Are Your Instruments Really Clean?

Infection Prevention

By: Christian Schappel

Published: 5/27/2020

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Ensure tools have been properly reprocessed before they're used on another patient.


Any reprocessing tech worth their scrub brush knows dirty instruments can't be properly sterilized. There's another instrument care risk hiding in plain sight, however, that can jeopardize patient safety.

"Staining is a major problem because it can lead to pitting, rust, instrument impairment, breakage and the protection of bioburden," says William DeLuca, CRCST, CIS, CHL, director of sterile processing at Mount Sinai West in New York City.

He says staining on instruments that have been cleaned and sterilized can be caused by several factors, including water with a high pH level, the use of improper detergents and enzymatic cleaners in instrument washers, caked-on blood, soaking instruments in saline, processing two different types of metals in ultrasonic machines and allowing water to dry on instrument surfaces. Mr. DeLuca says the following ways to prevent instruments from becoming stained are effective:

  • Make sure detergents are properly mixed and diluted in instrument washers.
  • Always follow manufacturers' instructions for use (IFUs).
  • Audit OR case carts in decontamination to ensure visible debris and gross soil is removed from instruments.
  • Make sure OR personnel are using enzymatic pre-cleaner solutions on instruments immediately after use.
  • Use clean, soft-bristle brushes (no hard-wired brushes) on instruments in decontamination.
  • When using surgical stain remover, make sure instruments aren't soaking it in for too long.

These practices can limit the repair and replacement of instruments, according to Mr. DeLuca. "In addition, the process can improve surgeons' satisfaction with the functionality and appearance of their instruments," he says. "Most importantly, it can improve outcomes."

Mr. DeLuca points out that advancements in water treatment systems are also helping in the fight against staining by reducing the levels of impurities in the water used in instrument washers and autoclaves. New and improved detergents and ?enzymatic cleaners ?can also be less harsh on ?instruments.

Finally, it pays to be proactive. "You don't have to wait until staining causes a patient care issue to start an instrument staining reduction project," says Mr. DeLuca. "Controlling stains should be an ongoing goal. Be creative and come up with ways to start auditing ?instrument trays. Then, when you observe instrument staining, perform a root cause analysis to find the problem and attack it."

Trust, but verify

As much as you'd like to think you can control how clean instruments get during reprocessing, that's not always the case. "Damage to a device, such as a cracked seal, can prevent reprocessing staff and equipment from completely removing bioburden, even if every single recommended step in the cleaning process is performed correctly," says Jimmy Henderson, materials manager at the Outpatient Surgery Center of Jonesboro (Ark.).

However, what your reprocessing staff can control is whether a contaminated device is returned to the ORs. Borescopes can be used to visually inspect the working channels of endoscopes to ensure internal components are free of bioburden. Adenosine triphosphate (ATP) tests are useful for detecting residual protein and bacteria on the surfaces of instruments and inside the channels of lumened devices.

"Cleaning verification tests can be used after reprocessing to detect the presence of very low levels of bioburden such as protein, carbohydrates and hemoglobin that can cause infections," says Mr. Henderson.

Verification tests have helped his facility identify when scopes aren't sufficiently cleaned during reprocessing or need to be sent out for repair or replaced. Before he implemented the tests, he had to get past the notion that such testing might appear excessive.

"Our reprocessing staff is excellent at getting instruments clean — we have no infection history," says Mr. Henderson. "It wasn't until our GI manager saw a cleaning verification test for lumened instruments at a conference that we began testing our endoscopes for bioburden."

SURE THING Verification testing can ensure instruments, such as flexible endoscopes with notoriously tough-to-clean channels, are free of bioburden.

The nice thing about verification tests is that they can be used on instruments with multiple channel sizes, points out Mr. Henderson. "The demonstration at the conference showed just how crucial the testing could be for ensuring that bioburden is completely out of endoscopes," he explains.

"After seeing the benefits for herself, our GI manager decided we should implement the same test."

The facility's GI techs test each endoscope for bioburden according to the process laid out by the manufacturer of the testing strips. After the facility's endoscopes are washed with enzymatic cleaner, they're placed into automated endoscope reprocessors (AERs). After the cycle, they're ready for the verification test.

Mr. Henderson says the verification test requires a tech to run 20ccs of sterile water through a reprocessed scope and catch the water in a cup, in which a testing strip is placed. The strip will turn color if bioburden such as protein, carbohydrates or blood is present, with the color of the strip indicating the type of soil detected.

"We compare the color of the strip to the results chart provided by the test manufacturer," says Mr. Henderson. "Following a successful test, scopes are hung in a drying cabinet."

The techs test five scopes at the end of each day. By the end of each week, a typical scope has been tested twice. "The test only takes a few moments to complete, allowing us to take corrective action immediately," says Mr. Henderson. "Every once in a while, a scope will test positive for bioburden. When that happens, the scope is rewashed, run through our AER a second time and tested again."

A scope almost always passes the verification test the second time. But on rare occasions when a scope again tests positive, Mr. Henderson sends it out for repair.

"Scopes that fail the test a second time always have a problem, such as a seal or rubber piece that has come lose or cracked, causing bioburden to get trapped inside," explains Mr. Henderson. "Some of these problems may not have been discovered if we weren't using the testing strips."

Show the benefits

SIGN OF TROUBLE Instrument staining is a problem that can lead to major issues such as rust, pitting, instrument breakage and difficult-to-clean bioburden.   |  William DeLuca, CRCST, CIS, CHL

Adding steps, no matter how small they might seem, to the reprocessing process in a busy facility is a significant concern, concedes Mr. Henderson. He says staff who think they're already doing a great job taking care of instruments might balk at verifying their work. He therefore emphasizes the importance of showing them the testing is worth the extra effort.

"When we first started performing the verification test, all of our scopes were passing, so naturally, staff started to think the testing was overkill," says Mr. Henderson. "That is, until the first time an endoscope didn't pass."

The techs cleaned that scope again, and even after a second cycle through the AER, it came back positive for bioburden. "That's when our staff realized just how valuable the test could be," says Mr. Henderson. "The repair facility sent back photos of what was wrong with the scope. If we had used it, a patient could have developed an infection. Testing was an easy sell after that."

Even with his staff fully embracing use of spot checks, Mr. Henderson still had to ensure using the test on a regular basis became a habit. "The best way to do that is to document everything," he says. "If you're going to make something a requirement, you need to create a record of it. Consistent documentation prevents staff from skipping steps in the process or overlooking an endoscope that's scheduled to be tested for bioburden after reprocessing."

His reprocessing team now records which scopes are tested, when they are tested, whether they pass or fail and — in the event of bioburden detection — when they're sent back for another spin through the AER. The detailed documentation provides Mr. Henderson with an accurate record of how each scope has been handled and how often its cleanliness has been tested and verified.

Since Mr. Henderson's reprocessing techs began testing for bioburden, his GI manager has made it a point to perform spot checks of both scopes and techs' abilities to perform the test.

"The manager will randomly pull an endoscope after reprocessing and test it herself," says Mr. Henderson. "Other times, she might ask a tech to perform the test and observe. These spot checks have helped emphasize the importance of the tests. They also serve as an important recheck of our reprocessing procedures and verification testing practices."

Through this new protocol, Mr. Henderson is better able to ensure bioburden is completely removed from scopes. "Our number one priority is always making sure patients get the best possible care," says Mr. Henderson. "So even though our verification testing isn't something we have to do, it helps us achieve our goal by going the extra mile for patients to ensure we continue to have no infections." OSM

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