FIRST THINGS FIRST Instruments must be properly cleaned before they can be properly sterilized.

Does your central sterile team follow recommended practices and evidence-based guidelines when it comes to decontaminating surgical instruments? If the results of a recent survey of 105 Outpatient Surgery readers are any indication, it wouldn't hurt your team to brush up on these basics.

Cleaning and rinsing instruments does not remove all visible and non-visible debris.
One-third of our survey respondents didn't know this, pointing to an overall lack of knowledge about the importance of each step in the cleaning process. No one step cleans everything, and cleaning and rinsing doesn't remove all debris. Instruments may appear clean to the naked eye after the manual cleaning and rinsing phase, but biofilm that dries on surfaces might remain intact in hard-to-see areas.

Each step in the decontamination process is critically important, from cleaning at the point of use to removal of biofilm in central sterile before sterilization. It's not possible to clean and disinfect without completing each step of the process separately and properly.

Half of the respondents believe enzymatic spray easily removes biofilm.
It's interesting that responses to this question were split down the middle. Many nurses think enzymatic spray is a magic elixir for biofilm, that all they have to do is spray dry, caked-on blood and — poof! — it's gone. That's simply not the case. Once biofilm establishes itself on surfaces, it's very difficult, if not impossible, to remove. In fact, manual scrubbing alone doesn't necessarily get the job done. The key is to keep it from forming in the first place, which is why point-of-use cleaning during cases is extremely important. In fact, proper point-of-use cleaning sets up the entire decontamination process for success.

Only one-fourth know covering instruments with a water-moistened towel is an appropriate way to ready them for transport from the OR to central sterile.
Instruments must be kept moist during transport in order to prevent biofilm from drying and sticking to surfaces, especially if a delay is expected between the time they arrive in central sterile and when staff there can begin the reprocessing process. It's a common misconception that enzymatic spray must be used for this purpose. It certainly can be, and it's a great first choice, but tap water is an acceptable alternative if you don't have spray available. Before sending instruments from the OR to the decontamination area, grab an unused hand towel, soak it under a faucet and throw it over the set. It's that simple.

20% of the readers don't know cavitation causes bubbles to implode and pull debris away from surgical instruments.
Cavitation is the basis for ultrasonic cleaning. Microscopic debris sticks to hard-to-reach areas on finer instruments, and can't be removed with manual scrubbing alone. Understanding that ultrasonic cleaners remove stubborn debris is important, but so is knowing that instructions for use issued by manufacturers of specialty and complex instrumentation include specific directives on how many times their devices should pass through an ultrasonic cycle and how long each cycle should last. In my experience, such directives aren't always followed on the front line.

10% don't know instruments should be cleaned at the point of use with soft, lint-free gauze moistened with sterile water.
Although most respondents got this right, all too often I see nurses who don't put sterile water on the back table. At previous jobs, they argued that sterile saline (0.9%) was available. However, saline has the potential to pit instrument surfaces and shouldn't be used for any instrument cleaning. If you don't make the supplies available to complete this simple task, how can you expect it to get done? I started out as an OR tech, so I know cleaning instruments during procedures can be done. When performed consistently, it takes only seconds to quickly wipe down instrument surfaces with a lap sponge or gauze pad as surgeons hand them back after use. Wiping down surgical tools during procedures keeps blood from drying on teeth and grooves and in lock boxes, which improves the decontamination process, keeps instruments in excellent working order and ultimately extends their usable life.

20% think it's OK to place small items in a plastic peel pouch with instrument sets for sterilization.
When the FDA validates the sterilization parameters of peel pouches, it is not done inside a rigid sterilization container. That means you can't place a peel pouch in a rigid container and guarantee its contents to be sterilized unless it has been validated for this purpose. There are several products available — finger mats, for example — for separating small instruments before sterilization. If you work with fine instrumentation, it makes good clinical and business sense to invest in the products you need to take care of them properly.

A majority of facilities keep current copies of AORN's recommended practice guidelines for instrument decontamination, AAMI's ST79 and instrument manufacturers' instructions for use in the OR.
Most surgical teams have easy access to instrument care guidelines, but are they always referencing them? Time is money in surgery, and some facilities unfortunately believe cutting corners during the cleaning and decontamination process is an acceptable way to shave a few seconds off turnaround times between cases.

In addition, some manufacturers' instructions for use are ridiculously long and contain so many labor-intensive and complex steps that they essentially set your staff up for failure. Medical manufacturers need to develop devices with streamlined reprocessing steps that can be realistically achieved in a busy surgical facility. In the meantime, current reprocessing instructions, however complex they are, must be followed.

Only three-fourths validate staff competency for cleaning and decontaminating instruments.

There are simple practices that aren't being followed that make a huge difference in the central sterile department's ability to properly decontaminate instruments. The cleaning process begins in the operating room, but that's not being done consistently.
It's your responsibility to get out from behind the desk to ensure staff is following through on what they have been taught about proper instrument cleaning. Walk around and see what practices are being followed. Make a checklist for surgical and central sterile managers, so they know exactly what to look for during performance audits. Post performance metrics on a prominently displayed bulletin board. If, for example, you're sitting at 40% compliance with following instrument manufacturers' directions for reprocessing, your staff will realize improvements are needed. You'll be able to show the progress they make in reaching full compliance, which helps build momentum and makes obtaining the goal much more likely.

TEAM BUILDING
Bridging the Divide Between ORs and Central Sterile

ZOOM OUT Personnel who work in central sterile might not understand the big-picture importance of instrument reprocessing.

In many facilities, a mental and physical disconnect exists between staffs in the central sterile department and ORs. There's also an underlying tension between the groups. One side wants instruments back into surgeons' hands as quickly as possible, while the other's primary focus is ensuring instruments are safe for use when they get there.

OR team members who want instruments returned in a matter of minutes often don't understand that proper decontamination and sterilization takes time. Central sterile techs have specific rules they need to follow when handling each instrument set. Asking them to deviate from those guidelines is asking them to do their jobs incorrectly.

Central sterile personnel need to understand the importance of cleaning instruments properly before each and every sterilization cycle, and what's at stake if they don't. Your surgical and sterile processing teams need to value their contributions to the overall success of your facility. If central sterile goes offline, surgeries literally grind to a halt.

We need to promote and embrace a team concept in instrument cleaning decontamination. Right now, many facilities have failed to find common ground. Cooperation between central sterile and perioperative professionals needs to be developed and celebrated. Until more facilities make that synergy a reality, we'll continue to see post-op infection problems related to improper instrument reprocessing.

— Mary A. Hillanbrand, DNP, RN, CNOR, CCNS, CNS-CP