SINK STEPS From instrument handling to manual cleaning to personal protective equipment use, proper decontamination relies on a host of important details.

The importance of decontamination in preventing surgical site infections can not be understated. I'll put it very simply: If a surgical instrument is not clean, it can't be sterile. If it's not sterile, your patients are at risk. The handling that occurs between the point of use and sterilization or high-level disinfection is critical to reprocessing instruments, and it all depends on these 5 elements.

1. Immediate action
Ideally, decontamination should begin before instruments reach the sterile processing department — and before they even leave the OR or procedure room — in the form of post-op pre-cleaning.

All surgical nurses and techs are taught to wipe the blood, tissue and other debris off of instruments with a sponge and sterile water after they've been used during a procedure. That way the items on the field can continue to be used in the field. OR staff can provide a great deal of assistance to reprocessing techs by taking the same action as soon as possible after a case concludes, before they send the used instruments down to decontamination. This cursory removal of visible soils goes a long way toward preparing them for efficient and thorough reprocessing.

Keeping the instruments moist by covering them with a damp towel or, even better, a treatment of enzymatic spray, foam or gel, can prevent the remaining contaminants from drying on their surfaces, which can make them more difficult to remove, and lengthen the time it takes to turn them around. If it's possible, sending down used instruments organized into the trays in which they arrived can also assist in reprocessing efficiency.

2. The rules are the rules
Every surgical instrument is different in material and structure. Some are heat-sensitive, delicate, powered or plastic. Some have lenses, lumens, channels or joints. One cleaning process does not fit all.

Once all of these devices arrive in the decontam room and have been sorted, separated and disassembled, look to the manufacturers' instructions for use (IFU) for the proper course of action for cleaning and decontaminating surgical instruments and the containers and carts they came down in. IFU, for instruments as well as for the machines you'll clean them in, are the leading evidence-based practices of the sterile processing department.

Decontamination typically begins with a soak and manual wash in warm water and detergent, followed by a rinse in distilled or de-ionized water. Depending on the instrument being reprocessed, a cycle through a mechanical washer-decontaminator or ultrasonic cleaner may follow before steam sterilization or high-level disinfection. For items that can't undergo high-temperature autoclaving, low-temperature sterilization may be the next step.

The details are in the IFUs, from the type and concentration of detergent to be used in manual cleaning to the proper manner of rinsing and drying, and from the load capacities to the time and temperature parameters of the mechanical cycles. Make sure your reprocessing techs have studied, and have access to, these essential documents.

3. The proof of the process
There's no room for error in decontamination: Even a tiny oversight can create a huge problem. Let's say a rongeur still has a fleck of bone stuck to it when it's assembled into a tray, wrapped and steam sterilized. The surface underneath that contaminant won't get sterilized, and may present a cross-contamination risk to the next patient on whom the tool is used. As such, quality control is essential to ensuring the proof of the process.

After the manufacturers' prescribed cleaning and decontamination steps have been completed, our techs closely inspect the instruments as they assemble and organize them into trays. If an item should fail this final inspection, it's returned to square one and goes through the process again.

Reprocessing depends on continuous supervision and monitoring. Not only the monitoring of your staff — whether they're operating the washer-decontaminators and ultrasonic cleaners properly, wearing personal protective equipment when it's mandated (and removing it in the right place), and even complying with hand hygiene requirements — but also the monitoring of the machinery, the functioning of which should be tested daily, as well as the effectiveness of the chemicals and the quality of the water that make decontamination work.

You've got to be on your toes with every aspect of correct procedure. Automated processes such as instrument tracking systems can help you to stay on top of each step of the process. By following the items through the department, you can see where feedback and training may be necessary.

CHECK IT OUT Reprocessing equipment should be tested and logged daily to ensure proper functioning.

4. Policies for consistency
Reprocessing has always played a key role in a surgical facility's operations. In recent years, however, after a few high-profile, cross-contamination-sparked patient outbreaks that drew authorities' attention to infection prevention practices, the people who work in the basement have had a bigger stake in what's going on.

Take as an example how surveyors have stepped up their game with regard to sterile processing. They used to drop by to see if there were puddles on the floor, if the ceiling tiles were clean. Now it's: "Let's see your EtO. Have you tested your staff's competencies? Are all of your techs certified? Show us your maintenance records." The questions are more intense now that they've seen the impact that a less-than-thorough cleaning process can have.

It's incumbent upon you to take responsibility for your process. Establishing and maintaining policies to govern that process, whether or not surveyors are watching, is at the foundation of consistent — and consistently compliant — behavior. The long days and turnaround pressures of sterile processing can be an invitation to find a shortcut, which you need to avoid at all costs.

One situation that tends to cause problems for central sterile services everywhere is the arrival of loaner instruments for upcoming cases. You need to reprocess in your facility anything that comes in on loan from an external source before it can be used, which means you need access to those items in a timely manner. The arrival of a tray the night before the case is not sufficient. That's where a policy that requires the delivery of loaner instruments 48 hours ahead of time or for frequently loaned items to remain on site can keep reprocessing on the right path. Communicate your reprocessing policies to instrument-handling staff members, instrument-requesting surgeons and instrument-loaning vendors.

5. Your people are your process
New hires often come to my department with certifications from IAHCSMM or CBSPD. Our first task upon their arrival, though, is to teach them "the VA way," which, as I learned when I arrived here, consists of the highest, most stringent recommended practices from AAMI, AORN and other industry organizations. We're putting a lot of trust in our employees, so we point them toward a goal that's higher than just the standard.

The most important element in the decontamination process is the techs who are doing the actual decontaminating. They need to be the experts on how to thoroughly clean the instruments and operate the equipment. One way to make sure you're staffed with the best people is to provide them with continuous training, through routine in-service sessions or attendance at industry conferences. Make sure your central sterile services are staffed with enough people and that they have the resources they need to do the job. And if they prove their worth, make sure they're compensated fairly if you'd like to keep them working for your facility.