Objective: The purpose of this effort was to develop and an evidence-based protocol to protect patients from an iatrogenic exposure to Creutzfeldt-Jakob Disease (CJD) within surgical environments and disseminate that information to clinicians in the surgical area. Design: This effort consisted of an integrative review of the extent research and literature, as well as existing clinical guidelines. The project resulted in the establishment of a practice guideline and organizational efforts to disseminate this information. Population Sample Years and Setting: This integrative review included 30 articles identified through MEDLINE and CINAHL searches and clinical practice guidelines developed by national or international organizations responsible for infection control policies. Reviewed sources described the infectivity of certain tissues, modes of transmission, resistance to conventional chemical and physical decontamination methods, and the latest evidence and recommendations related to special protocols for instrument care after possible exposure to the CJD prion. Concept: CJD is an infectious, degenerative, and fatal disease of the central nervous system caused by an uncommon virus known as a prion. It is one of a group of encephalopathies known as transmissible spongiform encephalopathies (TSEs). Recently, an additional human TSE called variant CJD (vCJD) has been recognized. Animal forms of TSEs include chronic wasting disease of mules, deer and elk and bovine spongiform encephalopathy (BSE) also known as mad cow disease. The pathogenic agent responsible for CJD is highly resistant to standard sterilization and disinfection methods. Unless special procedures are utilized, the CJD causative agent can survive routine sterilization and disinfection procedures. Exposures to this virus have occurred via transplantation of central nervous system tissue (dura mater and corneas), repeated injections of pituitary hormone extracts, and the use of contaminated surgical instruments or stereotactic depth electrodes. Methods: Each article and clinical practice guideline was reviewed and the strength of the evidence evaluated. Conflicts and inconsistencies in the extent knowledge and clinical recommendations were resolved by obtaining consensus with a group of experts in the fields of prion infections and disinfection and sterilization. Findings: Critical findings include the fact that causative prions are resistant to steam sterilization, dry heat, ethylene oxide gas, and chemical disinfection with either formaldehyde or glutaraldehyde. Additionally, it was noted that formaldehyde and glutaraldehyde actually serve as fixatives, causing the prions to become more stable and even less susceptible to conventional disinfection and sterilization protocols. Conclusions: Special evidence-based protocols for instrument care after potential exposure to prions should be followed to minimize risks of iatrogenic infections associated with contaminated instruments. This protocol must be based on whether instruments are critical/semi-critical or non-critical and if the tissue would be considered high-, medium-, low-, on no-infectivity tissue. Implications: An evidenced-based protocol can provide guidance to avoid unnecessary exposures to CJD during surgery. New information about prion infectivity and transmission modes is continually emerging. To ensure safe disinfection and sterilization practices, nurses must have easy access to an evidence-based protocol reflective of the most recent information and in a format that is easy to understand and implement.
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