Some may view pre-cleaning instruments as unglamorous grunt work, but manually wiping, soaking and hand-scrubbing the tools of surgery is the key to preventing biofilm buildup. You've heard it many times before, but it bears repeating: It's impossible to disinfect or sterilize inadequately cleaned instruments. Just ask Porter Adventist Hospital.

Biofilm appears to be behind the infection breakout that last month forced the Denver hospital to suspend all surgeries for nearly a week. We don't know for certain what caused post-op infections in several patients who had orthopedic or spine surgery performed at the hospital over the last couple of years, but a trail of evidence points to improper instrument cleaning practices and the hidden menace known as biofilm.

• When surgical site infections are linked back to surgical instruments, biofilm is likely a root cause.
• The infection outbreak spanned nearly 2 years, from July 21, 2016, to April 5, 2018. Whatever was causing the infections was recurrent and undetectable, telltale characteristics of biofilm.
• The hospital sent precautionary letters to about 5,300 patients who underwent orthopedic or spinal surgery at the hospital during that time. The letter explains that the sterilization issue revolved around the first step in a multistep process: a pre-cleaning process that occurs before instruments go through "an intense heat sterilization."
• Health officials determined that the infection control breach was due to human error that occurred during "a gap" in the manual pre-cleaning phase — before the tools underwent heat sterilization. Staff at Porter Adventist wiped down, soaked and scrubbed certain spine and orthopedic instruments, but apparently not well enough. The instruments likely still contained bioburden when they were sent along for automated cleaning and heat sterilization.
• Since warning patients of the pre-cleaning breach, the hospital discovered residue on instruments after sterilization. The hospital first suspected this was due to a water quality issue, but tests showed the water quality was well within the typical range found in drinking water. It turns out that a mineral buildup in a cleaning machine caused the residue.

Bacteria's slimy fortress

The Porter Adventist incident hammers home the critical importance of the first step in the instrument reprocessing process in the battle against biofilm. The incident also illustrates biofilm's tolerance and tenacity.

Biofilm forms when bacteria adhere to surfaces in some form of watery environment and begin to excrete a slimy, glue-like substance that can stick to all kinds of materials. Think of biofilm as bacteria's slimy fortress — a resistant protective barrier around infectious microorganisms on surfaces.

Microbes protected by biofilm will resist even high-level disinfection. As was apparently the case at Porter Adventist for nearly 2 years, instruments can move through an automated washer and a sterilizer cycle, yet still wind up back on the sterile field coated in biofilm. This happens more than you might think. Researchers have found that more than 60% of "correctly processed" surgical instruments showed a high degree of residual protein soiling, according to a study in the Journal of Clinical Microbiology (osmag.net/5SUFcv).

Steps you can take

Is this a problem that calls for us to focus our attention on fixing flaws in the cleaning process? Or are we faced with a systemic problem involving the limitations of the current standards of cleaning and disinfection? All that's certain is that any disinfection process is doomed to fail if cleaning is inadequate.

The good news is you can remove nearly all of the dangerous bacteria before you sterilize or decontaminate. Here are a few tips to eliminate opportunities for biofilm to start forming.

• Pre-clean at the patient's bedside. Pre-cleaning begins in the OR or procedure room and continues through transport with solutions that prevent soils from drying. During a procedure, keep instruments wiped clean of all bodily substances as much as possible so they don't dry and harden. For endoscope point-of-use pre-cleaning, for example, wipe the outer surface of the scope with an enzyme pre-cleaning sponge and suck the irrigation solution into the scope.

• Use an enzymatic detergent. The detergent you use as a presoak or for manual cleaning should contain enzymes that break down organic and inorganic soils, residues, films and deposits. If the detergent action is not efficient against biofilm matrix, bacterial biofilm can resist high-level disinfection. And if you don't get rid of biofilm when you clean your instruments, you'll lose the fight.

After all this cleaning, be sure to rinse instruments very thoroughly in order to remove all of the enzymatic detergent. Ineffective rinsing can let the very bacteria you are attempting to remove remain on instruments and continue to multiply.

• Follow the wet-dry rule. Keep instruments wet at the point of use and spray them down in the instrument pan; then keep instruments dry after disinfection or sterilization because biofilm forms in wet conditions. You have to set yourself up for success when battling biofilm — if the first part isn't right, the last part won't be right.

A background in biofilm

Before I became a perioperative educator, I worked for 8 years as a clinical education consultant for a company that made a popular high-level disinfectant solution as well as sterilization and disinfection medical devices. I visited hospitals and surgery centers to train clinicians on how to use sterilizers, endoscope reprocessors and the high-level disinfectant.

I think it's invaluable for the surgical team to become more educated in sterilization and disinfection techniques so they can appreciate and understand what happens to their instruments before and after they use them. Staff trust that sterile processing won't let a load go out if it's not sterile, but they should still look at the indicator when they rip open the pack or tray. OSM