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Infection Prevention
Keep Flashing to a Minimum
Dan Mayworm
Publish Date: October 10, 2007   |  Tags:   Infection Prevention

Dan Mayworm Q Is it necessary to flash instruments before they're wrapped and sterilized? One of our techs is under the impression that instruments must be cleaned then flashed for three minutes before being wrapped for final sterilization or left overnight.

Dan Mayworm\ A I have strong feelings about flash sterilization, and they're all bad. I would be interested in knowing how and why this practice started, as it sounds like a waste of time and money.

I know of no reason that you would need to flash-sterilize properly washed and dried instruments before you wrap and sterilize them again. This is an unnecessary and superfluous step in the decontamination process. Both your time and money would be far better spent assuring that the instruments underwent thorough cleaning - that is the only thing that is important in the decontamination process.

Use flash sterilization only as a last resort, after rigid cleaning and sterilization requirements have been met, in order to maximize the potential for delivering a sterile device to the OR - immediately before delivering it to the OR (see "A Sample Flash Policy"). This method of sterilization won't make your instruments any cleaner.

In fact, if the items aren't completely clean, the worst thing you can do is subject them to a flash sterilization cycle - it will only bake any leftover debris onto the instruments.

Whatever you do, don't flash sterilize as a final step in the decontamination process.

A Sample Flash Policy

If you keep in mind that you should use flashing only in an emergency (you absolutely need a piece of equipment but can't wait for it to be sterilized because you don't have a backup), this is a good set of rules to follow.

  • Before sterilization, inspect for defects and organic soil or debris, then clean the instruments according to manufacturer instructions, employing brushes for thorough cleaning of lumened and teethed devices. Thoroughly wash even those items without visible soil before sterilization. Do not re-sterilize pre-sterilized items that are still in protective packaging.
  • Arrange the items in the sterilization pan to maximize the sterilization cycle's effectiveness (disassembling all parts, for example). If the device must be transported to the OR through a semi-restricted hallway, place the implantable in a covered flash sterilization container.
  • If you've placed the item in a container, place a chemical integrator in each pan and sterilize the instrument using a cycle specified by the container manufacturer. If the item is in an open tray and the sterilizer is in a protected area of the OR, you can use a standard high vacuum cycle. Remember, though, that heavy items will come out of the flash sterilizer wet and shouldn't be left open to the environment any more than is absolutely necessary. If the item will be open to the environment after sterilization and before use, at least cover it with a sterile towel and follow the AAMI guidelines for time and temperature for flash sterilization of wrapped items.
  • At the conclusion of the sterilization cycle, verify that sterilization time, pressure and temperature protocols have been met.

- Dan Mayworm

Q What would you recommend as a way to identify equipment such as blood pressure machines, glucometers, IV pumps and various other monitors, for example, that have been cleaned? How can the users be certain that the equipment has been properly disinfected between patients and is safe to use?

A Once you've cleaned/disinfected and dried a piece of equipment, place a clear plastic bag over it (or place the equipment into a clear plastic bag) and secure it with tape. As an added precaution to ensure that you haven't bagged items before you've cleaned them, it would be good practice to place a label or sticker on the bag with the date, time and initials of the person who cleaned the item - this practice is often referred to as bag and tag.

Dan Maywor\m Q Our staff have been using tap water to irrigate simple wounds like small lacerations and for flushing scopes used for endoscopy procedures. They'll sometimes pre-fill the syringe and leave it on the endo cart for the physician to use during the procedure to flush a blocked scope. The tap water syringes aren't capped, and the syringes are sometimes stored on the cart for several days before use.

I'm not comfortable with this process, but I'm being told that tap water is acceptable from an infection control standpoint to use for either application, as it's going into a non-sterile area and patients do drink the same tap water. Is tap water acceptable, or should we use sterile water for flushing scopes during the procedure? Should it be drawn up at the time it is needed or can it be done beforehand? How long can pre-filled, uncapped syringes be stored before use?

A Let's take this one at a time. When anyone gets a superficial wound, a scratch or a nick with a sharp object, they're told to rinse the area and wash with soap and water before applying a disinfectant ointment and bandage. If this is what's being done, that is perfectly fine.

But you said "irrigating" the wound. I wouldn't recommend irrigation - below the skin into the fat or above the fascia - with tap water.

All tap water contains minerals, and coliform counts vary. Without knowing the purity of your water, it would be difficult to say simply, "Don't do it." However, it's so easy to keep sterile or distilled water handy to use anytime there is a chance the water might penetrate the wound. There really is no excuse to potentially compromise the patient.

You should inject only filtered, distilled or sterile water into endoscope channels. Tap water contains minerals and microbes; you shouldn't use it during any procedures involving significant breach of the mucosa. Calcium, magnesium and other mineral salts tend to precipitate out, causing scale within the long lumen of the endoscopes, resulting in potential damage to the scopes, and providing a surface that supports the development of biofilms. This could theoretically result in pathogenic colonization of the scope and infection of patients, and it definitely decreases the life of the endoscope.

The risk of preparing water syringes in advance includes the possibility of unrecognized contamination and potential resulting infection. Any bacteria present in your tap water will multiply quickly in an open pre-filled syringe. There is a similar danger even with sterile, filtered or distilled water in an uncapped syringe. My recommendation, therefore, is to use only sterile water to clear the channels, and prepare it just in time for use.

As to the argument that patients drink the same tap water that some facilities use during endoscopy: Please remember that drinking water normally has to pass through the acid in the stomach before reaching the intestines. There are a lot of non-sterile items that can safely pass through the mouth that you wouldn't want to be in contact with exposed mucous membranes and sterile areas of the body.