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Pitfalls to Avoid in Instrument Reprocessing
Follow these protocols to increase the longevity and efficacy of surgical instruments.
Nancy Chobin
Publish Date: October 10, 2007   |  Tags:   Infection Prevention

Surgical instruments aren't cheap. Considering their high cost and delicate nature, it's important that we maintain and monitor them to prevent loss and damage and to ensure their longevity. Instruments are an extension of the surgeon's hands and must work as intended during each and every case. Here are ways to ensure the proper care and efficacy of our trade's most important tools.

Instrumental knowledge
Most surgical personnel aren't aware of what it takes to deliver instruments from a manufacturer to the OR. There are actually more than 17 steps in the process. Only 25 artisans remain, worldwide, who perform the fine craftsmanship needed to perfect surgical instruments. Amazingly, most of the work is performed manually. Surgical instruments are truly works of art and they should always be handled with care.

To understand the difference in class of various instruments, realize that their quality can be traced to the base steel used in their manufacturing. Always ask the origin of the base steel when purchasing surgical instruments; American and German steel are considered the best. But remember, just because they're made of steel doesn't make them indestructible.

Two basic categories of instrumentation exist, based on the type of steel used in their construction. The 300 series instruments are called "austenitic" because they're non-magnetic and resistant to staining, pitting and corrosion. Retractors, probes or malleable instruments usually land in this category. The 400 series instruments are called "martensitic" and have high carbon content, making them stronger or harder. Scissors, needle holders and rongeurs typically make up this series.

We can further organize the two instrument categories into two basic instrument grades: surgical grade and floor grade (commonly referred to as Pakistani grade, based on the instruments' manufacturing location). Floor-grade instruments lack fine detail and precision; they break and corrode quickly and aren't suitable for OR use. In many facilities, high-loss instruments like towel clips or sponge loops are substituted with floor-grade instruments in surgical sets. This practice should be avoided because corrosion from the floor-grade instruments can corrode the set's surgical-grade components.

There are three types of instrument finishes: shiny (reflects light), dull or satin (does not reflect light), and ebonized or black (used for laser surgery). The dull or satin finishes are preferred in the OR to limit eye fatigue and reflections.

Surface blemishes sometimes appear on instruments. These blemishes create difficulties for cleaning, disinfection and sterilization because the instrument's surface is no longer a smooth, solid surface. Stainless steel corrosion usually appears as roughness or rust. Corrosion can indicate locations where future device failure can occur.

Stainless steel can corrode by several mechanisms. Pitting, caused by exposure to blood, chloride or bromide-containing solutions, is a highly localized corrosion. It occurs in shallow to deep, localized defects that appear as black holes (pits) on the instrument's surface. You can't repair this defect; remove pitted instruments from the set and replace them.

Found in box locks (joints) and other tight spaces, crevice corrosion often appears as red rust. It is caused by blood and other soils that gather in box locks that haven't been properly cleaned. Because corrosion interferes with proper cleaning and can inhibit the disinfection and sterilization processes, you should remove them from sets. In the early stages of corrosion, the effects are simply cosmetic. However, if corrosion is allowed to continue, the instrument can fail.

The staining of instruments can result from chemicals used to protect high-pressure steam lines in boilers. However, if you use a tabletop sterilizer, which generates its own steam, instrument staining shouldn't be a problem because these sterilizers typically use distilled water. When stains do appear, some telltale blemishes can indicate the cause. Blue stains are usually caused by liquid chemicals (acid glutaraldehyde, for example). Stains that appear in a purple-black hue are usually caused by exposure to ammonia; many cleaning compounds contain ammonia and these compounds must be adequately rinsed to avoid staining.

The quality of the water you use to clean and rinse instruments can also greatly impact their condition. In fact, rust on instruments can be attributed to high iron content in water. Chemicals such as sodium, magnesium and iron are present in water and can adversely affect cleaning, detergent action and even the life of the instrument. It's highly recommended that a detergent manufacturer analyze the water used for rinsing instruments at least twice annually. These manufacturers typically will do so as a value-added service.

Protection starts at the beginning
Read and follow the manufacturer's instructions for cleaning, inspection and sterilization upon receipt of each new instrument. Verify this information each and every time because a device's instructions for care may change.

Verify that the instruments you receive are indeed the instruments you ordered. Open the package and confirm that there is no damage and that the instruments function as anticipated. Manufacturers place a protective coating on instruments before shipping; this coating may or may not be visible and can be toxic. You must always clean instruments after the initial examination

Exposure of the instrument's metal to incompatible solutions during processing can cause a chemical and electrochemical attack. Liquids, especially chlorides (bleach, for example) are of concern for use on stainless steel. Never use bleach on surgical instruments, even if it's diluted. One exposure can destroy the instrument.

An instrument can last 20-plus years if cared for properly. There are many factors, however, that can cut that life expectancy short, including:

  • not using the instrument as intended by design;
  • dumping instrument sets onto a table or stacking them in storage;
  • improper cleaning or sterilizing; and
  • using harmful chemicals or detergents like saline, chlorine bleach, blood and even water.

When buying delicate instruments, also purchase a specialty container to help avoid unnecessary damage. These containers help keep items secure before and after use. Facilities spend thousands of dollars repairing instruments when a $400 container could have prevented the damage.

Put instruments in their respective containers at the end of the procedure. Separate rigid scopes from instruments to avoid damaging them. When using protective containers, place the items in the designated location. Protect instruments with fine or sharp tips by using tip protectors

Cleaning that counts
The detergent manufacturer's written instructions for dilution, water quality (tap or distilled) and water temperature can all affect the overall instrument cleaning process. Use an enzymatic cleaner as soon as possible after the instrument's use unless otherwise directed by the manufacturer. Employ a nylon - not metal - brush to clean instruments.

Most facilities use enzymatic detergents for cleaning. The concentration of these detergents and the temperature of the water used with them are known to affect the detergent's efficacy. Thermometers are available to monitor water temperature for enzyme pre-soak or enzyme wash solutions. The maximum temperature for most enzymatic cleaners is 140'F, a temperature you should never exceed.

Laparoscopic instruments. These can be extremely difficult to clean due to their long shafts and jaw assemblies, both of which can trap debris. The positive pressure of the insufflated abdomen can cause blood and body fluids to flow under the instrument's insulation and into channels, making cleaning difficult or even impossible. Several manufacturers now offer high-pressure water jets for lumens and channels as an alternative to manual brushing and flushing. These let you rinse repeatedly to remove all detergents and residues from the instruments. Tabletop ultrasonic lumen cleaners are also available, which adapt to the lumens of endoscopic instruments to enhance cleaning.

Despite the availability of automated cleaners, many delicate devices still require manual cleaning. Other devices, primarily power equipment, can't be immersed. When cleaning devices by hand, always wash below the water level to prevent aerosolization of microorganisms. If using a mechanical washer, don't overload it. Make sure all items have direct exposure to the water or detergent. Don't place bowls or basins over instruments simply to keep a set intact during reprocessing.

Items with lumens present particular problems for cleaning. Soak these devices in an enzymatic detergent as soon as possible after use. This is also true for metal instruments and flexible GI scopes. An immediate enzymatic soak can help keep debris and bioburden from coagulating and drying in the lumens, which will make it easier to clean later.

Force-flushing devices that have clean-out ports with a lumen cleaner will further break up any debris. Either connect a syringe to the port or use a water pistol or lumen cleaner on cannulated devices with or without special clean-out ports.

Up next, a manual cleaning with brushes. Adequate manual cleaning with properly sized brushes is the most important step in reprocessing laparoscopic instruments. The manufacturer's instructions will note the brush size needed at this stage. If the instructions are missing, measure the lumen's diameter. Either way, it's advisable to stock between 12 and 15 different-sized brushes in the decontamination area.

The diameter of the brush is critical to letting bristles create friction against the walls of the lumen. A brush that's too big will cause the bristles to bend back, missing the opportunity to scrub debris away with increased risk of scratching the inside of the cannula. Too small, and the brush won't create any (or at least not enough) friction between the bristles and the inner walls. Be sure to keep the instrument completely under the waterline when brushing. Never brush outside the water line; removed debris should remain in the water.

After cleaning with a brush, force-flush the lumen using the same syringe, water pistol or lumen cleaner that you used during the initial force-flush of the instrument. This time, use copious amounts of water to rinse the cannulas and flush them of debris and enzymatic solution.

Next, submerge compatible instruments in a mechanical ultrasonic washer to help ensure the outside is completely clean and to potentially loosen any debris that remains inside. Then run the instruments through a general mechanical washer.

As a last step before packaging cannulated devices for the autoclave, low-temperature gas plasma sterilizer or ozone sterilizer, recheck the lumen by passing an appropriately sized and moistened pipe cleaner or brush to test that the lumen is clean. If it is, you can wrap and sterilize. If not, you need to start over by sending it back to square one of the cleaning process.

Most instrument manufacturers recommend the application of a water-soluble lubricant (often called instrument milk) after cleaning and before sterilization. Lubrication not only keeps the instrument from seizing up, but also protects the instrument and extends its life. Perform this process in the prep and packaging area (clean area) to avoid contamination of the lubricant solution. If a mechanical washer is used, many offer a lubrication cycle. Always follow the lubricant manufacturer's instructions for dilution (mix with sterile distilled water rather than tap water, for example), use life (usually seven days to 14 days) and compatibility with the sterilization process. Note the date that the lubricant needs to be changed on the instrument milk container's lid. Let the lubricant air dry, since towel drying will inadvertently remove some of the lubricant.

Flexible scopes. Chief among the challenges in cleaning these very expensive and oft-used instruments may be a lack of trained and competent staff. In many facilities, a variety of personnel process scopes during their non-direct patient time. But not just any idle staffer can do it - it's essential that all staff processing flexible scopes are thoroughly trained and that you verify their competencies. The Certification Board for Sterile Processing and Distribution, which recently conducted a job analysis survey for flexible scope processors, will soon offer a certification examination for flexible GI scope processors.

When processing flexible scopes, it's critical to follow established guidelines such as "Standards for Infection Control and Reprocessing of Flexible GI Endoscopes," developed by the Society for Gastroenterology Nurses Association (SGNA), and the Multi-Society Guidelines for Reprocessing Flexible GI Endoscopes.

These guidelines call for an initial manual cleaning of scopes after use, no matter the type of automated endoscope cleaner used by a facility. They also note that you should use enzymatic cleaner to clean one scope only; due to high levels of bioburden removed, the enzymatic solution is maxed out after a single use.

Another important point: Track every scope to the patient. Keep written documentation of the patient's name or identification number, the physician's name, the type of procedure performed and the scope's serial number. If the automated endoscope cleaner used for the high-level disinfection process has two chambers, note the chamber used. This simple step will significantly reduce the number of patients you'll need to notify if the high-level disinfectant fails in only one chamber during a day's worth of reprocessing. In fact, the Association for the Advancement of Medical Instrumentation issued guidelines in 2005 that recommend the testing of the high-level disinfectant before each use.

The flexible scope's cleaning must then be correlated to the manufacturer's directions for specific directives, including special cleaning brushes or needed adaptors. Transport scopes to the soiled utility room for processing in a contained manner so they aren't exposed to the non-sterile environment.

Rigid scopes. Follow manufacturers' instructions for cleaning these delicate instruments. Generally, it's recommended to brush the distal end with a soft bristle brush before wiping the outer surfaces of the scope and accessories with gauze or a soft cloth moistened with detergent solution. Clean fiber optic light cables in similar fashion.

Lumens can be cleaned with high-pressure water jets, or else they should be brushed and flushed thoroughly. Rinse repeatedly to remove all detergents and residues. Don't process rigid scopes in an ultrasonic machine because the vibrations can damage the seals and fracture optical fibers.

Be a detective
Improper cleaning can lead to the stiffening of an instrument's joint. Soil buildup typically occurs in the box lock (joint) - the weakest part of the instrument. When the box lock cannot hold any more debris, a stress crack occurs in the joint; the crack is noted at the pin joining male and female parts of the instrument. Once this crack occurs, the instrument can't be repaired. It must be immediately removed from the instrument set because it can fail at any time. Also, the blood and body fluids that enter the crack will not be completely removed, no matter how vigorous the cleaning efforts.

Use a lighted magnifying lamp to inspect all instruments for cleanliness. Make sure all components are present. Check that the instrument works as intended, that there is no visible damage and that the instrument is the one assigned to the set. Further, test scissors for sharpness each time you process them. The testing should involve the cutting of a latex product with the distal third of the instrument; the scissors should cut through easily. If they fail this test, they should be removed from rotation and sent for sharpening.

Check ratchets for proper tension and ensure the tips of hand forceps meet and that the teeth are present if indicated. If you're using reusable trocars, test them for sharpness each time. Identify the maximum number of uses that would indicate re-sharpening. Look for nicks and defects that would interfere with the passage of a scope.

Rigid scopes should be inspected during assembly. Start by examining all areas of the scope for scratches, dents and burns. Also inspect the scope for image clarity. Hold the scope's tip approximately three inches above a non-glaring, printed, white surface. Move the tip closer to the surface until it is approximately a quarter of an inch away. The image should be crisp and clear.

A cloudy, discolored or hazy image may indicate improper cleaning, disinfectant residue, a cracked or broken lens, the presence of internal moisture or external damage to the shaft. After inspection, the scope's fiber optic cables should be wound into a coil no less than eight inches in diameter.

Insulated instruments used during laparoscopic procedures require special inspection. Repeated use or sterilization can cause cause a breakdown of the layer of insulation covering the instrument's shaft. Minute tears can go unnoticed during cleaning or inspection, and in surgery defective insulation could potentially allow 100 percent of the electrical current (700'F) to flow from the defect to the body's organs and tissue. The smaller the crack, the more concentrated the energy and the more likely the possibility of more current escaping from the small hole. To further complicate matters, approximately 90 percent of the active electrode is outside the surgeon's field, meaning the problem could go unnoticed in the OR.

Depending on the manufacturer, the insulation should last for approximately 20-plus cases. But insulation failures occur due to normal wear and tear, high voltages, the cleaning and sterilization process and contact with sharp instruments (trocars, for example). Insulation can also become damaged from dropping the instrument, placing instruments on top of other instruments or the dumping of instruments onto a table.

The Association of periOperative Registered Nurses recommends a comprehensive system for inspection of insulation. Develop policies and procedures to visually inspect insulation each time a scope is processed. Look for cracks, holes or flaking in the insulation. Follow with insulation testing equipment. These devices use electrodes to detect bare metal spots on scopes and can find minute imperfections that are missed by visual inspections. My facility employed the equipment three years ago and discovered a staggering 75 percent failure rate.