17, 20, 38,90
faucets ......................................... .47, 54, 94,222,224, 225                   HVAC systems ................ 13, 14, 16, 17, 19-21,27,30,51
fecal contamination ......................................................... 84             hydrotherapy equipment ........................................... 67-69
F!FRA ..................................................................... 75, 103          hydrotherapy pools ......................................................... 68
filter efficiency ......................................................... 27, 29           hydrotherapy tanks .............................................. 67, 68, 82
filtration .......................................................................... 15     hygienically-clean laundry .............................. 9&-1 00, 102
fire codes ........................................................................ 31       hyperchlorination .......................................... 50, 53, 54, 59
ftsh ........................................................................ I05, 108
fish tanks ....................................................................... l 08
flies ................................................................................. 81
flooding ........................................................................... 51
                                                                                                                                                                             233

I,J                                                                                       M
iatrogenic cases .............................................................. 87        manufacturer's instructions ........... 67, 69, 74, 86, 102, 116
ice machines and ice .................................... 25, 48, 65,66                   material safety data sheets (MSDS) .......................... 75, 87
ice-storage chests ........................................................... 66         1nattress cover ......................................................... 77, 104
immunocompromised patients .... 6, 7, 9, 26,29-31,34,42,                                  mattresses ........................~ ...................................... 77, 104
    47, 56, 66, 80, 107, 108,223                                                          medical equipment.. .................................................. 74, 83
impaction ................................................................ 90, 211        medical equipment surfaces ............................................ 72
ilnpactors .................................................................. 28, 93      medical gas piping .......................................................... 30
impingement ..................................................... 90, 93,211              medical records ............................. ,................................. 51
in1pingers .............. ,....................................................... 211    medicalwaste ............................................... 112, 113,117
inactivation studies ......................................................... 87         medical waste management .......................................... 112
incineration ........................................................... 113, 114         membrane filtration .................................... 70, 95, 96, 222
incubators (nursery) ........................................................ 76          methicillin-resistant Staphylococcus aureus (MRSA) ... 82,
indirect trans1nission ......................................................... 6           83, 104, 105
indirect contact ............................................................... 41       microbial inactivation ..................................................... 72
indoor air ................................................. 21, 24, 26, 27,90            microbial resistance ........................................................ 70
industrial-grade HEPA filter, ........... ,,,,,,,,,,,,, 16, 31, 38,39                     microbiologic air sampling ............................................. 27
infection-control risk assessment (ICRA) .... 26, 29, 31, 35,                             microbiologic cultures and stocks ................................. 112
    108, Ill                                                                              microbiologic sampling .................................................. 64
influenza viruses ............................................. 6, 12, 73, 85             microbiologic sampling of laundry ............................... l 02
innate resistance .................................................. 72, 73, 84           microbiological wastes ......................................... 112, 114
insects ....................................................................... 67,81     moisture ............... ,.......................... ,.. 20, 24, 32, 51, 70, 96
insulation material .......................................................... 20         1noisture tneters ........... ,................................................... 51
intermediate-level disinfectants ............... 73, 78, 83, 85, 86                       molecular typing ............................................................. 28
intermediate-level disinfection ....................................... 72                monochloramine ............................................................. 54
isolation/isolation areas .................................... 11, 36, I 00               mop heads ....................................................................... 75
                                                                                          multidisciplinary team .............................................. 23, 91
JCAHO ......................................................... 13, 14, 51,59             municipal water ................................................ 47, 50, 224
                                                                                          municipal water systems/utilities ............................ 45, 221
                                                                                          Mycobacterium tuberculosis ..................... 5, 7, 10, 73, 114
L                                                                                         myiasis ............................................................................ 81

laboratories, 12, 13, 32, 47, 78, 79, 83, 105, Ill, 112, 114,
    222                                                                                   N
laboratory confi1mation .................................................. 55
laminar airflow ................................................... 18, 34,38             negative airpressure ..... 6, 12, 18, 19, 21, 36, 99,100,104,
laser plumes .................................................................... 40         Ill
laundry ............................................................................ 49   neutralizer chemicals ...................................................... 96
laundry bags ............................................................ ,.... I 00      NIOSH ........... ,........ ,...................... ,, .......... ,, ................... 40
laundry chutes ............................................................... 100        nontuberculous mycobacteria (NTM).5, 41,44-46,60,63,
laundry cycles ............................................................... 101           70, 71, 223
laundry disinfection ...................................................... 101
laundry facility ................................................................ 99
laundry packaging ................................................. 100, 10 l             0
laundry process ................................................. 98, 99, 102
laundl)' services .............................................................. 99       operating rooms ..... 13, 15, 17, 34, 38, 76, 82, 87, 109, 111
laundry transport. .................................................. 100, 101
                                                                                          opportunistic infections ................................................ 4, 5
Legionella pneumophi/a ....................................... 210, 221                   organic matter ................................................................. 78
Legionella spp ... .41, 42, 50, 54-57, 59, 71, 222, 223, 225,
                                                                                          OSHA ...................................... 13, 73, 77, 79, 98, 100, 113
    227                                                                                   outdoorair ............................................... 14, 15,18,25,91
legionellae ................................................. 41, 54, 211, 223
                                                                                          oxygen-based laundry detergents .................................. I 01
legionellosis ...................................................... 53-56, 224
Legionnaires disease ............................. .41, 47, 57, 58, 224
liquid chemical sterilant.. ................................................ 70
low-level disinfectants .................................. 72, 73, 83, 86
                                                                                          p
low-level disinfection ...................... ,........................ 60, 64
                                                                                          pmiicle sampling ................................................. 27, 33, 89
                                                                                          performance measures ...................................................... 2
                                                                                          periodic culturing ............................................................ 57
                                                                                          peritoneal dialysis ..................................................... 64, 65
234

personal protective equipment ..... ??, 98, 99, 112, 114, 225                                 RODAC plates .............................................................. I 02
persons with disabilities ........................................ IO&, 109                   rodents ............................................................................ 67
person~to~person transmission .................................. 12, 85                       rooftops ........................................................................... 30
pest control ..................................................................... 82

~:~~~~~~~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::·i6~          s
pipes .................................................. 64, 69,221,223,224
planktonic organisms .................................................... 221
                                                                                              Sabouraud dextrose agar ................................................. 96
plastic enclosures ............................................................ 31
                                                                                              sample/rinse methods .................... ,................................. 97
plastic wrapping .............................................................. 74
                                                                                              sanitary sewer ....................................................... 116, 117
Pneumocystis cm·inii ......................................................... 9              SARS .............................................................................. 86
pneumonia ................................................................ 42, 55
                                                                                              SARS-CoV ..................................................................... 86
point-of-use fixtures .......................................... 47,51 224
                                                                                              scalding ..................................................................... 49, 51
polyvinylchloridc (PVC) ...........................................             46,   64
                                                                                              screens ............................................................................ 82
pools ............................................................................... 67
                                                                                              scrub suits ................................................................. 98 99
positive air pressure .................................................. 18, 38
                                                                                              sealed windows ............................................. 19, 26, 29' 89
potable water................................................................. 220
                                                                                              sedimentation .................................................... 90, 93, 2tt
potted plants ................................................................ 8, 80
                                                                                              select agents .......................................................... l 14, 115
pr~ssme differentials ............................... l8, 19, 25, 30,38
                                                                                              selfwclosing doors ............................................................ l9
pnmates ........................................................ 105, 106, Ill
                                                                                              semicritical device .......................................................... 70
~~:~~~~··~~;:t~i~~:::::::::::::::::::::::::::::::::::::::::::::::::::::::.~.~·. ~ ~~          service animal ............................................... I 05, I 08-110
                                                                                              settle plat~s ................................................. 28, 90, 93, 211
product Water ............................................................ 64, 70             sewage sp1lls ................................................................... 51
protective environment (PE) ............. 6, 18, 19, 34, 56, I 08
                                                                                              sharps containers ........................................................... 113
Pseudomonas aeruginosa .5, 11, 20, 42, 68, 70, 71, 73, 79,                                    shock decontamination ................................................... 51
   80, 96, I 04, 221
                                                                                              shower heads ................ 47, 49, 54, 220,221, 222, 224, 225
pseudo-~utbrea~<; ...................................................... 44, 70
pyrogenic reactions ................................................... 60,61                 :~~~v;~·:i~~~ti·~~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.~.:.'. ;~
                                                                                              sJnallpox .......................................................................... 36

Q
                                                                                              ::d~~~~~~~~:.:~~:·:::::::·::·:::: . : : : : : .:. : : : :.: : : ~~:·;.q~
quality assurance ................................................. 89, 94, 95                sodium hypochlorite 67, 69, 73, 77, 83, 84, 87, 88, 94, 225
                                                                                              solid-organ transplant program ....................................... 56
                                                                                              sorting (laundry) ..................................................... 98, 100
R                                                                                             Spaulding classification ............................................ 71, 98
                                                                                              spills .................................................................... 75, 77, 79
                                                                                              standard precautions ............................................. 100, lll
R2A n1edia .................................................................... 222
                                                                                              standards .................................... 2, 14, 71, 88, 90,112,223
rank order ........................................................................ 27
                                                                                              Staphy/ococcusaureus ............... IO, 11, 38, 64, 73, 99, 104
~:~:~~~::~:~~ ·~~~~·~·::::::::::::::: : : : : : : : : : : :::::::::::::::::.~.~. . !~         state codes/regulations .............................................. 55, 69
                                                                                              stemnjet ........................................................................ 101
recreational equipment .................................................... 69
                                                                                              steam sterilization (of medical waste) ................... 113, 114
reduced nutrient media .................................................... 94
                                                                                              sterile water..................................................................... 55
reducing agent. ................................................................ 94
                                                                                              storage tanks ............................................................. 63, 64
relative hu1nidity ............................................................. 17
                                                                                              streptococci ........................... ,................................... I 0, 38
reno:ation ..................................................... 13, 14, 23,37                supplemental treatment methods ............... ,..................... 53
repatrs ............................................................................. 31      surgical gowns and drapes ............................................ 103
reprocess hemodialyzers ......................................... 61, 223
                                                                                              surgical site infections (SSI) ............................... 11, 38, 65
research animals ............................................................ Ill
                                                                                              surgical smoke ................................................................ 40
reservoirs ................... 3, 6, 41, 42, 71, 79, 83, 95, 105,211
                                                                                              surveillance ........................................... 26, 51, 57, 99,223
resident animals ............................................................ 107
                                                                                              swabs ............................................................................ 224
respirable particles .............................................. 27, 28, 90
respirators ................................................................. 26 40
respiratory protection ................................................ 36: 78
respiratmy syncytial virus (RSV) ......................... 6, 12, 85                          T
respiratory therapy equipment ...................................... 224
return air ..................... ,................................................... 14      tacky 1nats ....................................................................... 76
return temperature ........................................................... 54             tap wa~er ........................................... 42, 44, 57, 65, 66, 70
rev~r~e osmosis (RO) .............................. 52, 54, 59, 60, 63                        TB patients ...................................................................... 38
l'e\VIr!Og .................................. ,............................... ,,,,,,.,, 25   temperature (air) ........................................... 13, 14, 17, 89
rinse water monitoring .................................................... 70                temperature (water) ................ 40, 45, 49, 68, 101,221,227
                                                                                                                                                                          235

thermostatic mixing valves ................... , ......................... 49             viral hemon-hagic fever ................................................... l2
transport and storage (of medical waste) ...................... 113                       viral particles .................................................................. 11
treated items/products ............................................. 79, 103              viruses ....................................................................... 11,85
tryptic soy agar ................................................. 94, 96, 222            visual rri.onitoring device ................................................. 34
tub liners ......................................................................... 68   volumetric air samplers ................................................... 29
tuberculocidal claim ....................................................... 73           volumetric sampling methods ......................................... 28
tuberculosis (TB) ............................................................ 35

                                                                                          w
u
                                                                                          wallboard .............................................................. 8, 22, 52
ultrapure dialysate.................................. ,,,,,,,,,,,,,,,,,,,,,,,,, 61        walls ............................................................................... 25
ultraviolet germicidal irradiation (UVGI) 14, 16, 17, 36, 38                              washing machines and dryers ....................................... 102
unifonns .................................................................... 98, 99      water conditioning .......................................................... 68
                                                                                          water distribution systems .............................. 64, 221, 227
                                                                                          water droplets .................................................. ,.............. 58
v                                                                                         water pipes ...................................................................... 46
                                                                                          water pressure ................................................................. 50
                                                                                          water quality ............................................................. 71, 94
vacuu1n breakers ....................................................... 47,50
                                                                                          water sampling .......................................... 54, 94, 221, 224
vacuum cleaners ....................................................... 76, 79
                                                                                          water stagnation ............................................................ 227
vacuuming ...................................................................... 79
                                                                                          water treatn1ent system ................................................... 63
vancomycin~resistant enterococci (VRE) .. 3, 5, 82, 83, I 05
                                                                                          walerbome lransrnission ................................................. 46
vancomycin~ resistant Staphylococcus aureus (VRSA) ... 83
                                                                                          weight-arrestance test ..................................................... 15
variable air ventilation .............................................. 20, 38
                                                                                          wet cleaning .................................................................... 79
varicella~zostervims (VZV) ................................... 5, 7, 40
                                                                                          whirlpool spas ..................................................... 59, 67, 69
vase \Vater ...................................................................... 81
                                                                                          whirlpools ................................................................. 68, 69
vegetative bacteria .......................................................... 73
                                                                                          windoVl' chutes ................................................................ 33
ventilation rates .............................................................. 18
                                                                                          Windo\VS .................................................................... 22, 59
ventilation systems ............................................... 8, 9, 111
                                                                                          wood ................................................................. 8, 9, I 5, 35
viable pmticles ............................................................ 9, 91
APPENDIX- ''15''
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                        Pharm<1cy                The OSH Act of 1970 strives to "assure safe and healthful working conditions" for
                                                 today's workers, and mandates that employers provide a safe work environment for
                        S~wgicalSuite I>         employees. Hospitals and personal care facilities employ approximately 1.6 mllllon
                        Expert Systems           workers at 21,000 work sites. There are many occupational health and safety hazards
                                                 throughout the hospital. This eTool* focuses on some of the hazards and controls
                                                 found In the hospital setting, and describes standard requirements as well as
                                                 recommended safe work practices for employee safety and health.

                                                 This eTool addresses the following areas:
                                                        Administratl.Qll
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                                                                                                    Other Healthcare Wtde Ha..~J.illi
                                                        I:!Qlj~ekeep!D_g

                                                       How do I find out about employer responsibilities and worker rights?
                                                       Workers have a right to a safe workplace. The law requires employers to
                                                       provide their employees with working conditions that are free of known
                                                       dangers. The OSHA law also prohibits employers from retaliating against
                                                       employees for exercising their rights under the law {Including the right to
                                                       raise a health and safety concern or report an Injury). For more
                                                       Information see ~.wlli:=iJEJ~!.9.¥.!!~9QY or WL~eLri.Q.h.t$..

                                                       OSHA has a great deal of information to assist employers In complying with
                                                       their l:f..1i.P.Qf1Jiil2l!!tiilli under the OSHA law.

                                                      OSHA can help answer questions or concerns from employers and workers.
                                                      To reach your regional or area OSHA office, go to OSHA's B.e.olonal ~...1.\I~i!
                                                      Offices webpage or calll-800-321-0SHA {6742),

                                                       Small business employers may contact OSHA's free and confidential g~
                                                       ~ll&!t&OMdY.i!;§. to help determine whether there are hazards at their
                                                       worksltes and work with OSHA on correcting any Identified hazards, On~
                                                       s!te consultation services are separate from enforcement activities and do
                                                       not result in penalties or citations. To contact OSHA's free consultation
                                                       service, go to OSHA's ~.!.~Q.!l webpage or ca!ll~S00-321-0SHA
                                                       (6742) and press number 4,

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                                               Workers may file a complaint to have OSHA Inspect their workplace if they
                                               believe that their employer Is not following OSHA standards or that there
                                               are serious hazards. Employees can file a complaint with OSHA by calling
                                               1-800-321-0SHA (6742), online via f'J'&mpliant Form or by printing the
                                               complaint form and mailing or faxing it to your local OSHA area office.
                                               Complaints that are signed by an employee are more likely to result In an
                                               Inspection.

                                               If you think your job Is unsafe or you have questions, contact OSHA at
                                               1-800-321-0SHA (6742). It's confidential. We can help. For other valuable
                                               worker protection Information, such as Workers' Rights, Employer
                                               Responsibll!ties, and other services OSHA offers, visit Q£:!8~~ page.

                                          *eTools are "stand· a/one'~ interactive, Web-based training tools on occupational safety and health
                                          topics. They are highly illustrated and utilize graphical menus as well as expert system modules.
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                                          regulations apply to their work site. As indicated ifl the disclaimer, eToo!s do not create new OSHA
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                                           Administration ) Central Supply I Clinical Services I Dletarv 1 ~ 1 ~ I Healthcare Wide Hawms
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                 ~TOOl$   HOrJ'le : Hospital                                                                          ~.~ry 1 Refe          ~llil!!i.d.l.aundry                                            Sl.!m>LD:in.sLFalls
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                                                                                      Contaminated Work Environments

                                                  Potential Hazard

                                                  Exposure of housekeeping staff to blood or Other Potentially Infectious Materials
                                                  (OPIM) through contaminated work environments. OPIM Is defined in 29 CFR 1901.1030
                                                  (Ill.

                                                  Possible Solutions

                                                  OSHA requires:

                                                  Clean and sanitary work environments to prevent contact with blood or OPIM.
                                                  Bloodborne Pathogens Standard (29 CFR 1910.1030(d)(4)fi)],

                                                  The employer must:

                                                         Determine and Implement an appropriate written schedule for cleaning and methods of
                                                         decontamination.

                                                         This written schedule must be based on the:

                                                                 Location within the facility,

                                                                 Type of surfaces to be cleaned.

                                                                 Type of soU present.

                                                                 The tasks or procedures to be performed In the area.
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Hospital eTool: Housekeeping                                                                                                       Page 2 of5

                                                             Appropriate Disinfectants

                          The CDC states that hepatitis B virus can survive for at least one week In dried blood
                          on environmental surfaces or contaminated needles and instruments.

                          Potential Hazard

                          Exposure of housekeeping staff to blood or OPIM by not using an appropriate or
                          approved disinfectant.

                          Possible Solutions

                          Who determines which disinfectants are appropriate?

                          Appropriate or approved disinfectants are determined by the EPA (US Environmental
                          Protection Agency), which oversees the registration of anti-microbial products. A llst
                          maintained by the Office of Pestk!ct?. Prom~ provides the most recent Information
                          available from the EPA on registered anti-microbials.

                          What disinfectants does OSHA recommend?
                                OSHA requires that work surfaces be cleaned with an "appropriate disinfectant." Appropriate
                                disinfectants Include a diluted bleach solution and EPA-registered antimicrobial products such
                                as tuberculocldes (list B), ster!lants (List A), products registered against HIV/HBV (list E),
                                and Sterila..!ltiLt~llllli'&oflli1m1..t1 for equipment sterilization.

                                       Fresh solutions of diluted household bleach made up every 24 hours are also
                                       considered appropriate for disinfection of environmental surfaces and for
                                       decontamination of sites. Contact time for bleach Is generally considered to be the
                                       time It takes the product to air dry.

                                       NOTE: Products registered by the EPA as HIV effective are not necessarily effective
                                       against tuberculosis (tuberculocidal) or against the hepatitis B virus (HBV).
                                Any of the above products are considered effective when used according to the
                                manufacturer's Instructions, provided the surfaces have not become contaminated with
                                agents or volumes of or concentrations of agents for which higher level disinfection is
                                recommended.

                                It is Important to emphasize the EPA-approved label section titled "SPECIAL INSTRUCTIONS
                                FOR CLEANING AND DECONTAMINATION AGAINST HIV-1 AND HBV Of SURFACES\OBJECfS
                                SOILED WITI-1 BLOOD\BODY FLUIDS." On the labels that OSHA has seen, these Instructions
                                require: 1) personal protection devices for the worker performing the task; 2) that all the
                                blood must be cleaned thoroughly before applying the disinfectant; 3) that the disposal of
                                the Infectious waste Is In accordance with federal, state, or local regulations; 4) that the
                                disposal of the Infectious waste Is in accordance with federal, state, or local regulations; and
                                5) that the surface is left wet with the disinfectant for 30 seconds for HIV-1 and 10 minutes
                                for HBV. OSHA would expect all such disinfectants to be used In accordance with their EPA-
                                approved label instructions, Q.SHA Dltectlve CPL 02·02··069. Enforcement Procedures for the
                                Occupational Exposure to Bloodborne Pathogens,

                                OSHA has commented on disinfectants In the following Interpretation letters and documents:

                                       Disinfectants claiming efficacy against the Hepatllis 8 virus. (1997, Apr!! 1).

                                       Ou!ck Reference Guide to   HH~   Bloodborne Pathoqens Standard. OSHA.

                                                             Contaminated Equipment

                          Potential Hazard
                          Employee exposure to blood or OPIM through contact with contaminated:

                                Equipment and working surfaces

                          Possible Solutions

                          OSHA requires:

                          Equipment and working surfaces:

                          All equipment and environmental and working surfaces shall be cleaned and
                          decontaminated after contact with blood or other potentially infectious materials [22.
                          CFR 1910.1030(dl{4){li)J,

https://www.osha.gov/SLTC/etools/hospital/housekeeping/housekeeping.html                                                             9/2/2015
Hospital eTool: Housekeeping                                                                                                          Page 3 of5

                                 Contaminated equipment, such as IV poles, require labels or tags In accordance with .l.2..Q:.B
                                 1910 103d(Q)..(l)CUU:i). The labels must also Identify which portions of the equipment are
                                 contaminated.

                                        Some equipment, if grossly contaminated, must be cleaned with a soap and water
                                        solution prior to decontamination, as some anti-microbial products will not work in the
                                        presence of blood, which intetferes with the sterlllzlng process.
                           Protective coverings:

                                 Protective coverings, such as plastic wrap or aluminum foil, shall be removed and replaced
                                 as soon as possible, when they become overtly contaminated, or at the end of a work shift if
                                 they may have become contaminated during the shift [29 .Cf.:RJ.9.lllJ.QJ_Q(d).(1}(ll).(BJJ.
                           Reusable Containers:
                                 All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable
                                 likelihood for becoming contaminated with blood or other potentially Infectious material shall
                                 be inspected and decontaminated on a regularly scheduled basis and cleaned and
                                 decontaminated immediately or as soon as feasible upon visible contamination [29 frf/3
                                 1910.1 03Q[Ql(1l(i!lliJ].

                           Glassware:
                                 Broken glassware which may be contaminated, must not be picked up directly with hands;
                                 use mechanical means, such as use a brush and dustpan, tongs or forceps [29 CFR
                                 191 Q,jj),]lli..lt
                          ~.

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                                                                  Hazardous Chemicals

                          Potential Hazard
                          Exposure to hazardous cleaning chemicals found and used in the laundry or
                          housekeeping process.

                                 Soaps and detergents may cause allergic reactions and dermatitis.

                                 Broken skin from soap or detergent Irritation may provide an avenue for Infection or Injury if
                                 exposed to chemical or biological hazards.

                                 Mixing cleaning solutions that contain ammonia and chlorine w!ll form a deadly gas.

                          Possible Solutions

                          Implement a written program which meets the requirements of the Hazard
                          Commu.ni!;illiQ.o.....S.tiH!!.iard (HCS) to provide for worker training, warning labels, and access
                          to Material Safety Data Sheets (MSDS).

                               • The Hazard Communication Standard ensures employee awareness of the hazardous
                                 chemicals they are exposed to In the workplace.

                          Provide appropriate PPE: (e.g., gloves, goggles, splash aprons), when handling
                          hazardous d!shwashlng detergents and chemicals [29 CFR 1910.132]. For more
                          Information see H.~.aJ.t.b~-~.r.§...WJd.!il..HJg~.n.t~ ..:..PJ~!;.

                          Medical SeiVices and First Aid: Where the eyes or body of any person may be exposed
                          to Injurious corrosive materials, suitable facilities for quick drenching or flushing of the

https://www.osha.gov/SLTC/etools/hospital/housekeeping/housekeeping.html                                                                9/2/2015
Hospital eTool: Housekeeping                                                                                                                              Page 5 of5

                                         eyes and body shall be provided within the work area for Immediate emergency use {.?2
                                         CFR 1910.15Hc)],

                                         fE'm For additional Information, see Healthcare Wide Hazards- Hazardous Chemicals,

                                                                                     Latex Allergy

                                         Potential Hazard

                                         Exposure to latex allergy from wearing latex gloves, during housekeeping processes.

                                         Example Controls

                                                Employers must provide appropriate gloves when exposure to blood or other potentially
                                                Infectious materials (OPIM) exists {JllEJU.QlQ,JQ}\1 Bloodborne Pathogens Standard].

                                                     • Alternatives shall be readily accessible to those employees who are allergic to the
                                                       gloves normally provided [29 CFR 1910.1030(d)(3l{lj!)],
                                                Eliminate the unnecessary use of latex gloves when no risk of exposure to Blood or Otht>r
                                                Potft.QliQ!!Y. Infectious Matc>rjals (OPIM) exists.

                                         !Ell,~ For additional Information, see HealthCare Wide Hazards- Latex Allergy.

                                                                                                                                       Back to Top

                                                                                  Slips/Trips/Falls

                                         Potential Hazard

                                         Exposure to wet floors, and possible slips, trips, and falls.

                                         Possible Solutions

                                                Maintain floors in a clean and, so far as possible, dry condition, and mats provided where
                                                practicable. Walking/Working Surfaces Standard [29 CFR 1910.22{a}(2U.

                                                Provide warning signs for wet floor areas [.22._£FR l91JL145fclQ)].

                                         Other Recommended Good Practices:

                                                Implement a program to provide safe, immediate, dean-up of floor spills.

                                                Housekeeping procedures such as only cleaning one side of a passageway at a t!me,
                                                providing good lighting for all halls and stairwells can help reduce accidents.

                                               Instruct workers to use the handrail on stairs, to avoid undue speed, and to maintain an
                                               unobstructed view of the stairs ahead of them·even if that means requesting help to manage
                                               a bulky load.

                                               Eliminate uneven floor surfaces.

                                         l[JII For additional Information, see Healthcare Wide Hazards- Sllps/Trips!Falls.
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