Decontamination of Surgical Instruments Begins in the OR

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

Q:  We are having an issue with our operating room (OR) staff leaving bioburden to dry on the instruments. I am having a hard time getting them to take me seriously. The OR does not seem to understand the significance of “decontamination begins in the OR.” I want to present to the OR in a way that will help them understand the importance of keeping their instruments clean and wet while not making them feel like I am trying to shift blame. Can you help me with this?

A: You are correct in your concern. Let’s start with Association for the Advancement of Medical Instrumentation (AAMI) ST-79, 2013 (NOTE: AAMI will soon publish an update to this important document; you should make sure you obtain a copy for your reference). You should always reference AAMI standards since these are national standards for sterile processing practices.

Here is some information to share with your OR staff (and other departments if indicated).

- 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 not be used for this purpose because it can be corrosive to surgical instruments.
- AAMI states, “Instrumentation should be placed into containers, instrument pans, or other transportation pans so as to prevent damage to the instrumentation.”  In addition, all instrumentation should be placed in its original container or basket and should be protected from damage.  To prevent sharps injuries, separate all reusable sharp instruments from non-sharps inside the container or basket. 
- 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.
- There is also concern about formation of biofilm, so cleaning should occur as soon as possible after use.  Some manufacturers are now specifying a time frame from use of the instruments to implementation of cleaning.  One way to prevent formation of biofilm is to prevent organic soils from drying.  Once biofilm forms, direct friction and/or oxidizing chemicals are needed to remove it. Prompt cleaning reduces or eliminates the population of biofilm-forming microorganisms and thus prevents the formation of biofilm.

It is important to understand the ramifications of not cleaning instruments in a timely manner:
1. Soil removal becomes more labor intensive in the sterile processing department (SPD). The instrument manufacturer’s instructions for use might not achieve the level of cleanliness desired.
2. The turnaround time for sets will be increased due to the need to extend the cleaning process (see photo below). This can increase costs in SPD (more labor) and can cause delays in the OR because sets will not be ready when needed due to the additional time needed for cleaning.
3. If biofilm does form, this can result in the biofilm shielding microorganisms from the routine cleaning recommended by the instrument manufacturer. Ineffective cleaning could interfere with a subsequent sterilization process.

Grossly soiled instruments returned from the OR

Grossly soiled instruments received from the OR.

The recommendation to remove gross soil is removed as soon as possible is to be able to reduce the number of microorganisms on the item; reduce the nutrient material that might support microbial growth, reduce the potential for environmental contamination by aerosolization or spillage, and to minimize damage to devices from such substances as blood, saline, iodine, and radiological dyes or from the subsequent vigorous cleaning processes needed to remove encrusted material.

The Association for periOperative Registered Nurses (AORN) states, “Instruments should be cleaned and decontaminated as soon as possible after use.” Preparation for decontamination should begin at the point of use.  AORN also recommends “moistening and removing gross soil at the point of use can help prevent organic material and debris from drying on instruments.” AORN aligns its cleaning guidelines to AAMI’s ST-79.

In summary, in order to ensure the sterilization process, the instruments must first be cleaned correctly. This process starts in the OR.  There should be collaboration between the OR and SPD to ensure that devices can be effectively cleaned so the sterilization process can be successful. While everyone is pressed for time, an unsterile item is of no use in the OR.

Surveying organizations (e.g., the Joint Commission) use AAMI standards as their guide, therefore, compliance is necessary. Many facilities have implemented a process whereby the instruments are pre-cleaned in the OR and sent to SPD expeditiously so that cleaning and decontamination can are not adversely affected.

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

References:
AORN. Guidelines for Perioperative Practice, 2017. Guideline for Cleaning and Care of Surgical Instruments.

ANSI/AAMI. ST79:2010 & A1:2010 & A2:2011 & A3:2012   A4:2013Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities.

Basics of Sterile Processing 6th Edition. Sterile Processing University, LLC. Lebanon, N.J.