Avoid Long Delays in Instrument Decontamination, Reprocessing

By Nancy Chobin, RN, AAS, ACSP, CSPM, CFER

Q:  There has been a question from the staff here about leaving instruments overnight with an enzyme foam product on them. If we are here and a case comes in where the instruments were treated with the enzyme foam and we have time to wash them but will not be here long enough to run the load of instruments through the washer, is it best to leave them with the enzyme foam overnight or hand wash them and have ready to be put in the washer in the morning?

A:  This is an excellent question and one I am sure others have faced because of cut-backs in staffing or hours of operation for the sterile processing area. There are several guidance documents and alerts to help with this which I will reference.

It is important to remember that on September 11, 2015, the CDC and FDA issued a CDC Health Advisory entitled “Immediate Need for Healthcare Facilities to Review Procedures for Cleaning, Disinfecting, and Sterilizing Reusable Medical Devices.” The purpose of the communication was to alert “healthcare providers and facilities about the public health need to properly maintain, clean, and disinfect or sterilize reusable medical devices. Recent infection control lapses due to non-compliance with recommended reprocessing procedures highlight a critical gap in patient safety. Healthcare facilities (e.g., hospitals, ambulatory surgical centers, clinics, and doctors’ offices) that utilize reusable medical devices are urged to immediately review current reprocessing practices at their facility to ensure they are complying with all steps as directed by the device manufacturers, and have in place appropriate policies and procedures that are consistent with current standards and guidelines.” (CDC, 2015b).

Ideally, soiled items (especially surgical instrumentation) should be transported immediately to the decontamination area for processing to prevent blood, body fluids and other contaminants from drying on the surfaces. Pick-up schedules should be designed to facilitate transport as soon as possible after use and to avoid high-traffic areas. Gross soil should be removed at the point of use with a disposable gauze pad or a cloth moistened with water. Saline should never be used for this purpose because it can damage the surface of the item. (Basics of Sterile Processing 2016).

According to ANSI/AAMI ST-79 (section 6.3), “In many healthcare facilities, however, immediate containment, transportation, and cleaning might not be feasible, so gross soil should be removed at the point of use. A disposable sponge moistened with water (not saline) should be used to wipe gross soil from instruments. Gauze sponges and similar items used in the cleaning process are contaminated and should be handled, contained, and discarded according to the health care facility’s policy for infectious wastes. (Section 6.3)”

Instruments should be prepared in such a way that organic soils will not dry on surfaces. This can be accomplished by placing a towel moistened with water (not saline) over the instruments and placing the towel and instruments inside a package designed to maintain humid conditions; or  using an instrument spray designed for pre-treatment (ANSI/AAMI ST79). For example, the instruments are placed in an appropriate container and treated with an enzymatic foam or gel designed for this purpose. The foam or gel adheres to the surface of the contaminated items, breaking down soils. In addition, the foam or gel will not splash or spill during transport. Soaking contaminated items in an enzyme solution at the point of use is discouraged because the solution must be discarded before transport. As each item is introduced into the solution, the contamination level increases, as does the potential for cross-contamination of staff and the environment. (Basics of Sterile Processing 2016).

Leaving instruments unprocessed for any period of time can lead to the development of biofilm.  The recommendation is to begin the cleaning process as soon as possible. As a matter of fact, a number of manufacturer’s instructions for use (IFUs) are now specifying the time frame that cleaning should be implemented. This ranges from “immediately after use” to “within 10, 20 or 30 minutes;" it varies with the device/instrument manufacturer.  The manufacturer’s IFUs should always be followed. 

In addition, according to AAMI ST-79, “Long delays in processing can result in the “formation of formation of tenacious and difficult-to-remove biofilm that will shield microorganisms from routine cleaning procedures and possibly interfere with disinfection or sterilization.”

The use of pre-cleaning disinfectants is discouraged unless specified by the device manufacturer.

You should first develop a policy and procedure based upon:
 - Manufacturer’s instructions for use (which are updated routinely to ensure they reflect the most current recommendations from the manufacturer)
 - Processing of all reusable medical and surgical devices processed in your area
 - The cleaning chemicals and methods recommended
 - The specific use (e.g. water temperature, dilution) of the chemicals in use
 - Specific information regarding when and how to clean the devices
 - Procedures for manual and mechanical cleaning (including ultrasonic cleaning)
 - Cleaning effectiveness testing including frequency of testing          

There should be a process whereby monitoring for compliance with stated policies and procedures is routinely performed and documented.  Any non-compliance issues should be corrected.

I cannot answer your question specifically because I do not know the specific IFUs and if your process would be in compliance with those IFUs. There is a potential for biofilm formation since the instruments are being left overnight.  If the manual cleaning is done correctly then this should remove the soils however I would completely re-clean the instruments according to the IFUs in the morning.

Nancy Chobin, RN, AAS, ACSP, CSPM, CFER, is a sterile processing consultant/educator.

 References:
 
Association for the Advancement of Medical Instrumentation, “Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities, (ST-79), 2013.  

Centers for Disease Control and Prevention. Immediate Need for Healthcare Facilities to Review Procedures for Cleaning, Disinfecting, and Sterilizing Reusable Medical Devices. CDC Health Advisory. Sept. 11, 2015b. Available at: http://emergency.cdc.gov/han/han00382.asp.