This week I will be giving a talk to the Podiatric Assistants at the APMA National Meeting in Boston on the topic of office infection control. I believe that this is an area which does not receive enough attention since it is far from “sexy” or cutting edge but is still important. Last year I sat in on discussions by the Clinical Practices Committee of The American Podiatric Medical Association in an attempt to come up with some Guidelines for disinfection and sterilization of instruments for the podiatric physician. This document, available online for members of APMA by searching the term “disinfection” in the Members Section at www.apma.org, incorporates information from the CDC document “Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008” also available online at http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf. Much of the CDC document is not directly applicable to daily office practice, thus the need for the specialized Guidelines.
In the APMA document we approached podiatric instrumentation much the same way as the dentist classify their instruments. They are broken down into 3 categories:
Critical Instruments: These are any object that enters sterile tissue or the vascular system and therefore must be sterile because any contamination could transmit disease. These would include any instrument used in a surgical procedure. These instruments should be sterilized.
Semi-critical Instruments: These instruments contact non intact skin. Examples would include tissue nippers or curettes used in debridement of an ulceration or incision and drainage of an abscess. These devices require high level disinfection.
Noncritical Instruments: These come in contact with intact skin or nails. Virtually no risk has been documented for transmission of infection through noncritical instruments. Examples would include nail nipper and burrs or handles used for debridement of keratotic lesions. Low level disinfection can be used by intermediate level disinfection is recommended.
Sterilization is the complete elimination of all vegetative bacteria, fungi and viruses along with any bacterial spores. It can be achieved through a number of methods including the most commonly used steam/autoclave with a recommended minimum exposure of 30 minutes at 121° C. Other techniques such as gas sterilization with ethylene oxide for moisture or pressure sensitive devices can also be used. In the current document, based on FDA findings in dental offices, glass bead sterilization is not recommended.
Disinfection has been broken down into 3 “levels”:
High level disinfection: This is the complete elimination of all microorganisms on an instrument except for a small number of spores. It is usually accomplished with a chemical such as glutaraldehyde.
Intermediate level disinfection: Destroys all vegetative bacteria, viruses and fungi but not bacterial spores. This can be accomplished with phenolic compounds, iodophor, alcohol or chlorine.
Low level disinfection: Destroys all vegetative bacteria (except tuburcule bacilli) viruses and fungi but no spores.
Finally, the APMA Guidelines discuss the need for various levels of disinfection with debridement procedures. Debridement is broken down into manual, mechanical and dust extraction:
Manual: Instruments used in the manual debridement of nails such as nipper and curettes should be cleaned with intermediate level disinfectants. Scalpel blades should not be reused and their handles can be treated as non-critical instruments.
Mechanical: Burrs should be thoroughly cleaned of any nail debris/dust and then treated with intermediate level disinfectants as noncritical instruments.
Dust Exposure Precautions: The APMA recommends a dust extraction system or other safeguards to avoid exposure. This may fall more under an OSHA recommendation than an infection control practice but I feel it is a critically overlooked precaution in many podiatric offices (as evidenced by the response I receive when I talk to Podiatric Assistants about this issue!).
This was just a superficial review of a complex topic but it is one of importance to all practices. These Guidelines are practical and quite “do-able”. I remember sitting in on a lecture on office infection control at a Washington State Pod Med Assoc meeting a few years ago. This talk, given by an infection control nurse working with a local county’s health department, basically required every single surface of the treatment room to be covered in disposable plastic drapes before each and every patient and thoroughly wiped down between patients. It was far from practical and would have bankrupted the practice! If we don’t follow basic infection control procedures as outlined in this APMA document who knows what agency will be telling us what to do next.