PRE-TREAT Today's instruments have complex, movable parts that are difficult to disassemble and clean thoroughly. To prevent debris from drying on instruments, it's best to soak them right away.

The decontamination of instruments by removing organic material is critical in the process of disinfection and sterilization and, subsequently, preventing healthcare-associated infections. Effective sterilization cannot occur if debris is left on or inside instruments. Protein material is not penetrable by steam or gas. Staff who are unaware of the importance of pre-disinfection may wrongly assume that instruments headed for the sterilizer need not be decontaminated. Be sure to conduct reprocessing competencies for central processing department staff annually and as needed.

The purpose of decontamination is to remove all organic material, including blood, secretions and tissue that has collected on the surface, in the grooves and hinges of instruments before high-level disinfection and sterilization.

Essential steps
If you're going to monitor your decontamination process, pay close attention to the following 7 steps. Ensuring they're followed appropriately and according to guidelines will likely avoid suboptimal disinfection and sterilization. Remember to always wear full PPE, including gowns, gloves and face shields or masks and goggles, when decontaminating instruments.

1. Rinse instruments in warm water immediately after the procedure to remove organic material. This will aid in the cleaning process by preventing blood, secretions and tissue from drying and caking. Dried protein matter is difficult to remove and the possibility of residual bioburden is increased.

2. If immediate rinsing is not possible, then pretreat as soon as possible after use in an enzymatic-soak solution before the cleaning process.

3. Cleaning is the critical decontamination step after the pre-steps described above. It's during this step that debris, including dried body fluids, should be completely removed. Remember, sterilization will not be effective if debris remains on an instrument.

4. Ultrasonic cleaning is most effective, particularly for hinged instruments and those with moving parts. The use of distilled or demineralized water is preferable. Be sure instruments are in the open position before placing them in the ultrasonic cleaner. The full ultrasonic cycle must be completed. Rinsing after cleaning is important, and changing the solution according to manufacturers' instructions is just as important. Another method to use is the automatic washer-sterilizer. Lubricating instruments after the last rinse cycle, and before sterilization, is important if using the automatic washer-sterilizer.

5. When manually cleaning using stiff nylon cleaning brushes, don't reuse brushes unless indicated by the manufacturer. Separate delicate instruments from general instruments. Examine instrument surfaces for gross debris, stains, and proper function and condition.

SEQUENTIAL STEPS
If It's Dirty, How Can It Be Sterile?

MULTISTEP PRACTICE It's a mistake to believe that sterilization alone adequately prepares equipment for reuse.

Reprocessing is a multi-step practice. If you don't properly clean devices before they're disinfected and sterilized, tissue, bone, or other organic material can remain in or on the instrument. ECRI Institute PSO (Patient Safety Organization) has created a list of its top 10 essentials for effective instrument cleaning:

1. Provide the sterile processing department with adequate trained staff, facilities and resources.

2. Standardize and simplify procedures in all areas where instruments are reprocessed.

3. Monitor the quality of instrument reprocessing through post-cleaning inspections.

4. Seek input from reprocessing department staff on instrument and equipment purchases.

5. Limit the operating room's dependence on immediate-use sterilization.

6. Establish delivery criteria for loaned instruments and prohibit immediate-use sterilization of them.

7. Require regular competency assessments of staff who reprocess instruments.

8. Foster collaboration and teamwork among reprocessing department and operating room staffs.

9. Recognize and respect the contribution by reprocessing staff to patient safety and quality care.

10. Encourage prompt reporting of events or near-misses involving contaminated instruments.

— Gail Horvath, MSN, BS, RN, CNOR, CRCST

Ms. Horvath ([email protected]) is a patient safety analyst at ECRI Institute PSO.

IN THE OR
During the Procedure

THEN AND THERE Pre-clean instruments at the point of use, before bioburden has a chance to dry.

Because bioburden tends to dry and cake very quickly on instruments after any type of invasive procedure, it's important to decontaminate devices during surgery. Here are 3 action steps from the AORN perioperative standards:

• Wipe instruments as needed with sterile surgical sponges moistened with sterile water during the procedure to remove gross soil.

• Irrigate lumened instruments with sterile water as needed throughout the surgical procedure.

• Cannulated instruments or instruments with lumens can become obstructed with organic material. Irrigating these tools with sterile water helps remove residue. Instruments should be rinsed with water because of the corrosive nature of saline.

— Phenelle Segal, RN, CIC

6. Cleaning instruments removes lubrication and prevents protein buildup. Water-soluble, antimicrobial lubricating solutions such as instrument milk are preferable. After cleaning and lubricating, but before high-level disinfecting or sterilizing, instruments should be irrigated with distilled, de-ionized or sterile water.

7. The final step in decontamination includes unlocking all instruments so they're sterilized in open positions. If instruments are being stored before sterilization, be sure to keep them in a clean and dry environment.