DETAILS MATTER If your scopes didn't come with a proprietary brush, be sure the one you use has the right diameter, the right length and the right bristle type.

From cannulated drill bits to flexible endoscopes, lumened instruments are likely to be your toughest reprocessing challenge. Fortunately, the tools designed for the job generally work very well — with some important caveats. One is that you need to follow manufacturers' instructions to the letter. Another is that you need to let your most important tools, your SPD people, function at their highest level. More on that below.

But no matter how good your equipment is, and no matter how precise, attentive and dedicated your sterile processing techs are, their job will be far more difficult, and they'll be far more likely to fail, if reprocessing doesn't begin where it ought to: at the point of use. Otherwise, by the time an instrument gets down to the sterilization department — which may be hours later — the contaminants coating the insides of the channel are likely to be rock hard and almost impossible to remove. The clock starts ticking when blood, bone and bioburden enter the channel of a drill bit or an endoscope. It's crucial that you flush, clean out and irrigate channels and lumens at the point of use — whether you're in an OR or in an endoscopy suite. That's a lesson you need to emphasize and re-emphasize until point-of-use cleaning becomes as automatic as sunrise.

Be sure to flush lumens and channels with a syringe and sterile water periodically throughout the procedure to reduce the risk that biofilm will form. It's important to use sterile water with stainless steel instruments, and not saline, which is corrosive and can cause pitting. Depending on what the manufacturer recommends, you can also soak instruments in an enzymatic solution. Make sure instruments stay moist until they get to the processing department. Pre-cleaning kits are also available for flexible scopes.

TURNOVER TIME Automated endoscope reprocessors, which high-level disinfect endoscopes and accessories, can also eliminate some steps in the manual cleaning process.

Tools of the trade
Once lumened instruments arrive in sterile processing, pre-cleaning continues.

• Enzymatic pre-soak. The first step is usually a 5- to 10-minute soak in an enzymatic detergent.
• Brushing. Brushing is usually next. If your instrument manufacturer has proprietary cleaning products, use those. In any case, use the right brush for the job — with the right diameter, the right length, the right bristle type, and so on. One manufacturer claims its microfiber brush tested more effective than others in a head-to-head matchup, but it doesn't say whether the brush it compared itself against was the one the instrument manufacturer recommended, so there's no way of knowing for sure.
• Automatic flushing devices. To further dislodge stubborn soil, you can use an automatic flushing device that can fit into sinks and on countertops to force pressurized water through channels. Different systems can accommodate different specialties, including delicate ophthalmology instruments. In addition to doing a better job than manual flushing, flushing devices may also help eliminate the ergonomic challenges associated with repeated manual use of syringes.
• Sonic irrigation. As a final step, some manufacturers recommend sonic irrigation, which combines ultrasonic technology and controlled irrigation to deliver exceptionally high wash-fluid pressure. But not all instruments are suitable for the sonic machines, so remember your IFUs.
• Dual-chamber cleaning. A relatively new cleaning device on the market uses a dual-chamber approach, which simultaneously pushes and pulls water through endoscope channels. Though it sounds promising and may be a very effective approach, there are drawbacks. It's been validated for only a few flexible scopes and it can process only one scope at a time with what turns out to be a fairly long cycle time.
• Low-temperature sterilization. This may also be a viable alternative for heat-sensitive instruments and scopes, but some units are limited in terms of the length and diameter of channels they can handle.
• Automated endoscope reprocessors. Some of the newer AERs claim they can either augment or eliminate steps in the manual cleaning process. Be sure you use the appropriate connectors for the specific scope model, load the machine correctly, don't overload and follow all other instructions.

The most important tool
Manufacturers may try to reduce the human factor — some, in fact, claim to have eliminated it — but the entire process is still very human-dependent. You need to pre-clean, scrub and flush; you need to carefully follow instructions; and you need to use equipment the way it's designed to be used.

In fact, people are the most important tool of all. Having managed sterile processing departments, and having had the opportunity to do consulting work at many hospitals over the years, I've found sterile processing techs to be very dedicated and very capable — as long as you give them the tools, the inventory, the training, the support and the patience they need to do the job.

Along with the complexity of the instruments, the big challenge they face is pressure to hurry up, move a little faster and get it done already. In fast-paced, demanding environments, there's a real danger, because when sterile processing departments are pushed and nagged and urged to reprocess more quickly than they should, they're tempted to take shortcuts. The phenomenon is especially prevalent in facilities that don't have sufficient inventory to accommodate the volumes they're striving for. The answer isn't to push people to move faster; the answer is to make sure you have enough inventory to meet your demands.

Why not certify?
All in all, reprocessing personnel do a remarkable job, but it seems that all we ever hear about are the few instruments that have fallen through the cracks. When you hear about a contaminated instrument in the news, it was probably one of thousands that were processed that day by that facility. And across the country, for every one that fails, there are millions that don't fail. If you're looking at a Six Sigma defect-free rate as the ultimate goal, for the most part that's what we're reaching.

Still, I think we should require central sterile processing personnel to be certified. I'm from one of the very few states (New Jersey) that requires it. I also participate in the AORN Legal & Governmental Affairs Workgroup, which is fighting for certification to be required in all states. I'm encouraged that even in states where certification isn't required by law, more and more hospitals are requiring it. There's an increased awareness that people who are doing that job need to be trained professionals in sterilization and disinfection practices, and they need to be recognized as such. Certification validates it, and certified personnel are our best bet when it comes to reprocessing increasingly complex instruments. OSM