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Hospital Sterilizers: P2 Opportunities
Table of Contents
Background and Overview
Reasons for Change
P2 Opportunities
Glossary of Terms
Where to Go for P2 Help
Complete List of Links

Essential Links:

Best Management Practices for Hospital Waste
Report: Comprehensive 392 page document handling all types of hospital waste. Includes section on ai...

Disinfection and Sterilization High Level Disinfectants & Sterilants
Lists alternative sterilization and disinfecting products and resources.

Ethylene Oxide Fact Sheet
Fact sheet written to give employers the information they need in order to manage staff exposure to ...

Fact sheet and information papers about Ethylene Oxide (EtO) Sterilizers
Fact Sheet: Background of regulations concerning EtO. Presents alternatives that can be used. *Note ...

FDA-Cleared Sterilants and High Level Disinfectants with General Claims for Processing Reusable Medi...
Alternative Disinfectants: A roster of FDA cleared steriliants and high-level disinfectants (HLDs) ...

Replacing Ethylene Oxide and Glutaraldehyde
Gives an overview of where EtO and glutaraldehyde are used in hospitals, the reasons to find alterna...

Safer Products and Practices for Disinfecting Surfaces
Comprehensive report and analysis of different disinfection chemicals and their health and environme...

Many hospitals have already moved away from using EtO sterilization to other methods. Since EtO was recognized as a known human carcinogen in 1994, the estimated total tonnage of EtO used by U.S. hospitals has dropped from about 1000 tons per year to approximately 135 tons per year in 2005.

A number of other sterilization technologies exist. Many of these can replace some but not all EtO applications, so a hospital's sterilization strategy may include two or more options. These include steam, chemical sterilization with less-toxic processes such as sonic sterilization, gas plasma, electron beam, microwave, or hydrogen peroxide.

One hospital, for example, estimates that they have been able to reduce EtO use by 60-70%, but that EtO is still used, with proper safety precautions for angioscopes, choledocoscopes, surgiiscopes, bone flaps, and hysterectoscopes.

If EtO is still used for some purposes, the following practices will reduce hazardous emissions and risk to employees and patients.

  • Sterilize full loads to the extent practical.
  • Use self-contained scrubbers, combustion units, or gas collection to prevent EtO from escaping into the air.
  • Recover and dispose of EtO as dangerous waste.
  • Filter air and dispose of spent filters as dangerous waste.
  • EtO may be manufactured with another gas as a carrier. Choose EtO with less-toxic carriers such as carbon dioxide or 100% ethylene oxide. Prior to the ban on chlorofluorocarbons, Freon was a carrier gas, which added to the toxic emissions. Note that the carrier gas doesn't add to the sterilization efficacy so the concentration of EtO has to be sufficient for proper sterilization.

Alternative Sterilization Options: Advantages and Disadvantages

Some available alternative sterilization options include the following list. Potential pros and cons are listed in the tables below.

  • Plasma phase hydrogen peroxide
  • Peracetic acid
  • Ozone
  • Ionizing radiation
  • Steam or dry heat autoclaves
  • Disposable single use devices (SUD)
  • Reprocessed/sterilized SUDs
  • Chlorine Dioxide (ClO2)
  • Pulsed light systems

1. Plasma phase hydrogen peroxide

Advantages Disadvantages
Acceptable alternative in many cases Some manufacturers haven't approved this method for their devices yet (such as mixed material devices)
Shorter processing time = higher productivity High initial cost
No utility connection except power Items must be completely dry
No waste No paper or liquids
Completely sealed sterilant eliminates contact  
Automated processing  
Small footprint  
Moderate cost per cycle  
Single channel flexible endoscopes can be processed  

2. Peracetic acid

Advantages Disadvantages
Acceptable alternative in many cases Some manufacturers haven't approved this method for their devices yet (such as mixed material devices)
Shorter processing time = higher productivity "Just-in-time" technology; so sterilized items must be removed from the unit and used immediately, which makes it impractical in certain applications
Small footprint Limitation on types of scopes that can be processed
Closed automated system Is an irritant and possible problem for asthmatics
  Highly toxic and corrosive substances
  High repair costs

3. Ozone

Advantages Disadvantages
Devices don't have to be completely dry to process New untested technology
Large capacity Can't reprocess flexible endoscopes
Closed automated system Many materials are incompatible
No toxic waste Possibility of O2 enriched atmosphere
Water and electricity are the only utilities needed  
Low cost per cycle  
Conditionally approved by the FDA  

4. Ionizing radiation

Advantages Disadvantages
May be used for product designs and packaging materials that are impermeable to gases as long as they are "transparent" to energy of the wavelengths employed in the sterilization process  

5. Steam or dry heat autoclaves

Advantages Disadvantages
Good alternative for many traditional surgical instruments High pressure and high temperature makes this alternative unsuitable for products that are sensitive to heat, like mixed media instruments, rubber, plastics, glass and those affected by the corrosive and dielectric effects of steam
Comparable to chemiclaves without the hazardous waste Disposal of wastewater may be subject to state regulation

6. Disposable single use devices (SUD's)

Advantages Disadvantages
Eliminates need to sterilize devices Creates direct increase in solid and hazardous waste
Eliminates internal costs and workload Higher Cost

7. Reprocessed/sterilized SUD's

Advantages Disadvantages
Outside provider takes the responsibility of sterilization. Eliminates internal costs and workload Dependant on reliability of vendor
Reduces solid and hazardous waste May not reduce EtO if reprocessor is using it

8. Chlorine Dioxide (ClO2)

Advantages Disadvantages
No significant levels of residual sterilant on product Can't be safely stored under pressure for transport and subsequent use since it is explosive in liquid form
Not flammable in gaseous systems Unstable and corrosive in liquid form
Used for contact lenses and foil suture packages Concentration rapidly diminishes when in liquid form
When used with stabilizing agents, liquid form is used for fiber-optic endoscopes  

9. Pulsed light systems

Advantages Disadvantages
Reported to be effective killing micro-organisms including spores Effectiveness depends on light access to surface, so porous surfaces, turbid liquids and non-transparent materials are not applicable
Low costs around one cent per square meter sterilized Possible degradation of surface of opaque materials

Specific sterilization options vary by vendor and by type of device. Some of the characteristics to consider are the following:

  • Processing time
  • Up front cost
  • Ongoing costs for supplies
  • Length of time devices remain sterile
  • Residue requiring special handling or not
  • How wastes can be neutralized
  • Types of devices accommodated; soft metals, plastics, packaging

For a detailed list with pros and cons by vendor name brands, see the Vendors List: Less Hazardous Products and Waste Management in the link to the Best Management Practices for Hospital Waste from the Washington Department of Ecology,

Keep the following tips in mind when choosing a vendor: [1]

  • Ask for least toxic products available. Ask if they have products that do not become dangerous waste when spent or are recyclable.
  • Ask vendors for customer references (name, phone and address) that use the product or service in the same manner you will be using it. Contact these customers and ask for their opinion of the product or service. Ask the customers what they like or don't like about the product or service.
  • Contact your state ecology office for vendor's compliance history.
  • Get a number of bids and compare. Choose your vendors carefully; consider reliability as well as costs.
  • Test the product or service to see if it satisfies your requirements prior to making a commitment to purchase the product or use the service.
  • Ask if the product or service is "drop in" prior to product purchase or service use or if new equipment will be necessary. Ask to see total costs or fees associated with the product or service.
  • Whenever possible, require your waste contractor to pick-up only on request. In your contract with your waste hauler, have it clearly written that they will only pick up on request. Keep wastes separate, if necessary. Don't over-accumulate wastes. Fill all containers prior to disposal. Keep containers closed, labeled and in good condition and stored in secondary containment, when necessary.
  • Know the fate of your waste. You are ultimately responsible for the proper disposal of your waste.

[1] Best Management Practices for Hospital Waste, Washington Department of Ecology


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Hub Last Updated: 5/21/2015