Facilitator:
Terri Stoner

1. Review literature; study current practices to recommend the establishment of a standard UI Hospitals and Clinics protocol for use of high level disinfectants.
2. Review cleaning and high-level disinfection practices leading to standardization of product purchases and appropriate use and disposable of disinfectant.
3. Evaluate and recommend an acceptable standard disinfectant product.
4. Evaluate and recommend the most cost effective and safe location for disinfection to be performed. Include a procedure for Safety and Security to assess exposure in all work places identified.
5. Define appropriate cleaning methods for disinfection or sterilization based on Manufactures guidelines.
6. Identify disinfection dilution or concentrations required.
7. Evaluate current practices and propose changes to standardize use procedures to comply with current standards that are applicable.
8. Evaluate and propose improved patient and staff safety practices in the use of high level disinfectants. Include evaluation and testing of solutions, environment, and staff exposure.
9. Identify all budgetary savings by specific MFK and/or necessary revisions associated with teams recommendations.

After a through review of the literature, we documented the policies and procedures that were required for use of High Level Disinfectants. We then created a UI Hospitals and Clinics policy for the use of High Level Disinfectants that once approved will become hospital wide policy.

1. The Protocol developed by the team includes cleaning and disinfection practices.
2. Product standardization occurred as it was discovered that 2 percent gluteraldehyde was being purchased from two different vendors and distributed by two different departments in the hospital. We will be converting all users to Processed Stores as their supplier and will be using a Novation Supply Contract for savings of over 21 percent.
3. Safety for the use of the product and for the staff using the product were the major issues the team hoped to clearly define in the new protocol. Eye wash stations will need to be installed in each area that uses this product. Environmental monitoring will need to be done annually at each location to ensure that the levels of gluteraldehyde present are below the OSHA standard of 0.2 PPM.
4. Cleaning methods and disinfection guidelines were established based on the manufacturer guidelines for the specific product. Products varied per area, but the same standard for cleaning and disinection was consistently applied to all decisions.
5. Team recommended a concentration of 2.4 percent Glutaraldehyde Solution.
6. The team evaluated all practices were able to eliminate the use of high-level disinfection in favor of more desirous cleaning or sterilization practices.
7. An educational piece, which includes use of high level disinfectants and staff safety, is being rolled out for each area that uses gluteraldehyde. Each employee will be in-serviced as to the proper use of the product and the dangers of using the product. Each employee will then be given a test to make sure that they understand how the product can be used. This testing of staff knowledge will be done annually and filed in their personal folders. Areas using glutaraldehyde will be evaluated annually or as directed by Safety and Security. Safety and Security will contact areas using glutaraldehyde to schedule testing. If a change in process or location occurs, contact the Safety and Security office.

To determine if the Minimum Effectiveness Concentration (MEC) of the glutaraldehyde solution is still effective, the glutaraldehyde being used must be tested daily (or before use) with the appropriate solution test strip. This information should be logged.

The Savings identified will be in product standardization, $5,417 per year.

The major barrier for this project was identifying those areas that use gluteraldehyde and finding out why they were using it. We continue to find areas that are using one or two gallons of this solution a year. Once areas were identified, we were able to contact specific users and determined whether or not disinfection or sterilization would be the best way to provide their products. Of the 28 users identified, only 16 remain as needing high level disinfection in their procedures.

1. Each area that uses gluteraldehyde will be sampled using an active sampling system. This will be coordinated with Safety and Security, Eric Bauer an industrial hygienist will do the initial sampling and establish a baseline for each area.
2. The need for eyewash stations will be reviewed with Chuck Kupka, Director Safety and Security. If needed requisitions will be prepared for Facility Services to install.
3. The entire committee will put a gluteraldehyde spill kit together so each area will have access to the proper products should there ever be a need to clean up a minor spill.
4. The policy will be presented for approval to HAC Subcommittees, Infection Control and Safety for inclusion in their minutes. The final report will be presented for acceptance at the Subcommittee Coordinating the Value Analysis Program.
5. The approved hospital wide protocol on the use of gluteraldehyde will be distributed to all user areas.
6. The Department of Pharmacy budget will be adjusted by the reduction in costs to supply gluteraldehyde to users, and the users budgets will be adjusted to accommodate the cost of ordering gluteraldehyde from Processed Stores. This will take effect in the next budget cycle.
7. The Processed Storeroom will be notified that usage of gluteraldehyde will be increasing slightly so they can best manage their inventories.
8. Mike Murphy, CSS Manager, will monitor areas requesting or using gluteraldehyde.
9. With the approval of the protocol and new policy guidelines we are assured that all areas following these recommendations will be in compliance with OSHA.

In addition of the operation savings that will be realized by multiple UI Hospitals and Clinics departments, we have also improved the process for product standardization, sterilization and disinfection. The safety of the products used by patients and the safety of the staff disinfecting the products has been greatly improved..