audiometry

Cleaning and storing equipment


Store equipment and attachments

Cleaning and storing equipment is important for infection control and hygiene. Correct storage will ensure longevity of your equipment as well as reduce the need for calibration outside of the normal calibration period.

Otoscope speculae, impression syringes and ear lite should be cleaned after each client in accordance with infection control guidelines.
Insertion gain tubes need to be cleaned with an alcohol wipe after each use or replaced, and then calibrated.

Go to Resource 2 and Work through the resource Certificate IV in Audiometry–HLT02-8 – 3064-8/HLSP (Equipment) if you have not already done so. [WHAT IS THIS?]
Read the entire resource and do all activities and exercises.
Remember: At the end of the day, all equipment should be checked and switched off.

Care for equipment being transported

Sometimes a home visit is required or equipment needs to be transported to a visiting site. When transporting equipment, it is important to observe these guidelines:
• Large pieces of equipment such as an audiometer and tympanometer should have their own specially designed travelling cases to protect them from damage. These cases are lined with foam to reduce movement, which also reduces the chance of calibration being affected.
• If your equipment is moved often, it will need to be calibrated more than once a year.

If travelling with a Real Ear Machine, a secure case designed for the purpose should be used to avoid damage. In this case, equipment should be calibrated by a qualified technician more often.
Check manufacturer’s instructions for further details.

Clean environmental surfaces and audiometry equipment

Cleaning is part and parcel of infection control — and infection control is part of risk management in any health facility. In this topic, we look at the importance of cleaning in containing the spread of infections. We will examine the use of personal protective equipment, the various cleaning techniques as well as the storage of cleaning equipment.
Remove all dust, dirt and physical debris from work surfaces

The importance of cleaning

Dust, soil and microbes on surfaces can all transmit infection. Cleaning removes foreign material and reduces the numbers of infectious agents and thus makes transmission of infectious organisms less likely.
The cleaning practices discussed here include cleaning of general surface areas such as floors, walls, vents, ceilings, furniture and fittings, and work surfaces. To be infection-free, most of these need only be clean and dust-free. Also covered is the important task of cleaning audiometry equipment.

Every health care facility must have documented policies and practices to ensure its environment is clean. These policies must specify:
• the areas and equipment that need cleaning, how they will be cleaned and how often
• how waste will be disposed of — soiled materials, chemicals sharps, etc
• the method of cleaning sterilising and related equipment - how often, the specific cleaning materials to be used and any manufacturer operating instructions that need to be observed.

Cleaning practices based on risk levels

Health care facilities must comply with set cleaning standards, but not all areas are equally vulnerable to the spread of infection, so not all surfaces need the same level of cleaning.
As a minimum, all surfaces should look clean and have no wet or dry residues or staining. How clean an area or surface must be depends on what it is, where it is and how it is used.

Practical cleaning procedures

Wherever possible, everything in the hearing clinic should be easy to clean. A hard floor is easier to keep clean than carpet. A smooth, non-porous work surface is less likely to harbour infection than a rough or damaged one.
• Try to develop cleaning procedures that make the task easier, safer to do and easier to monitor.
• Display cleaning policies and practice for each area on a prominent noticeboard.
• Establish cleaning routines with set tasks and set intervals. Clean more often and more thoroughly in areas of greater risk.
• Make sure all cleaning staff are trained so they know what to do and how.
• Use checklists to record completed cleaning routines.
• Always wear PPE and protective clothing when doing general cleaning and cleaning of equipment.

Workflow

Be aware of the need to perform cleaning tasks in a logical sequence to avoid dirtying what you have already cleaned. For example:
• carry out surface cleaning before mopping or vacuuming
• work from clean areas to contaminated or dirty areas.

Floors

Vacuum carpets and clean hard floors daily. Sweeping with an ordinary broom releases dust and bacteria into the air and so is not suitable. Choose a method that avoids this, such as:
• a vacuum cleaner that retains particles and directs exhaust away from the floor
• a ducted vacuum cleaner, properly vented
• damp dusting with a dust-retaining mop, using detergent and hot water. Wipe or mop the surface until it is thoroughly wet, then use clean dry cloths or wrung mop heads to soak up all excess fluid. If weather conditions or poor ventilation prevents rapid drying, you may need to wipe the surface dry.

Wash buckets and mops after use with detergent and water and store them dry. Ideally, detachable mop heads should be used and these should be sent to a commercial laundry at the end of each day.
Hard floor sealers need to be periodically stripped and reapplied. Sealing the floor makes cleaning more effective and may increase slip resistance. It also extends the life of the floor.

Walls and fittings

Generally, walls, blinds and curtains need less attention than floors unless they are in areas where soiling often happens (particularly if soiling is with blood or other body fluids). They should all be cleaned regularly and when visibly soiled. Curtains need changing regularly.

Note that wet surfaces are hazardous and should have some form of barrier or warning notice to prevent slips and falls.
Source: Infection Control (Health) Toolbox. © Australian National Training Authority (ANTA) 2004.

Clean all work surfaces with a neutral detergent and warm water solution daily or when visibly soiled
Most routine cleaning tasks require only detergent and water. The detergent should remove soiled materials, suspend them in water and rinse away leaving little residue. A neutral pH detergent is best for environmental cleaning because it is less likely to damage metal or irritate skin. Disinfection is not needed for routine surface cleaning. If you do use a disinfectant, only use one approved for your workplace. If cleaning procedures at your facility do not specify chemicals to use, consider what other facilities use and check available material safety data sheets (MSDS).

A MSDS is a document prepared by the manufacturer of a hazardous substance to:
• identify the product
• describe the product’s properties, uses, health risks
• to be given by the supplier to the purchaser
• be made available by the employer to anyone using the product.

Cleaning agents

What cleaner is used for what occasion? There are a multitude of cleaners available on the market each claiming to kill more germs than the others. They come as foams, aerosols, liquids, gels and sprays. How many can you think of?

Search the Internet to find out about the various cleaning agents available. Use search keywords such as ‘cleaning products’ and cleaning supplies’.

Each hearing clinic uses its own particular cleaning products. When you use a new cleaning product it is extremely important to read the label and follow the manufacturer’s guidelines on the container. Also if you are cleaning, using any chemical agent, wear gloves to prevent any reaction with your skin. It is important to know what product is used in what situation. You must also know the precautions to be taken when using each product and who to contact and what to do in the event of a spill, splash or poisoning.
POISONS INFORMATION HELP LINE 13 11 26

If the area, that requires cleaning, is low in micro-organism activity and has infrequent use or contact, then cleaning with hot, soapy water will be sufficient. Basic scrubbing with hot, soapy water is effective for most low germ areas — it will remove all surface bacteria. Using strong chemical cleaners where it is not necessary is not only expensive but is also harmful to the environment. Where possible, use hot soapy water or environmentally friendly cleaners.

Surface cleaning of non-critical areas

Routine cleaning

Clean with detergent and hot water solution and remove spillages as they occur.
In some situations, electrostatically-charged cloths and hot water without any chemicals may be suitable, however special techniques are needed for using these cloths – a fresh surface of the cloth needs to be used for each new surface being cleaned. Also, these cloths need to be laundered at 90 degrees Celsius, like theatre linen.

If you need to also disinfect the surface, follow the disinfectant manufacturer’s instructions on use and safety precautions and keep out of the reach of children.
Keep a mop, bucket, detergent and disinfectant in a convenient place, easily accessible to all workers. Launder cleaning cloths regularly.

Work surfaces
Clean and dry work surfaces daily or when you can see the surface is dirty. Remember this includes the technical area and reception as well as the clinic and offices.
Most modern clinics are designed with smooth, flowing surfaces rather than corners and joins. This makes cleaning easier and there is less chance of ‘missing’ difficult to reach areas which can harbour micro organisms.
Clean any spill as soon as possible.

Decontaminate equipment requiring special processing in accordance with quality management systems to ensure full compliance with cleaning, disinfection and sterilisation protocols


Disinfection

Disinfection a process that eliminates many or all micro-organisms except bacterial spores.
Any instrument or equipment that comes into contact with non-sterile tissue (other than intact skin) must, before it is used, be disinfected. All instruments and equipment must be cleaned prior to disinfection.
Disinfection removes almost all micro-organisms. It is necessary when body fluids are spilled or there is an outbreak of infection. The usual disinfecting agent is a diluted bleach solution which can be found in many different commercial cleaners. Bleach is generally diluted to one part bleach in nine parts of water. Before you can disinfect it is extremely important to wash first with hot, soapy water then apply the disinfectant.

Disinfection can be:
• thermal
• chemical – which can only be used if thermal methods are unsuitable or unavailable. Items should not be stored in disinfectants before or after any form of disinfection.

Thermal disinfection

Heat and water are the two active ingredients to achieve thermal disinfection with the holding time dependant on the temperature. That is, the higher the temperature the shorter the time the items need to be exposed. The chart below shows the time temperature recommendations for thermal disinfection.

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Figure 1: Time temperature recommendations for thermal disinfection

As with all types of disinfection it is essential that all surface areas of the items being disinfected are able to be in contact with the disinfecting agent in this case hot water.
Thermal disinfection can only be achieved by mechanical means and should, where possible, be used in preference to chemical disinfection.

Chemical disinfection

Some items requiring disinfection are composed of materials that do not withstand heat so they are unable to be processed using the thermal method. Pre-cleaning is especially important as the chemical disinfectant can act as a strong protein coagulant. Organic soils serve as an excellent nutrient medium for micro-organisms to multiply, and must be removed prior to disinfection.

Properties of disinfectants

All disinfectants work best in a particular pH range that is normally very narrow.
All groups of chemical disinfectants have an optimum pH performance. It is therefore important when using a disinfectant that the pH of a solution is not altered either accidentally or deliberately, such as by the addition of a second chemical product to the solution.
The addition of detergents also seriously alters the chemical balance of most disinfectants. It is therefore essential not to add detergents into disinfectants. Items should also be dried prior to being placed into a disinfectant solution as wet items will dilute the solution.

There are differences in the brands of commercial products so your selection should be based on the following criteria:
• the product meets the legislative requirements
• the product has a microbial spectrum appropriate for the particular use for which it is intended
• the product is the most effective but least toxic to the operator.

Suitable chemicals for disinfection
Only chemical disinfectants that are registered with the Therapeutic Goods Administration in Australia can be used for high level disinfection in health care facilities. Currently the only product groups available are both aldehydes, Glutaraldehyde and Orthophthalaldehyde (OPA).

Requirements for the safe use of chemicals used for disinfection
In an effort to reduce the risk to workers and the environment the following points need to be addressed when using chemicals for high level disinfection:
• Containers should be well labelled with all relevant information.
• MSDS (material safety data sheets) must be readily available.
• Substances should be listed in the hazardous substance register.
• Use and access to chemicals should be strictly limited.
• Comprehensive procedures covering all contingencies of use must be available.
• All areas using these chemicals should be identified and listed.
• Risk assessments must be completed for all stages of the process.
• Workplace sample monitoring should be in place.
• Staff working with these chemicals must be adequately trained with at least annual updates to training.
• Accurate list of employees working with these chemicals should be kept.

Responsibilities of health care workers

It should be noted that staff are required to meet the obligations of not only the OHS Act but also hazardous substance regulations. These include:
• following safe work practices
• co-operating with the organisation regarding monitoring and health surveillance
• reporting anything that may affect the safe working environment.

Sterilisation

Do not confuse the term disinfection with sterilisation. Sterilisation is the process to remove all living organisms rendering it sterile.

If your facility has a small bench top steriliser it may be one of three types:
• non-jacketed non-plumbed downward displacement
• jacketed non- plumbed downward displacement
• non-plumbed pre-vacuum.

Non-jacketed non-plumbed downward displacement
The simplest form of a steam steriliser is the non-jacketed non plumbed type. These single shell sterilisers produce steam within their chamber by boiling water using heating elements. Non-jacketed sterilisers are designed to sterilise unwrapped instruments only and should never be used for porous or wrapped items as they do not have the penetration or drying ability required for these items. This type of steriliser is often used when items need to be sterilised for immediate use or when items may need to be sterilised between patient uses but not required as a sterile item.

Jacketed non-plumbed downward displacement
Jacketed sterilisers with a drying cycle are designed to sterilise wrapped instruments. The jacket is the thin outer section of the chamber which contains steam, even when the chamber is empty. These sterilisers work by generating their own steam in the chamber with the air gradually being replaced by steam. Steam and air is released via the drain line back into the water reservoir within the unit. Drying of the load is achieved by the aid of the heating element and is not a totally efficient method. Generally only a small number of single packs can be successfully sterilised at any one time.

Non-plumbed pre-vacuum
These small bench top units are generally used when wrapped items need to be sterilised. The pre-vacuum bench top steriliser has a vacuum pump that assists in air removal by drawing one or more vacuums below atmospheric pressure together with positive pulses of steam, prior to the sterilisation phase of the cycle. The steriliser then draws another vacuum to assist with drying.

Dry all work surfaces before and after use
• All clinical work surfaces should be wiped over daily, before the first client of the day and at the end of the day using neutral detergent, warm water and paper towel.
• Some areas may need to be disinfected such as the front reception counter, child’s play table. If a disinfectant solution is used make sure you follow the instructions.
• You should use a systematic routine so that you don’t forget any surfaces. Start with the least contaminated areas and move to the most contaminated areas.
• Change and dispose of the paper towel regularly.
• Clean up any spills immediately.
• Make sure that all surfaces that have been cleaned are thoroughly dry.

Maintaining and storing cleaning equipment


Cleaning equipment

Safety tips
Most cleaning procedures require the use of some equipment such as spray applicators, cloths, mops, buckets, brooms, power scrubbers and polishers. There are correct and safe operating practices for each item of equipment. Choose the right equipment for the task and know how to use each item correctly and safely.
Maintain equipment in good working order and store all items dry.

The use of cleaning equipment may create a hazard for cleaners and for others:
• Surfaces can be slippery when wet.
• Electrical equipment may need care to control its movement while in use.
• Water can be an electrocution hazard if spilled on live electrical equipment.
• Cleaning chemical fumes should not be breathed in. Work in a well ventilated area or wear a respirator.
• Skin contact with cleaning chemicals needs to be minimised by wearing rubber gloves and eye protection whenever needed.

Cleaning cloths
Ideally cleaning cloths should be laundered after each use, or be disposable.

Mop and bucket
When using a mop and bucket, empty the bucket regularly into an appropriate waste drain (not a washbasin, bath or shower area) and replenish with fresh water and cleaning chemical.
In situations where chemical solutions cannot be used, microfibre cloths or mop heads with hot water provide an alternative:
• Use a fresh surface of the microfibre cloth for each new surface being cleaned.
• Wash cloth or mop head after each surface is cleaned.
• Launder re-useable cloths or mop heads at suitably high temperature before reuse.

Vacuum cleaners
Check vacuum cleaner dirt bags regularly to avoid overfilling. Dispose of full bags carefully without spilling, and replace with clean bags. Avoid reusing paper bags.
Clean vacuum cleaner filters and cleaning heads regularly. Accumulation of dust may reduce the performance of the machine.
Vacuuming is not appropriate for removing blood, body fluids or any other contamination of a biological nature.

Source: Infection Control (Health) Toolbox. © Australian National Training Authority (ANTA) 2004. All rights reserved.

Cleaning audiometry equipment

Manual cleaning


Pre-rinsing
One of the most important ways to limit cross infection from occurring is the removal of all wax and debris from reusable clinical items as soon as possible after use. This is done by wiping, damp wiping and rinsing. The easiest way is a cold pre-rinse. This will remove the majority of gross soil and, with it, 80 per cent of micro-organisms. After the pre-rinse, instruments should not be allowed to fully dry until processed.

Transport to cleaning area
Soiled instruments should be transferred to the cleaning area safely and in puncture resistant and leak resistant containers or trolleys. These should have a lid or liner that can be closed.
All equipment used on a client should be cleaned no matter whether it is then to undergo disinfection or sterilisation. It is important to remember that an item that has not been cleaned thoroughly cannot be disinfected or sterilised. Where possible it is advisable to do any cleaning of instruments in an area separate from the clinical area as previously discussed. There should also be clear definition between dirty items and clean items.

The degree of processing required for items can be established by Spaulding’s classification which has been adopted by NSW Health and documented in Infection Control Policy 2002/45. There are three categories within the classification and they are:
1. non critical
2. semi critical
3. critical

Non critical
This classification refers to any item or equipment that comes into contact with intact skin only. These items must be cleaned with detergent and water.

Semi critical
This refers to items that will come into contact with intact non-sterile mucosa or non intact skin. These items require cleaning with detergent and water followed by disinfection or high level disinfection.

Critical
Any item that enters or is capable of entering sterile tissue or the vascular system must be cleaned with detergent and water and then subjected to sterilisation.

The cleaning process

The cleaning process depends upon various conditions. These are:
• surface being cleaned and type of instrument (eg do they have to be dismantled for cleaning?)
• nature and amount of soil (eg blood, bone and tissue fats)
• composition and concentration of detergent
• pH of detergent to be used
• quality of water (eg hardness factor, pH)
• pH of cleaning solution
• mechanical factors (note: most cleaning operations require some measure of physical effort, be it rubbing or scrubbing)
• temperature of cleaning solution

Whether the cleaning process is being performed manually or mechanically the same basic steps need to be performed.

Step 1: Pre-rinse
An initial cold pre-rinse will remove the majority of gross soil and, with it, 80 per cent of micro-organisms. The pre-rinse will hopefully be performed soon after use. After the pre-rinse, instruments should not be allowed to fully dry until processed. Items for pre-rinse and steps1 to 4 are otoscope specula, tympanometry tips, inserts, impression syringes and utensils, repair tools, toys. Can you think of others?

Step 2: Wash
Water is the universal cleaning agent and an adequate supply of hot water (40˚ to 50˚C) is the strongest weapon against contamination. Although water alone possesses some detergent value, it cannot effectively remove proteinaceous soil, or oil or grease from the surface of instruments and utensils. Adding a suitable detergent to water is most important for effective cleaning. Detergent acts as a wetting agent, or surfactant, and facilitates the exchange of a soiled surface condition for a clean surface plus a soiled detergent.

Step 3: Rinse
A hot rinse will carry away soil entrapped in the detergent. The heat of the rinse helps decontamination and is an aid to subsequent drying. The temperature for a manual hot rinse is between 50˚– 60˚C and for a mechanical hot rinse it should be between 80˚ – 85˚C.

Step 4: Drying
All drying should be done in a mechanical drier. Items should not be dried with towels or left to dry in ambient air. However if a mechanical dryer is unavailable, lint free wipers can be used to wipe instruments as soon as possible after washing.

Points to observe when cleaning manually
Do all the scrubbing underwater so that you do not create aerosols (small particles of water that float in air) which can contaminate you and the surrounding area with infected material. Always wear appropriate PPE such as gloves and protective clothing, mask and/or eye protection. Hand washing is essential before and after the cleaning process.

Mechanical cleaning

Your facility may have the use of a mechanical cleaning device such as an ultra-sonic to assist in the cleaning process. There should be clear written instructions on what equipment is suitable for cleaning in an ultra-sonic (you may refer to manufacturers instructions for cleaning), as well as a standard procedure on how to operate the ultra-sonic.

Ultrasonic cleaners
There are two main types of ultrasonic cleaners available: the standard type and the irrigating type. Either type involves immersion of the articles in a water and detergent solution which has waves generated in it. These waves are generated at a speed higher than normal sound-waves hence the term ultra (above) sonic (sound). An ultrasonic relies on generators, transducers and a stainless steel tank and in the irrigating models a manifold designed to hold instruments with lumens (internal channels).
The transducers attached to the underside of the tank, convert the high-frequency electric generator current into mechanical vibrations, which create waves of alternating high and low pressure in the cleaning medium (water and detergent). When pressure of the wave is on the low half of the cycle, thousands of vapour bubbles form, just as they would if fluid were heated over a flame. When pressure swings back on the high side, those tiny bubbles collapse (implode). This vigorous cavitation (continuous build-up and violent collapse) of vapour bubbles causes a small vacuum around each bubble. When this vacuum comes in contact with soil on the instrument, it lifts the soil off and it then remains in suspension in the cleaning fluid. This makes it possible to clean quickly inside small holes, joints and other places that are difficult to clean by the manual method.

Ultrasonics fitted with an irrigating system work in the same way with the addition of the cleaning fluid being pumped through the lumens allowing soil to be pumped out as well.
Rinsing is important. The larger, heavier particles of soil loosened from the instruments fall to the bottom of the tank, while the more finely dispersed soil rises to the top of the tank. As a result, fine, loosened dirt and a film of detergent remains on the instruments after ultrasonic cleaning. Therefore, after cleaning, items must be rinsed thoroughly with hot water.
Whether items are manually or mechanically cleaned it is important to remember that thorough cleaning is the prerequisite to all other processes.

Drying items following cleaning

Once items have been cleaned they must be dried. If you have no alternative other than hand drying, then you should always use a lint free cloth. Single use absorbent cloths are available and should be discarded following use. Equipment that is left wet can encourage both damage to the item and lead to microbial and other contamination. =

Further processing of items

Items that do not require either high level disinfection or sterilisation can, after cleaning, be wiped over with an alcohol preparation of 80% ethyl alcohol or 60-70% isopropyl alcohol. The items must then be dried prior to storage.
Items that can be cleaned in this way on a daily basis include:
• audiometers
• tympanometers
• otoscopes
• insertion gain machines
• automated ABR and ABR machines
• otoacoustic emissions screeners
• laptops.

There may be specific manufacturer’s cleaning instructions for you to follow. Cover these items or store them in their case when not in use.
Other items in the clinic require wiping with an alcohol wipe after every use. These items include the audiometer headphones (band and cushions), bone conductor, client response button, demonstration hearing aids if handled, insertion gain ear piece and the nappy change table.

Otoscope specula used on discharging ears should be discarded after use and treated as clinical waste.

Care for toys

Toys are considered non-critical items because they do not come in contact with blood or broken skin. They should be cleaned on a regular basis making sure that any gross contamination is removed. How often the toys are to be cleaned will depend on how the children use the toys. For example, any toy that is put in the mouth should be cleaned before being used again.
Toys that can be cleaned should be chosen. The best choices are those that are non porous and that can be put in warm to hot water. Soft toys should not be chosen to use in the hearing assessment as they are difficult to clean. You should also be able to dry toys thoroughly. That is, water should not be able to be trapped inside the toy.
If you do need to disinfect a toy you can wipe it over with alcohol. Alcohol wipes can be purchased in a size similar to tissues and these are useful for wiping down toys.

The National Health and Medical Research Council has provided guidelines for cleaning toys in chapter 5 of a book called “Staying Healthy in Childcare” that you can find at http://www.healthykimberley.com.au/communicable/stayinghealthyinchildcare.pdf.

Visiting sites, homes or remote communities

Following correct infection control procedures when working away from the hearing clinic need not be difficult. The main barrier to cross infection is hand washing. If hand washing facilities are not available there are several good waterless antibacterial gels available for use. These contain over 60% ethanol and will destroy bacteria. They should be used correctly by applying the gel to the palm of the hand and, with the fingers of the other hand massage the gel into hands making sure of complete coverage of both hands. Allow to air dry.

Waterless antibacterial gel should be used before and after every client, before meals, after the toilet, nappy change etc.
Infection control processing of reusable items such as otoscope specula and tympanometry tips should be carried out as soon as possible on return to the clinic. Always use alcohol wipes for cleaning headphones, bone conductor etc after every client while working offsite.


Have a look at the information on these websites:
Infection Control Resource Centre: www.sesahs.nsw.gov.au/albionstcentre/infection/information_sheets.asp (Have a look at the information sheet ‘Cleaning healthcare facilities’.)
Cleaning standards (Victorian Government): www.health.vic.gov.au/ideas/infcon/cleaning