The first and most important step in decontamination is thorough cleaning to reduce bioburden on surgical instruments. No other step so greatly enhances the likelihood of sterilization.

Your key weapon in this thorough cleaning? Enzymatic cleaners, which are valuable in removing soils, particularly dried soils, without mechanical action. That's because they work via chemical reaction to break down organic soils, such as protein, blood, pus and tissue. Usually formulated with a surfactant to improve wetting ability and saturation of the enzyme into dried soil residues, enzymatic cleaners can remove soil from lumens that are too intricate to clean using other methods. But which enzymatic is right for you? Here's what you need to know about the types of cleaners and how to use them to ensure top-quality decontamination.

What type of enzymatic do you need?
First and foremost, enzymatics break down bioburden. If you're at a multi-specialty facility, you'll want to consider broad-spectrum formulas. Typically used as soaking solutions, these formulas are appropriate for a range of procedures. But if your facility is single-specialty or heavy in one area, you might want to consider an enzymatic that targets the specific components of bioburden: protein, blood and fatty tissue.

Proteolytic and lipolytic enzymatic cleaners are normally used to soak instruments that have hard-to-remove or dried protein or fatty substances on them. Proteolytic enzymatic cleaners ease the process of removing protein substances (blood and other body fluids). Lipolytic enzymatic cleaners make it easier to remove fatty substances (bone marrow and adipose tissue).

If you're performing a lot of abdominal surgeries and orthopedic procedures, for example, you'd want to buy an enzymatic specifically made to break down the fat and bone marrow that come with the territory. On the other hand, if you have a high volume of colonoscopies, a protein-geared enzymatic is probably the right choice. This may let you avoid the extra expense of, say, an enzymatic specialized for lipids.

Also think about your facility's procedure volume. A 15-gallon barrel doesn't make sense for low-volume facilities, where a 5-gallon jug may make more sense. If the jug's hard to pour, though, that makes it inconvenient to use, and several jugs would take up a lot of storage space. Keep in mind, too, that if you don't use it quickly enough, the enzymatic may begin to become thick and viscous.

ASAP after the procedure
AAMI standards recommend that you maintain surgical instruments as free of gross debris as possible during the procedure, and that you clean them as soon as possible after the procedure.

After the surgeon is done with a device, the standards call for the device to go through an initial cold-water rinse with running tap water, or a soak in either cold water or blood-protein-dissolving enzymatic cleaner. This will "prevent the coagulation of blood onto the device and help remove blood tissue and gross debris from the device's lumens, hinges and serrations."[1]

If you begin soaking the device immediately in enzymatic cleaner, you're already making progress toward the recommended decontamination process that the AAMI standards call for before manual cleaning.

Breaking down the bioburden helps ensure that cleaning will "remove visible debris and reduce the number of particulates, microorganisms and pyrogens," all of which interfere with sterilization.1 Be sure to consult the device manufacturer's instructions for proper cleaning to ensure that you don't damage the device.

Do enzymatics with detergent save time?
An important note: There are enzymatics and enzymatics with detergent. With the former, the substance functions only to break down bioburden - you must follow up use of the enzymatic with cleaning. Enzymatics with detergent don't preclude your having to clean, but they do let you combine the soaking and cleaning steps.

There's no infection control reason that you should perform the three-minute to five-minute soak and cleaning separately, but in my opinion, it's ideal to use an enzymatic with detergent so you can save a little time as well as resources.

Using an enzymatic with detergent doesn't mean, however, that you can skip the soaking step; it won't do you any good unless you've soaked for at least three minutes (depending on what the enzymatic/detergent manufacturers' recommendations are). Keep this in mind if central sterile uses an automatic washer for instruments.

Your automatic washer may have an enzymatic cycle, but those machines run through that step as if it's just another washing cycle. You can't just spray down an instrument with an enzymatic; the instrument needs to actually soak. So if your washer doesn't soak, it's a waste of energy and product.

Another small controversy is whether foam enzymatics are as effective as liquid. The reason foam is nice - if you spill it, it won't run all over the place, getting into who-knows-what and soaking it - is my precise argument against using it. How do you get foam into devices' lumens and crevices? I question whether squirting provides enough force to propel foam into hard-to-clean areas so that it's equivalent to a liquid.

Part of the process
Enzymatic cleaning solutions are an important step in the decontamination process of surgical instruments. If a device isn't clean, you can't sterilize it. My advice: Keep instruments wiped off during the procedure, reprocess the items as soon as possible after the procedure, soak in an enzyme and detergent product to loosen dried debris and, above all, follow manufacturers' recommendations for the solution and the specific type of instruments you're cleaning. Remember, when it comes to cleaning bioburden, enzymes are your friends.

Reference
1. AAMI ST46 2002 Steam Sterilization and Sterility Assurance in Healthcare Facilities. Page 23 5.5.2.1, 5.5.2.2, 5.5.2.3