ORDERLY PROCESS Typically, an enzyme soak and an ultrasonic cleaning precede a mechanical washing.

Show me a facility that didn't do its due diligence before buying an instrument- washer, and I'll show you a bad case of buyer's remorse. As a sterile processing consultant, I see a lot of expensive eyesores. If you're in the market for a new washer, or expect to be soon, here's some advice to help make sure you don't end up regretting your decision.

Talk to other users before you buy
There are many critical issues to consider when you're looking at washers. How easy is it to use? Is it complicated for your staff to select the cycle, and to read and interpret the cycle? Do you have to make any major changes with the baskets you use? My advice: Don't buy anything until they've talked to a facility that has had the same machine for at least a year, and ask whether they'd purchase it again.

Some facilities overbuy, wasting money on fancy accessories they never use. For example, many ultrasonic cleaners come with special inserts and tubing that can be used to clean lumens. But at facility after facility, I see those attachments sitting in a corner unused. Why? They're too much trouble to hook up, people say, so we don't use them. Which means they likely wasted $4,000 or $5,000.

With washers, there are a lot of different options available, depending on your needs, and most are very efficient. Machines are getting more versatile and more user-friendly, and are increasingly equipped with cycles that are more attuned to the demands of outpatient facilities. One goes through the entire cycle and does a great job in 40 minutes. Manufacturers realize that the goal has to be to increase throughput without increasing footprint, and they've been able to shorten rinse and dry cycles to improve efficiency.

Remember, if a washer is going to be used for multiple purposes, you have to make sure people are using the correct cycles and the correct detergent. The wrong detergent can destroy instruments.

NIMBLE Today's instrument washers are more attuned to the demands of outpatient facilities. Some have cycle times as short as 40 minutes.

Another step in the right direction is the introduction of multi-level sonic cleaners. That's huge, especially for orthopedic facilities with limited space, where at any given time you might have 20 trays that need to be sonic-ed before they go into the washer. Too often, people are inclined to simply skip that crucial step. Now you can handle several trays simultaneously in one machine, provided they all require the same amount of sonication time.

A washer can't do everything. The ideal cleaning process typically starts with an enzyme soak, is followed by ultrasonic cleaning, and then by mechanical washing. Virtually every instrument manufacturer's instructions for use (IFU) recommend including ultrasonic cleaning as part of the reprocessing process. If you don't have an ultrasonic cleaner and bypass that step by placing instruments directly in the washer, you're not complying with the IFUs. You're in effect saying you know more than the manufacturer, and you think you can get the device clean by doing it your way instead.

Mechanical washers and ultrasonic cleaners have different processes and different functions. Ultrasonic cleaners agitate water and create bubbles that implode and create pockets of suction around instruments. They're good at removing debris out of all the nooks, crannies and serrations, but they don't disinfect. Washers, on the other hand, aren't nearly as effective at dislodging debris from hard-to-reach areas, but they do usually raise the temperature at the end of the cycle to a level that reduces microbial count.

Some facilities may be able to get by with just an ultrasonic cleaner (as long as that's the instrument manufacturer's recommended protocol and the people doing the prepping and packaging wear powder-free gloves), but most need multiple pieces of equipment to comply with the manufacturer's IFUs.

And you'll need more than one. You should never have just one of any type of equipment, because when it goes down, which it inevitably will, you'll be facing a major problem. This may be one of the reasons that tunnel washers — the car-wash types that let you put instruments in one end and have them come out the other end having gone through all the essential cycles — seem to be falling out of favor with both manufacturers and users. In addition to providing less control — for example, you can't change the length of time instruments spend in the sonic cycle, which is an important consideration in orthopedics — they take up a lot of space and are extremely expensive. For the price of one tunnel washer, you can get several mechanical washers.

Test your cleaners every day
A lot of surgical centers that were set up to do small procedures and have since gone way beyond that still have small processing rooms and a small tabletop ultrasonic cleaner that's not powerful enough to do the job. So the staff doesn't use it.

We live in a litigious world. Surgeons have the right, legally speaking, to assume that everything brought into the OR is safe to use. If an instrument turns out to be unsafe, the person running the facility is the one who's liable.

Make sure you have mechanical cleaners that comply with IFUs, and test them continually to make sure they're doing the job. One test uses actual blood and fibrinogen, and not just chemicals. That's my preference — the most stringent test available. The Association for the Advancement of Medical Instrumentation (AAMI) recommends testing at least once a week. But if possible, you should test every day. After all, if you test on one Monday, and the next Monday you find out the machine has failed, you'll have no idea when it went bad. And you'll be looking at a whole week's worth of instruments that might not have been adequately cleaned. OSM