When you think of ways to reduce post-op infections in your facility, you talk about cleaning, disinfection and sterilization - in that order. Cleaning is first on the list, not because it's the least important, but because you can't disinfect or sterilize reusable surgical instruments and utensils if you don't first do a good job of cleaning them. Here's a step-by-step guide to cleaning your reusable surgical instruments and utensils.
What does "clean" mean anyway?
Despite the lack of any standards to define "clean," it is generally accepted that, at a minimum, a cleaning process should:
- reduce the natural bioburden on the devices
- remove organic and inorganic contaminates
- provide devices that when sterilized have a sterility assurance level (SAL) of 10-6.
It is much easier to rid your instruments of blood and other debris if the cleaning process starts immediately after the instrument is used. Remember, the sterilization process starts not when you push the button on the sterilizer, but the moment an instrument is used. And it ends when the instrument is to be used again.
The step-by-step guide on the next page (see "Safe Handling and Cleaning of Surgical Instruments") illustrates an ideal situation in a facility that has enough activity to warrant the installation of the required equipment and training of the healthcare workers. Not all facilities can implement this "ideal" process due to financial and personnel restraints, or because the turn-around time is too short or the volume is too small.
Keys to Reducing Post-op Infections | | |  | |
Manual cleaningThe alternative to this five-step process is manual cleaning. This time-consuming method is suitable only for small-scale work or for items requiring individual treatment due to their size, shape or complex design. The first step is still the enzymatic cleaning. The next step is disassembly (if not done at the source) and rinsing in cold water to remove whatever still clings to the surfaces.
If blood and debris have dried (
boo!...bad procedures in place), you may need a warm solution of a blood solvent. You can use a soft brush to assist with the removal of stubborn debris. Keep in mind that you must clean and sterilize (or disinfect) the brush at the end of each session to prevent colonization by Gram-negative bacteria.
Instrument manufacturers must approve the detergents and disinfecting agents you'll use. Avoid soaps that precipitate in hard water and abrasives that could damage smooth surfaces, as well as highly caustic detergents. Consider these factors when choosing agents for cleaning:
- The materials used in the construction of the device
- Design of the device
- Time required for turn-around
- Cost and availability
Quickly dry manually cleaned instruments and other equipment to prevent corrosion and stains. And there's no need to manually clean devices before you place them in an instrument washer. This is a redundancy that makes the people involved feel good, but it adds cost and the possibility of unnecessary and dangerous sharps cuts and punctures. If your washing equipment does not remove all the soil, get one that does. I've seen common kitchen dishwashing equipment do an excellent job on highly contaminated instruments.
Monitoring the process Routine inspection of articles for efficiency of cleaning and for the need of repair or lubrication is an important step in the preparation of articles for sterilization. All metalware should be free from corrosion. Examine instruments for:
- alignment of jaws
- tight closure of ratchets
- sharpness of blades and points
- correct stiffness of hinges and joints.
If the incidence of nosocomial infection related to a procedure in which a reusable device is involved is exceedingly high, call in the infection control department or senior management.
A review of studiesThe ability of a sterilization process to sterilize a medical device to a given SAL depends on the efficiency of the cleaning process, and the effect of organic and inorganic contaminants on the sterilization process.
Studies have demonstrated that:
- Steam under pressure will penetrate organic materials and render the items sterile when other low-temperature methods will not.
- General surgical instruments have a lower level of contamination than flexible gastrointestinal endoscopes.
- None of the cleaned general surgical instruments had a bioburden greater than 103 colony forming units (CFU), and 80 percent had bioburden less than or equal to 102 CFU.1 This is considerably less than the level of 106 organisms normally placed to challenge the efficiency of a sterilization process.
- None of the cleaned rigid lumened devices contained bioburden greater than 104 CFU and 83 percent had bioburden less than or equal to 102 CFU.2
Cleaning flexible endoscopes
Flexible endoscopes present a more rigorous cleaning challenge. In a 1997 study,3 the bioburden levels of a colonoscope insertion tube immediately after clinical use ranged from 1.3 x 107 to 2 x 1010 CFU. Manual cleaning reduced the range to 1.3 x 103 to 4.5 x 105 CFU. This is a dramatic reduction, but still leaves a bioburden impossible to sterilize by any low-temperature methods. There are many new scope-cleaning machines specifically manufactured to reduce the CFU level to one that can be sterilized. I highly recommend that you abandon the practice of manual cleaning of scopes. Not only is it very labor intensive (if done correctly), but the results are generally not satisfactory.
Contact Dan Mayworm at danmayworm@wans.net.
