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The Devil Is in the Details in Decontamination
Technicians are faced with many detail-oriented tasks throughout their shift. The manufacturer’s IFUs must be followed and procedures should reflect best practices. The work is fast-paced and there is motivation to go as fast as possible. In the decontamination area, it’s easy to become flustered and feel pressured to work quickly when the first round of cases arrives, sometimes all at the same time. This creates opportunities for errors. It’s important to take your time during cleaning to protect the instrument assemblers and avoid rework. There are many seemingly small details that can ultimately affect whether the instruments are clean.

The first opportunity to start the decontamination process is at the point of use. Failing to pay attention to this detail can be a monumental point of contention between the operating room and sterile processing. Gross soil should be removed from instrument surfaces and cannulated items should be periodically flushed. This prevents the formation of biofilm and damage to instruments. At the conclusion of the procedure, the instruments need to be safely contained in a puncture-proof and leakproof transport container to protect employees. They must also be kept moist with towels dampened with water or a pretreatment. Pretreatments are designed to start the cleaning process with enzymatic or surfactant action. Because they begin breaking down bioburden, they are the preferred method of keeping instruments moist until they are received in the decontamination area. At the bare minimum, wet towels can be used to keep bioburden from drying on the instruments. Failing to perform these activities should be considered a cardinal sin. Not only are these steps thoroughly described in evidence-based standards and OSHA requirements, they are a point of scrutiny during surveys. Findings involving point-of-use cleaning can be considered conditional and may even result in shutting down surgery. Correctly performing these tasks will help protect employees, prevent damage to instruments, and begin the decontamination process as soon as possible.

Once instruments arrive in the decontamination area, the need for attention to detail multiplies. The instructions for use for the device, chemistries, and equipment must be followed. In addition, there are many tasks that make technicians use their best judgment. This can lead to opportunities to make mistakes that result in ineffective cleaning.

The most basic, commonly used tool in the decontamination area is the brush. Yet, this seemingly simple tool can be used incorrectly, or not used at all. As a general rule, anything cannulated should be flushed and brushed, unless the IFU states not to. Brushes with bristles that are bent or broken or with rusty or bent stems should be thrown away. The appropriate size brush should be used for the instrument. For example, a 7 French brush should be used on a 7 French suction tube. If a brush is too small, the bristles will not contact the entire inner surface of the instrument. If a brush is too large, the bristles will be compressed inside the instrument and will not brush the surface correctly. Brushes may also have instructions for how to clean the brush itself or how many times it should be used before it’s discarded. Some brushes, especially for endoscopes, are single-use and should be disposed of after being used on one scope. A variety of sizes of brushes need to be available and enough brushes should be stocked in the decontamination area to encourage technicians to use them appropriately. Failing to brush correctly, especially with cannulated instruments, will lead to unpleasant surprises on the clean side of the processing area. If it’s not caught, a contaminated instrument may be used on a patient.

If the instrument decontamination process continues with a mechanical wash, there are several details that can make a huge difference in cleaning quality. For the sake of time and efficiency, many technicians will load as many items in the washer as possible. If the instruments are not properly cleaned, they will have to be sent back to decontam. It is more efficient to prep and load instruments correctly in the washer. 

Washers clean instruments using impingement, which is the mechanical process of a cleaning solution striking a surface. If the solution is unable to reach the surface of the instrument, it is unlikely to be clean when it comes out of the washer. There are several ways to help improve the force and amount of solution that contacts the instrument during the washer cycle. According to evidence-based standards, instruments should be disassembled (according to the IFU), and hinged instruments should be opened to full extension. Multilayer sets should be separated. Instruments should be arranged in an even, single layer. Technicians may try to save time by loading up a container with instruments. This makes it difficult for the washer to remove debris. Lids or utensils should not be covering the instruments. Most washer racks have arms that spray water from the top and bottom of the rack level. Placing lids or utensils on top of the instruments means they will only get sprayed from below. Items should not be stacked so high that they prevent the washer arms from spinning.

Finally, an often overlooked task is to check the washer arms and screen for debris and function. Debris such as shreds of paper, plastic, or bioburden can become lodged in the washer arms. This will affect the amount of water that strikes the instruments. If debris remains on the screen, the pressure of the water can dislodge it, and it may end up on an instrument.

A quick check of washer function is to watch a wash cycle. All the arms should be spinning at the same speed.  Water should be spraying out of the arms at a uniform rate. If this is not happening, there may be debris in a washer arm or the manifold of the washer rack may not be lined up correctly with the washer. Paying attention to these simple details will ensure the mechanical cleaning action is performed to the best of the washer’s capabilities.

Washers should be optimized to clean cannulated items. Most washer racks have the capacity to connect tubing to instruments to make sure the inner surface is cleaned as thoroughly as the outside. Imagine laparoscopic forceps sitting in a tray in a washer. We’ve seen what can be inside the shaft when they’re not cleaned properly. Without the flush tubing, water is only striking the forceps from the top and bottom. If you connect the washer rack tubing to the flush port of the forceps, the cleaning action that takes place on the outer surface is also happening inside. This will lead to better cleaning quality, fewer dirty instruments found in assembly, and less time spent rewashing instruments.

The final step in cleaning is to verify that the instrument is clean on the assembly table. There are many tools and techniques that can be used to perform cleaning verification. There are also wonderful resources available to understand which parts of the instrument need to be inspected and which parts are prone to being soiled or retaining bioburden. However, sometimes experience is the best teacher. As technicians, we quickly learn which instruments are problematic. The process at your facility can incorporate a combination of lighted magnification, borescopes, critical water, and compressed instrument air. Any time cleanliness is verified by flushing cannulas with critical water, the excess water should be removed from the instrument, unless the IFU specifically says to moisten the lumen. In addition, AAMI ST79 states in Section 7.4.1, “Instruments and devices should not be treated with any additional chemical (e.g., alcohol, disinfectant wipes) unless such treatment is specifically recommended by the manufacturer’s written IFU.”1 

There is often debate about what constitutes “cleaning” on the clean side. Some facilities will use a pipe cleaner through lumens to verify cleanliness. This method is acceptable, but ensure that the pipe cleaner is low-linting or non-linting. If the item was clean, water and instrument air should be forced through the lumen to remove any potential lint and ensure the instrument is dry. If the pipe cleaner comes out dirty, the instrument should be sent back to the decontamination area to be cleaned. Any time you see bioburden remaining on an instrument, it needs to be sent back to decontam. It is time consuming and inefficient to wait for an instrument to be re-cleaned, but under no circumstancesshould you use a brush or disinfectant wipe in the assembly area to remove bioburden. This is why it is critically important to take your time and pay attention to detail during the initial cleaning process.

There are many small actions in the decontamination process that can add up to affect cleaning efficacy. Paying attention to point-of-use cleaning, brushing techniques, washer loading, and cleaning verification can help ensure instruments are safe to handle on the clean side. Ultimately, it reduces the chance for a contaminated instrument to be used on a patient.

References

  1. ANSI/AAMI ST79:2017 Comprehensive guide to steam sterilization and sterility assurance in health care facilities, p. 40.

Alison Sonstelie has 10 years of healthcare experience in sterile processing and supply chain. She is currently a lead sterile processing coordinator at Sanford Health in Fargo, North Dakota. In addition to her current role, she is an educator, speaker, a member of AAMI work groups, and a consultant for healthcare facilities and industry suppliers. 

 

 

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