include "_nav_tab.php";Instrument reprocessing is a multi-step process that has immense potential for error. Your staff must know the purpose of each step and how each phase interrelates to one another. Reprocessing includes all the steps performed to render a contaminated device patient-ready. Sterilization is the application of a terminal process designed to remove or destroy all viable forms of microbial life to an acceptable sterility assurance level.

These 15 questions will help you test your staff's knowledge of some of the many challenging facets of cleaning and sterilizing medical instruments. The early steps of the process tend to be particularly overlooked and will be the main focus here. See "A Step-by-Step Instrument Sterilization Guide" on page 36 for more detailed information on the common sterilization methodologies.

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Below are the correct answers to the previous questions. You scored =$cor_ans out of =$tot_ques.

1. How many distinct phases of reprocessing are there?
echo" Answer: ".strtoupper("c) 4")."
"; Instrument reprocessing can be divided into 4 phases, which begin as soon as one procedure concludes and ends when the instrument is next used in the OR. The four phases are:

• decontamination for safer handling,
• cleaning and rinsing,
• sterilization (or high-level disinfection)
• and immediate re-use or storage (depending upon the type of sterilization).

2. What is the single most important - and overlooked - step of instrument reprocessing?
echo" Answer: ".strtoupper("b) Thorough cleaning and rinsing")."
"; Each step is important, of course, but the single most important step of reprocessing is thorough cleaning and rinsing of the instrument. Too many facilities don't realize this. I have witnessed many staff members merely "swishing" used and contaminated instruments in a basin of water on the back table and then wiping it "clean" with an instrument wipe. These actions do not satisfy the "decontamination" needs of the instruments. All instruments opened on the sterile field require decontamination. Unless instruments are decontaminated and cleaned properly, bioburden may still remain on the instruments and potentially cause an unnecessary surgical site infection.

Manufacturers' instructions should be followed for detergent selection and proper use, care and maintenance of instruments. AORN and ASORN both publish recommendations for disinfection and sterilization.

3. Vendors are generally a good source of information about the use and care of medical instruments.
echo" Answer: ".strtoupper("b) False")."
"; When you purchase any instrument, check directly with the manufacturer for use, care and handling instructions. You need to know whether the instrument is single use or a reusable item. What method of sterilization and/or resterilization is/are required? Objective number one, before the instrument ever enters the facility, read and understand the manufacturer's guidelines for the use, reprocessing and disposal of the instrument. Don't be surprised with infection control headaches by not doing your homework before purchasing any surgical instrumentation.

4. Which of the following statements about instrument decontamination is true?
echo" Answer: ".strtoupper("d) It is important to begin decontamination immediately after a procedure")."
"; Decontamination should always be done immediately after the end of the procedure because it makes items safer to clean and process. None of the other answers in this question are correct. Let's look at them individually.

In general, it is not good practice to leave instruments sitting in a decontamination solution. Items such as forceps, scissors, scalpel blades, and suture needles absolutely should not be left soaking indefinitely or stored in a disinfectant solution. Microorganisms can live and multiply in disinfectant solution which can contaminate the items, leading to infection.

Be aware that the decontamination solutions themselves may be prone to becoming contaminated. Microorganisms from the water used to dilute the solution or the container in which the solution is placed could become contaminated.

Just as solutions with too-weak concentrations of the active decontaminant is not good for the instrument because it may not adequately kill the microorganisms that collect on it, you shouldn't use concentrations that are too strong. Too strong concentrations can damage the instruments. A 0.5% concentration of active chlorine, for example, is an effective compound that is neither too weak nor too strong.

Proper decontamination kills many strains of viruses (including HIV) and bacteria. However, it has its limitations and is a merely a precursor-not a substitute- to cleaning and rinsing before sterilization.

The EngenderHealth Web site offers a comprehensive tutorial for each step of reprocessing (http://www.engenderhealth.org/ip/instrum/index.html). The course defines proper decontamination steps as the following two-step process:

• Step 1 Immediately after the procedure, place instruments in a plastic container of 0.5% chlorine solution. Let them soak for 10 minutes. A container of this solution should be kept in every OR and procedure room so that used items can be placed directly into the bucket. Staff should put instruments in the chlorine solution as soon as they are finished using each item. Be sure, too, that disposable devices are segregated from re-usable instruments and placed in an appropriate (puncture resistant) container to minimize the potential for infection and sharps injuries to staff.
• Step 2 After 10 minutes, remove the items from the chlorine solution. Always wear personal protective attire when removing instruments and other items from any solution. Transportation for cleaning and rinsing is the next phase. Keep the instruments in a covered or closed container with a tight-fitting lid.

5. What of the following is not a recommended cleaning practice?
echo" Answer: ".strtoupper("b) Use of hand soap on the instruments")."
"; The fatty acids on hand soaps can react with the minerals in hard water, leaving a residue that is hard to remove. All other steps in this question are among the recommended steps for the decontamination phase of reprocessing.

Enzymatic pre-soaking (not hand-soap cleaning) can be used as the next step to break down and loosen blood or bodily fluids on submersible devices. Enzymatic cleaning breaks down proteins, fats and/or starches. Lumened instruments require flushing. You should then thoroughly rinse the instruments before doing the actual cleaning of the instrument. Prior to cleaning, your staff should always inspect the instrument visually to check for contamination, corrosion or physical damage. Make sure the area is well-lit and that PPE is worn at all times. Keep in mind, of course, that just because the instrument "looks clean," the job is still far from finished.

Depending upon the device and the sterilization method, the instrument may also need be lubricated to ensure ease of opening and closing and to protect it from corrosive action in the sterlization phase. You should test the instrument to make sure it functions properly after reassembly. If not, remove the item from the tray and tag it for repair.

6. When manually cleaning instruments in a sink basin, the detergent should not form a lot of suds.
echo" Answer: ".strtoupper("a) True")."
"; Foam has no bearing on cleaning itself. Low-sudsing detergents are preferable so that the person cleaning the instruments needs to be able to see into the sink and identify all the instruments. It also makes it easier for rinsing. Lastly, there is a safety concern involved - it is a lot easier to sustain a sharps injury in a sink full of suds.

Cleaning can be performed mechanically or manually. Many smaller facilities still do manual cleaning for all instruments. Even larger, busier facilities still must know how to manually clean instruments because depending on the size, fragility, and sensitivity to cleaning agents, certain items should still be cleaned by hand rather being put through whatever type of washing machinery the facility uses.

Manual cleaning of instruments is low-tech and labor intensive but still highly effective for killing most microorganisms on the device. All you need is a sink, non-abrasive cleaning brushes and tools and low-sudsing detergent. Stay away from abrasive brushing devices, such as steel wool. These products can scratch metal or stainless steel, resulting in nicks and grooves that can become a nesting place for microorganisms.

After the instrument is disassembled and readied for cleaning, use the soft brush to vigorously scrub the instruments to completely remove all remaining foreign matter. Hold the instruments under the surface of the water while scrubbing and cleaning to avoid splashing. It is especially important to clean below the water line in the sink when you are cleaning lumened instruments. This is done to prevent exposure to microorganisms through aerosolization.

Be sure to brush in the grooves, teeth, and joints of disassembled items where organic material can collect and stick. The brushes must be suitably sized to get into the crevices (or channels) of the device.

Some infection control experts recommend having three sinks for cleaning-one for cleaning with the detergent, a second for rinsing off the detergent and any remaining soil, and a third with distilled or ionized water to do a second rinse to prevent spotting or hard water damage.

7. Alcohol is an effective cleaning agent for contaminated instruments.
echo" Answer: ".strtoupper("b) False")."
"; Alcohol, of course is effective for quick bacterial kill in patient prepping and hand washing. However, contaminated instruments should never be exposed to alcohol during cleaning. Alcohol binds proteins, making them more difficult to remove. Also avoid saline, which is corrosive, and glutaraldehyde, which cakes on. Distilled water is the way to go for rinsing, especially with lumened items.

8. The instruments should be allowed to dry prior to further processing.
echo" Answer: ".strtoupper("c) It depends on the sterilization process")."
"; Instruments that will be further processed with chemical solutions must dry completely to avoid diluting the chemicals. Items that will be boiled or steamed do not need to be dried first. Boiling is considered high-level disinfection, not sterlization.

9. From an infection control standpoint, which of the following factors is important in the selection of packaging materials for your surgical pack.
echo" Answer: ".strtoupper("f) Do they permit the removal of air? Do they allow the penetration of the sterilant? Do they provide an adequate barrier of protection to prevent the entry of microorganisms? Do they drape well?")."
"; Some may debate this and select answer e) all of the above. However, disposability is not an infection control issue per se. While they can be a hassle to care for properly, reusable wraps are safe and effective with proper care.

Here are some other important factors to keep in mind when assembling your surgical packs:

• Are you using perforated, wire-mesh containers? The sterilant needs to penetrate the container and sterilize the contents.
• Are the trays large enough? This is important to equally distribute the mass of the set and to reduce the possibility of wet packs.
• Is the bundle too heavy? Your staff shouldn't strain to pick up the pack.

10. What is the purpose of a Bowie-Dick chemical indicator test?
echo" Answer: ".strtoupper("a) To test the proper function of the vacuum cycle in a steam sterilizer.")."
"; If you have a pre-vacuum steam sterlizer, the Bowie-Dick test is a helpful way to check to make sure that the vacuum cycle is working properly. Place the test pack in the sterilizer and run it through by itself in a pre-vacuum cycle. If the ink changes color uniformly, the cycle works correctly.

You should also perform this test if the sterilizer shuts down for any reason, assuring that no air is leaking into the chamber.

• Mechanical indicators. These indicators record and allow you to observe time, temperature, and/or pressure readings during the sterilization cycle.
• Chemical indicators. There are several types, including: —Tape with lines that change color when the intended temperature has been reached. —Pellets in glass tubes that melt, indicating that the intended temperature and time have been reached. —Indicator strips that show that the intended combination of temperature, time (and, in an autoclave, steam) has been achieved. —Indicator strips that show that the chemicals are still effective.
• Biological indicators. These indicators use heat-resistant bacterial endospores to demonstrate whether or not sterilization has been achieved.

11. It is never possible to autoclave instruments at facilities in which a constant supply of electricity is not available.
echo" Answer: ".strtoupper("b) False")."
"; Not all autoclaves require electricity to run. Others can run on alternative types of heat sources, such as gas.

12. Technically speaking, flash sterilization is never a permissible sterilization method?
echo" Answer: ".strtoupper("b) False")."
"; According to the AORN Recommended Practice on Sterilization, flash sterilization should only be used in specific situations when all the following conditions are met:

• Work practices specify proper cleaning and decontamination, inspection and arrangement of instruments in the tray.
• Direct delivery of sterilized instruments can be provided to the point of use.
• Policies and procedures define aseptic handling and personnel safety during the transfer of the "flashed" item to the point of use. Audits of adherence to policy and procedure are conducted.

Adherence to proper decontamination principles, transfer guidelines for the sterilized materials, personnel safety, manufacturer's guidelines and parameter monitoring of the sterilizing cycle (time, temperature and pressure) and sterilizer function (each flash cycle/load with a monitoring device) are essential for effective and appropriate flash sterilization of instruments.

13. The same processes are used for steam sterilization in autoclave and dry heat sterilization.
echo" Answer: ".strtoupper("b) False")."
"; Dry heat does not utilize water or have pressure gauges. Because of the high temperatures involved, only anhydrous items (waterless) can be sterilized by this method. Examples of items that can be sterilized by this method are: dental instruments, burrs, glassware and reusable needles.

14. Even if all other steps of the sterilization process have been performed successfully, instruments can still become contaminated if they are not properly stored.
echo" Answer: ".strtoupper("a) True")."
"; You should already be aware that all sterilized items should either be transported immediately to the point of use or stored for later use. For optimal storage, place sterile trays/packs in closed cabinets in areas that have low traffic flow, have moderate temperatures and have a dry environment with low humidity. Properly wrapped items can be considered sterile as long as they remain uncompromised. If in doubt about the sterility of an item (and if the manufacturer permits), resterilize it or discard it. A little common sense also goes a long way. A lightweight pack that drops a short distance to the ground probably need not be re-sterilized, for example.

15. Which of the following is the least expensive autoclave technology?
echo" Answer: ".strtoupper("d. steam")."
"; Steam is highly effective and the least expensive. You should already know, however, that you can steam sterilize everything. Steam may ruin some delicate devices, including endoscopes.

That's why various other technologies exist, such as ethylene oxide. Unfortunately, safety issues present a real concern with these autoclaves. Those actually using the sterilizer must take precautions, as well as those who move the devices from the autoclave to an aerator.

Peracetic acid can be used for lensed instruments such as cameras, for instance. Plasma sterilizers allow sterilization of hard-to-sterilize items that otherwise would have to be done with ethylene oxide. The drawback with plasma sterilizers is that you can't run instruments with channels and lumens, for instance lumens longer than 12 inches or smaller than 1 inch.