Truly thorough, effective instrument processing begins in the OR, often as the case is still underway, when a little extra effort on the part of the surgical staff can help prevent blood and other contaminants from drying and hardening on the surfaces and in the nooks and crannies of instruments and scopes. Here are some step-by-step tips for pre-cleaning surgical instruments, particularly those used in orthopedics, where there is often a lot of blood and other biological matter involved. See "Pre-Cleaning Flexible Endoscopes:?Timing Is Everything" for tips specific to flexible endoscopes.

Step 1: Wipe intraoperatively. Effective pre-cleaning actually begins during the case. As much as possible, the scrub nurse or tech should continuously wipe soiled instruments throughout the course of the procedure with sterile water and a sterile sponge to prevent blood and other contaminants from drying on the devices.

Step 2: Account for all instruments. A common standard for surgical counts is to count whatever items could conceivably be left in the patient. However, AORN recommends that all instrumentation be accounted for, and this is a good rule of thumb to follow, as it helps to improve inventory control and prevent loss of instrumentation. It's very easy for instruments to get accidentally folded into a drape, for example, and thrown into the trash. Then when the tray is brought back to the sterile processing staff, they're going to have to track down that item before they can begin cleaning, wasting precious time and resources that could be spent getting that set turned over as quickly and effectively as possible. Develop a systematic, standardized count process that includes documentation that can be sent back with your trays to let processing techs know that all instruments are accounted for and that they can proceed with cleaning right away.

Step 3: Keep instruments (and soil) moist. In a perfect world, surgical instruments would begin to be cleaned as soon as the case was completed. In reality, you've got to anticipate delays in the schedule and backups in sterile processing. When instruments have to wait their turn to be decontaminated, it's important to keep them moist to prevent dirt and biomatter from drying on them. At the same time, you must be careful not to create a non-sterile liquid environment in which biofilms can form on the instruments or inside lumened devices. Have your nurses or scrub techs treat instruments waiting to be processed with an enzymatic foam or gel that begins the process of breaking down the soils. They should do this step for all instruments, regardless of whether they appear soiled to the naked eye, since dirt and biomatter aren't always visible.

For maximum efficiency, complete this step in a soiled utility room or area, if you have one, rather than in the OR so that staff can proceed with room turnover as quickly as possible. Ideally, instruments that have been sprayed with enzymatic foam or gel should be transferred immediately to the sterile processing area. If there's going to be a delay before they're cleaned, you can place the instruments in an impervious container for transport (for example, a rigid container with the lid on, a covered tote bin or a surgical case cart) and place a damp towel over the instruments (after squeezing out excess moisture) to keep the soils moist.

Step 4: Transport the items to sterile processing. Place all instruments in the basket or container from which they came when transporting them to the sterile processing area. The items must be securely confined and contained; it's not enough to throw a cover over the back table and wheel it into the soiled utility room. You need to make sure soiled instruments aren't sitting out in the open where they could be tampered with or accidentally bumped into. Use closed case carts, biohazard bags or tote bins affixed with a biohazard label to let others know that the contents are dirty. If items were sitting in a solution, that liquid should be suctioned up before the instruments are transferred, so the solution can't splash or drip and contaminate other people or surfaces.

Clearly label baskets and containers with tags that identify which sets — "arthroscopy set," for example — are contained within. This helps the processing department identify and prioritize the sets. However, OR staff shouldn't separate instruments based on whether they are "used" or "unused." The processing staff must treat all instruments that come back to them as if they're grossly soiled. If you separate instruments based on their perceived level of contamination, it could confuse the processing department, leading them to believe they can clean them 2 different ways, paying less attention to items that weren't used. This is a very dangerous situation, as instruments that may appear unsoiled to the naked eye can still contain traces of blood and other microorganisms.

Where efficiency meets infection prevention
Too often there's a misunderstanding on the part of the OR staff of what's required for effective instrument processing. A surgical staff that doesn't understand all the steps that must be followed for effective cleaning, disinfecting and sterilizing instruments and devices can strain the interactions between the OR and sterile processing. OR personnel should be informed of the manufacturers' instructions for processing devices, especially when these instructions require extended cleaning and/or sterilization practices that will impact the turnaround time for the instruments. Additionally, educating your OR team about what goes into the process and what their roles should be in preparing, accounting for and sending back instruments in a timely fashion not only helps prevent infections, but also promotes efficient room and instrument set turnovers to keep your facility running at a smooth pace throughout the day.