Clean Instruments: Perfection Is the Mission

Here’s how top sterile processing pros handle this essential task.

Anthony LaSita, CST, knew a breakdown in the sterile processing procedure when he saw one.

He was doing a trauma case when a total hip tray came onto his surgical field. When he opened the case, he saw right away that the instruments were full of debris from their last surgery.

“You obviously can’t take that tray and you have to send it back to sterile processing to be reprocessed again,” says Mr. LaSita, now the manager of clinical and operational logistics at Merritt Healthcare in Ridgefield, Conn. “You have to break it down and start over again, which is very stressful, but time is of the essence and you have to work efficiently.”

After the case was completed, Mr. LaSita wanted to identify at what point the sterile processing procedure broke down. Not because he wanted to fingerpoint at anyone, but because he wanted to find out what happened to try to fix the problem.

That’s the simple reality about sterile processing: If the surgical instruments are not sterile, they can’t be used in surgery, which can lead to delays and cancelations.

But how do you ensure instruments are sterile?

Surgical conscience

One way, Mr. LaSita believes, is to develop what he calls a “surgical conscience,” an acute awareness that the sterile processing department (SPD) works hand-in-hand with surgical technology.

“The way I think about it is simple — I want to make sure those instruments are as clean as they can be, as if it was my family member on the table,” says Mr. LaSita. “That’s the type of surgical conscience that I have and that’s what I try to bring to the process. And I try to teach our staff members to have the same mindset.”

Training the staff, of course, is a big part of the process. Walking staff members through SPD procedures step by step, even to the point of having them in the operating room during a case to see exactly how the instruments are used, can help raise awareness and understanding.

Policies and procedures are the foundation of sterile processing departments, which are also guided by regulatory agencies on the best evidence-based practices. One of the organizations that facilities rely on for sterilization guidance is the Association for the Advancement of Medical Instrumentation (AAMI).

“In general, you have a very robust orientation process for employees, with detailed policies and procedures and competentcy skills evaluations to see that team members can perform the tasks successfully,” says Heather Ridge, RN, BSN, BS, CIC, infection prevention leader with Novant Health in Winston-Salem, N.C., and the chair of the 2025 Association for Professionals in Infection Control and Epidemiology (APIC) Communications Committee. “We are always reviewing our instructions for use (IFUs) and making sure we are following best practices and what the manufacturer recommends,” she says.

Prepping starts early

The cleaning process starts on the instruments immediately after they’ve been used on the patient. The importance of thorough “point-of-use treatment” or “pre-treatment” is vital, according to Ms. Ridge. “Make sure that we get the visible bioburden off of the instruments before we even leave the room with it and transport to sterile processing,” she says. Once the surgical case is over, the surgical tech breaks down the setup and opens all the clamps so any blood, debris or bioburden that’s inside gets cleaned. Tips of instruments often have teeth in them, and blood and tissue can get stuck there, too, so they must be carefully checked.

It’s important to keep the instruments moist until they are cleaned by either saturating them with an enzymatic pretreatment product or placing a towel moistened with water over the instruments.

“We have a bioburden spray that we use on the instruments in the room after the patient is gone to make sure blood is not drying,” says Mr. LaSita. “We try to soak the instruments in water basins so lumens don’t get clogged with tissue. You can’t soak them in saline because the salt water deteriorates the integrity of the metal.” Once the instruments are ready, they should then be covered and transported.

Keeping on schedule

DIRTY WORK Attention to detail with every piece of instrumentation and equipment is what it takes to run a successful sterile processing department.

Understanding the procedures, providers and tools needed for successful surgeries is critical. What you want to avoid is immediate-use steam sterilization (IUSS), formerly known at flash sterilization, which has a list of conditions that must be met in order for the process to be an option. If the conditions for IUSS have been met, you can use sterilization containers which are validated for immediate-use scenarios. To stay on schedule and ensure peak sterilization, SPD pros have an array of tools at their disposal.

• Lighted magnification. These should be on all the prep and pack tables to make sure staff members can magnify the instrument to see that it’s cleaned properly. “Lighted magnification is one of the better options because you can see everything more clearly,” says Ms. Ridge. “Everybody’s vision is different, and there are tiny crevices and nuances in these instruments. It’s really important to look at them closely.”

• Borescopes. Use these to make sure the lumens inside the scopes are clean, that the lenses are intact and that the lumens have been cleaned properly. When talking about scopes, be aware that the lenses are delicate and can get scorched or scratched.

• Verification tests. This should start at the beginning of the day. There are biological tests that sterile processing must pass. These are crucial for verifying the effectiveness of the autoclave sterilizers.

There are all sorts of chemical and physical and biological indicators to ensure that the instruments are sterile, depending on the type of sterilizations, steam or temperature sterilization.

For example, with steam sterilization a visual chemical indicator on the outside of the packaging — a sticker or tape — will change colors. There are also chemical integrators that go on the outside and inside of the packaging to ensure that the sterilization has penetrated the package and reached the instruments.

According to Ms. Ridge, most surgical centers and hospital SPDs run biological indicators (spore tests) in every load. Spore tests for steam sterilization are the gold standard, she says.

“I think the biggest challenge we have in the industry is cleaning the instruments because some instruments are extremely complicated,” she says. “It’s very tedious, and because of all the nooks and crannies, channels and lumens, it’s difficult to clean,” she says. “The sterilization process is simple and works very effectively. It’s the cleaning that is the most difficult.”

To ensure there are no issues with the equipment and everything is running smoothly, focus on the following items:

• Test the autoclaves. Perform a DART (Daily Air Removal Test) to make sure the pre-vac autoclaves are operating properly.

• Indicators inside the trays. Make sure to check these after the trays are reassembled.

• Indicators outside the trays. These are locks that have a dot on them. They typically start out blue and then once they go through the sterilization process, they turn black.

• Lock placement and effectiveness. If the lock is broken, you need to redo the set.

• Water quality. Monitor and control the quality of water that is supplied to washer-disinfectors.

Always take extra precautions

After instruments come out of the washer, they need to cool down. From there, staff members start taking the sets and making sure they are complete.

SPD professionals will go through instruments one piece at a time — clamps, scissors, needle-drivers, specialty clamps, fine tips. They’ll look at instruments under the magnifying glass and then, as an extra precaution, wipe them down with alcohol prior to putting them into the autoclave.

“The washers typically do an excellent job and if you’ve prepped the instruments ahead of time, done ultrasonic and then put them in a washer, they usually come out pretty clean and you don’t have to wash them again,” says Mr. LaSita. “But that’s where your surgical conscience has to come into play. The staff have to be trained well enough to look at something and say, ‘Hey, this is not cleaned properly.’”

Keep the pressure off

Mr. LaSita believes that keeping the pressure off the sterile processing staff starts with management and leadership, especially when the staff is tasked with getting the instruments cleaned and turned over in a hurry.

“You want to make sure you see how the day is laid out and to give the staff the proper structure of how their instruments need to be turned over for the day. That’s a way to reduce the pressure,” he says. “We always work to make sure that the people we’re hiring have the right background and right skill sets to do these jobs.”

Ms. Ridge agrees. She’s an advocate of the proven mitigation strategy of pictures, reference guides and other visual aids being placed throughout the areas where the cleaning, decontamination and sterilization is being done.

“Developing standards of work so team members know what to do with every piece of equipment is key,” says Ms. Ridge, who adds that sterile processing personnel should brush up on training annually at a minimum.

“At the end of the day, we’re people, and we’re trying to do the best we can,” she says.

It takes the entire team

Making sure surgical instruments are properly cleaned and sterilized takes collaboration from the whole team, from top to bottom, according to Ms. Ridge.

“It’s really important to understand your providers and the needs that they have for their individual patients — having your schedule in place, having everything ready, knowing what you have to pull for all cases,” she says.

“It’s all about teamwork, working together and being organized. And at the end of the day, always remember who it’s all about — it’s all about the patients.” OSM