SPRAY IT DOWN Enzymatic cleaners can keep bioburden from setting before instruments are delivered to central sterile.

The critical first steps in instrument reprocessing are cleaning (removing visible soil and other foreign material) and decontamination (removing or reducing infectious organisms) through manual and mechanical efforts. Carrying them out depends on the consistency of your staff's practices and their using the correct cleaning implements (correct type of brush and brush size) that assist in the task. Here's a step-by-step overview.

Point-of-use pre-cleaning
For best results, reprocessing of instruments should begin in the OR or the procedure room during between-case turnovers. Some instrument manufacturers' instructions for use (IFU) recommend cleaning begin at the point of use, but in the absence of specific, validated instructions, you can follow sterile processing standards, such as those put forth by the Association for the Advancement of Medical Instrumentation (aami.org).

Post-op pre-cleaning protocols generally entail removing gross debris from instruments as soon as possible after use, before they are sent to the decon-tamination room. Blood, tissue and other visible soils should be wiped off with a sponge and sterile water — not saline, which can corrode instrument surfaces with prolonged contact. Flexible endoscopes and other lumened instruments should be flushed.

To prevent bioburden from setting, keep instruments in a moist environment while they're awaiting transport to the decontam room. Place a damp towel on top of them, or apply an enzymatic spray, foam or gel into trays and basins.

Decontamination room details
Inspect, separate, sort and disassemble instruments upon their arrival in the decontamination room. Manually clean those that have debris on them. Inspect all instruments for debris and thoroughly clean all instruments — even if the instrument or instrument set was not used.

SURVEILLANCE SWAB ATP testing can determine how effective your cleaning process is.

Be sure your processing staff wears a full complement of personal protective equipment: general-purpose utility gloves and a liquid-resistant covering with sleeves (for example, a backless gown, jumpsuit, or surgical gown). Liquid-resistant shoe covers should be worn if there is potential for shoes to become contaminated and/or soaked with blood or other bodily fluids. If there is any risk of splash or splatter, PPEs should include a fluid-resistant face mask and eye protection. PPEs used to protect the eyes from splash could include goggles, full-length face shields, or other devices that prevent exposure to splash from all angles. While it is acknowledged that the utility gloves can hinder dexterity and render instrument disassembly more difficult (imagine unscrewing the hinges on your eyeglasses while wearing thick gloves), the gloves are as important to staff safety as disassembly is to thorough cleaning.

Instrument cleaning continues with a soak and manual wash in a solution of warm water and enzymatic detergent. Change the water frequently; it can appear soiled after a single instrument set. Be sure the cleaning solution temperature is at the temperature specified by the detergent's instructions for use.

Most healthcare decontamination rooms will have a pH-neutral enzymatic detergent that's effective against protein-fat-carbohydrate soils and organic matter. As a precaution, however, consult the instructions for use for the instruments to be washed to ensure their compatibility with the detergent. And make sure your staff consistently adds the manufacturer-specified amount of detergent to the water in order to attain the proper concentration. Too much detergent in the sink can leave a residue on your instruments, while not enough lacks the chemical strength to clean them.

One sterile processing supply manufacturer offers a plastic sink insert that not only serves as a convenient caddy for transporting and protecting instruments, but also includes a built-in temperature gauge and water and detergent volume metering marks for exact results.

For manual washing, equipping your sterile processing staff with the correct size and type of brushes (and enough of them, since single-use brushes are intended as such) is important, particularly for such lumened objects as endoscopes. Medical device manufacturers are beginning to specify in their instructions exactly which type and size of brushes or other cleaning implements are to be used for reprocessing each device.

Quality control
After manual washing, rinse instruments thoroughly. Distilled or deionized water is preferred to prevent impurities from leaving surface residue. Dry instruments with low-linting cloths, and inspect them again for debris or defects as they're reassembled and organized into trays. Prepare instruments undergoing mechanical cleaning so that all surfaces are exposed to the cleaning solution.

Processing personnel must have ready access to the equipment manufacturers' instructions for use — whether they're in loose-leaf page protectors and binders on a nearby shelf, in posters on the wall (plasticized so you can wash them down) or online. Train them to consistently comply with those instructions.

Central sterile service departments are implementing verification testing to demonstrate the cleaning process is effective. This testing is performed on instruments to demonstrate they have been successfully cleaned. One such method relies on the bioluminescence of adenosine tri-phosphate (ATP), a compound found in all organic matter. Here's how it works: Swab a surface after it's been cleaned, then slide the swab into a handheld meter. In less than a minute, the meter will calculate whether bioload remains on the surface, quantitatively reporting the results as a number. In another method that uses protein testing, the swab changes color to indicate bioload. The rapid assessments offered by both methods make them easy to implement, even in rapidly paced surgical facilities.

These tests can be put to several different uses. With new instruments, they can tell us if our cleaning methods are effective. With new employees, they can determine if standards are being met. Or they can just provide routine assurances that your instruments are clean.