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Infection Prevention
Soiled Scopes, Peel Packs, Wet Loads, and Other Issues
Dan Mayworm
Publish Date: June 9, 2008   |  Tags:   Infection Prevention
After asking for your infection control questions last month, I found that cleaning soiled scopes, glutaraldehyde, peel packs and wet loads were among the most confoundingtopics to readers. In this column, I'll try to shed light on some of these issues.

I am a new employee at my facility and I find some of the staff's procedures suspect. The one I find most disturbing is that they clean their scopes in the same sinks in which they wash their soiled instruments. Do you think this is appropriate?

As long as you don't immerse scopes in the same dirty water you use to soak and clean other instruments, it is okay to clean the scopes in the same sink. Just make sure all the debris is constantly being flushed away.

Here are some other tips on cleaning scopes:
  • Clean scopes as soon as possible after use.
  • If it's not possible to clean them immediately, disassemble them and place them in closed containers that have an appropriate enzymatic solution in them. The solution will prevent any debris from drying on the scopes. Covering them with a "wet towel" does not work.
  • Before transporting the scopes from the point of use, be sure to close the containers to prevent any possible spread of contamination.

There are several low-cost devices now on the market that do an excellent job of cleaning both rigid as well as flexible scopes. I recommend you look into these as a better alternative to hand cleaning.

Are there any new guidelines for using glutaraldehyde? We clean and decontaminate our scopes in a long, narrow room measuring 4' x 25'. There are no fume hoods in the room, just a ceiling exhaust fan, and all the soaking occurs at the far end of the room (away from the entrance). Is our process acceptable?

There are no new guidelines for using glutaraldehyde. The American Congress of Governmental Industrial Hygienists (ACGIH) made a recommendation of a vapor level of 0.05 parts per million that was published in the Federal Register, Vol. 54, No. 12, January 19, 1989; however, as of now, OSHA is not enforcing this recommendation. Your best source of current regulations, guidelines and recommendations, including the use of fume hoods and monitoring, would be the glutaraldehyde manufacturer.

Without taking measurements, I hesitate to comment on the level of vapors that might be present in a room that measures 4' x 25'. Much depends upon what goes on in that room, i.e., how much and what kind of activity, how many people go in and out of the room, etc. I strongly recommend that you get facts on the vapor levels that are being encountered at the operator breathing areas and act accordingly.

At our facility, we package surgical instruments in one peel pouch. We've recently come under some criticism for this practice by other facilities that use two peel pouches. My personal belief is that steam and air passes through the paper side of the pouch and does not pass through the plastic side. When you use two peel pouches, it is conceivable that at the point where the outside portion of the inner package plastic touches the inside portion of the outer package, there may not be contact with the sterilant, and that point could possibly be non-sterile. If this inner package was dropped in a sterile field, and the outside of the plastic portion of the pouch is not sterile, it could contaminate the case. Using single peel packaging forces the OR personnel to hand off the instrument aseptically, and reduces the possibility of non-sterile items being dropped into a sterile field. Obviously, using a single pouch also saves materials and labor costs. Am I wrong? Should I be using two peel pouches for our surgical instruments?

You make some good points. I do believe that in most cases the old adage "if one is good, then two is better" does not hold true in the case of peel pouch packaging.

The practice of using two peel pouches goes back to the days when it was customary to use two CSR wraps. The thread count of the linen wrap was ineffective as a barrier when used as a single wrap, and it was thought that two wraps were necessary for aseptic presentation into the sterile field. Both of these reasons are no longer valid. New wraps have vastly improved barrier properties, and many facilities are now using a single "One-Step?" wrap.

The only reason I know of why two peel pouches might be necessary is when you are packaging bone pins and screws. In this case, the inner package is necessary for keeping the loose items together while on the sterile field.

When you do use two peel pouches, make sure that the inner pouch is small enough to fit loosely inside the outer pouch so that the sterilant has easy access to all inner and outer surfaces of the inner pouch. This same theory is valid when you are stacking peel pouches into baskets for sterilization-don't stack them tightly squeezed together. The rule of thumb is that you should be able to pass your hand between the packages.

What is standard practice in handling a wet load? At our facility, if we find one wet item, we tear down the whole load. However, we never know if we have a wet load until we open a pack from that particular load, and by that time, other packs in the load have been opened and used. We then recall every item sterilized in the load. If we don't find an item, we have to notify any surgeons who might have used it, write up an incident report, and treat patients with antibiotics. Is there an easier alternative?

First, let's differentiate between a wet load and a wet pack. Moisture found on the outside surface of packages coming out of the sterilizer (wet load) could be the result of:
  • condensate dripping from the sterilizer cart shelving and railings;
  • condensate on metal items like sterilization containers, heavy ortho trays, basin sets, etc., dripping onto the items below; or
  • condensate collected in the steam lines that has been blown into the improperly trapped sterilizer.

All of these are the result of too-wet steam and/or improperly trapped and filtered steam lines, and improper load configuration. If this happens, you should consider the entire contents of the load potentially open to contamination and not release any items for distribution. Properly trained staff should know how to load a sterilizer cart and be able to detect this problem well before the load is released. To correct this problem, you need to contact your engineering department so it can ensure that high-quality steam is being sent to the sterilizer.

A wet pack, on the other hand, can be the result of:
  • putting too many metal instruments into a package that is too small;
  • preparing instrument and basin sets without enough absorbent materials;
  • making textile packs from moisture resistant materials and wrapping them too tightly;
  • packaging items when they are wet; or
  • loading items onto carts in such a way that moisture can be trapped.

In all of these cases, the only package that is potentially contaminated through moisture pathways is the package in question. If you open a package with wet instruments, you should consider it to be contaminated and not use the items. You do not, however, have to recall other packages within that load that have been properly assembled, and we certainly do not recommend over-treating patients with antibiotics when there is no clear indications of the need.

If you continue to have wet packs, you need to re-evaluate your staff training. Make sure any staff worker who is responsible for the cleaning, packaging, and sterilizing of re-usable medical products has had comprehensive training by accredited instructors.

We will cover the subject of wet packs in our August issue.

Dan Mayworm is the former publisher of The Journal of Healthcare Resource Management.