Sterilized With Certainty

No sterile processing department (SPD) manager wants to add another step to the complex and strategically redundant process of sterilizing surgical instruments. But wouldn’t you add that extra step if it provided absolute certainty that every instrument is returned to the OR free of bioburden?

That was our thought process when it came to implementing adenosine triphosphate (ATP) testing to validate that instruments are properly cleaned before being sterilized. Although we didn’t have an issue with bioburden or infection rates, we were running up to five surgical suites each day that performed cases in a range of specialties, including orthopedics, total joints, general surgery, otolaryngology, urology, obstetrics and gynecology. Because our SPD decontaminates and sterilizes such a wide range of instrumentation, ATP testing seemed like a worthwhile addition.

ATP testing, a bioluminescence technology that detects the presence of biologic material such as blood and tissue, uses premoistened swabs that are easy to use and provide results in less than 30 seconds. The rapid-result test reveals whether there is any presence of microscopic bioburden on an instrument and confirms the decontamination efficiency. Like all process improvements, seamlessly adding ATP testing into your workflow requires some flexibility and a lot of attention to detail.

When trays full of a variety of difficult-to-clean tools — from clamps to instruments with lumens, grooves or rigid jaws — arrived in decontamination, we randomly selected instruments to test and noted the specific locations that were swabbed. We didn’t inform reprocessing techs which tools were selected to ensure they didn’t make an extra effort to clean the instruments. We wanted them to maintain their normal practice of manual decontamination.

The instruments were swabbed and documented at four testing points: 

• The initial receipt prior to manual decontamination;  
• after vigorous manual decontamination; 
• after completion of a 15-minute cycle in an ultrasonic bath; and 
• after a 36-minute washer-disinfector cycle.

The swabs were placed in a handheld device, which displayed ATP readings in relative light units (RLUs). Results that yielded zero through 100 RLUs were noted as a passing mark, while instruments yielding 101 RLU or greater were noted as a failure. A failure of any instrument required it — as well as the other instruments in its tray — to be sent through the decontamination process again. We found that the amount of bioburden dropped significantly from that initial baseline (immediate receipt of instruments) to the second testing point (after instruments had been manually cleaned). Re-swabbing instruments after the ultrasonic bath would usually result in RLU readings of less than 10. Considering our initial swabs generally resulted in readings in the 1,000s or even 10,000s, achieving a mark like this before the decontamination process was finished was outstanding. We swabbed instruments one last time after the washer-disinfector cycle, which lowered readings even more.

We swabbed 118 instruments. Each rendered an RLU of less than six, indicating all tested instruments had passed ATP testing and our decontamination practice was up to the standard patients deserve.

ATP testing is one of the many tools that can bolster sterile instrument reprocessing and help your SPD techs perform their job safely and efficiently. For instance, rigid sterilization containers are solid and sturdy, so staff don’t need to worry about instruments falling out and breaking as they travel from the OR to SPD or punctured blue wrap requiring the resterilization of entire trays. As a general infection control practice, these containers must be properly cleaned in the case-cart washer before being reused. In our SPD, we place Class 5 chemical indicator strips inside instrument trays and individual peel packs before the terminal sterilization process. These strips change to a dark, almost black color, making it easy to see if the adequate temperature in the sterilization cycle has been met.