Instrument Cleaning, Repair and Handling

Infection Control Today sought industry input on the issue of instrument cleaning, handling, repair and processing and received several varied responses. The recommendations from these representatives can save facilities thousands of dollars, since a well-cared-for instrument is an instrument that does not need to be replaced frequently. Participants include Dan Dwyer, healthcare sales manager of Raven Labs; Alex Vrancich, vice president and general manager of Spectrum Surgical Instruments Corp.; Jack Kinville, marketing manager for Ruhof Healthcare; and Kathie Fulks, SterilMed education manager. Their responses are below.

ICT: What are the most significant impediments to effective cleaning of instruments?

Spectrum: While in a sterile processing department, it’s not uncommon to see a row of multiple case carts lined up awaiting decontamination. Soiled instruments should not be allowed to sit for long periods, as this allows the blood and other surgical debris to dry and form onto the instruments, which makes cleaning and decontamination much more difficult. Our recommendation has always been to start the decontamination process as soon as possible after a procedure — within 10 to 15 minutes is recommended. Surgery departments can do this by applying wetting agents to the instruments before sending them to the sterile processing department. Wetting agents come in many forms. Some are liquid spray-on detergents, some are foaming enzymatics, but they all achieve the goal of beginning the decontamination process sooner rather than later. This is one of the best things we can do for our instrument sets to improve the cleaning process. If these solutions aren’t available at your facility, we recommend taking a towel dampened with water and draping it over the instruments. This is not as effective as a wetting agent, but at least we are helping to prevent blood from drying.

Ruhof: Proper cleaning of surgical instruments is the most crucial step in instrument care. When proper cleaning protocols are not followed, it can lead to rusting and spotting of instruments and ultimately cross contamination of patients. If a multi-enzyme detergent is not used for disinfection, then you are not able to remove all biofilm. When biofilm is left on an instrument it will break down and start to rust the instrument. While this is visibly noticeable on the surface of the instrument, it can also be detected when box locks and joints don’t articulate well and begin to grind. Also, it is crucial not to let dirty instruments set overnight; this will allow the biofilm to dry onto the surface and will be extremely difficult to remove in the morning. Dried on biofilm is extremely difficult to dislodge manually or in the most capable of washers. Lastly, letting instruments soak in any type of solution over night will rust the instruments.

ICT: What suggestions do you have regarding proper handling of instruments to lengthen their use and reduce repairs?

Spectrum: Establishing a preventive maintenance program is the best way to extend the life of surgical instruments. By regularly maintaining the instruments, your repair vendor will discover minor repairs before they become major issues. Keeping instruments sharp and functioning properly is also a major contributor to overall patient safety. This can’t be overlooked and although facilities try to reduce expenses, choosing not to initiate a preventative maintenance program will surely cost you more in the long run. An important step that is often overlooked is lubrication. Instruments with moving parts, such as scissors, needle holders, and hemostats, require more lubrication than what is applied during the washer/decontaminator cycle. Acceptable lubricants are water-based, have a neutral pH, and contain a rust inhibitor. A bottle of lubricant should be at every work station and applied often to ensure that instruments function smoothly. This will prolong the life of an instrument and also ensure the instrument functions properly in surgery.

ICT: What suggestions do you have regarding proper handling of instruments to lengthen their use and reduce repairs?

Ruhof: Immediate cleaning of surgical instruments will have a major affect in lowering repair and replacement cost. The longer instruments sit after a procedure, the more open they are to long-term damage from rust caused by dried-on biofilm or soaking in a water-based solution. Using a high-level multi-enzyme detergent will also help lengthen the life of an instrument by removing any biofilm that can also cause rust and possibly harm patients. Mineral-based oil lubricants should be used on all instruments to keep them in top-working condition. Lubricants form a protective barrier on instrument surfaces to help prevent rusting and spotting. Also, mild acidic rust and stain removers should be used routinely to keep instruments in their original condition.

SterilMed: Hand cleaning is most appropriate for fine, delicate instruments and those that should not be immersed in water or solutions. Mechanical cleaning is accomplished by ultrasonic washers as well as washer sanitizers. For surgical instruments, it is important to understand the enemies or threats. Bioburden such as blood, tissue, as well as medication and saline, are the primary causes of pitting, staining, and discoloring of instruments. At the point of use, do not allow blood to dry on the instruments. Wipe instrument clean using a damp towel or sponge as soon as possible after use. Surgical instruments left in water for a prolonged period is also harmful. Air bubbles formed in standing water will cling to the instrument surface, which can stain. Failure to dry instruments thoroughly will leave water spotting, which can lead to corrosion. Be sure to check the cleaning detergents’ instructions for use to ensure proper dilution and water temperatures. Surgical instrumentation care includes preventive or predictive maintenance for sharpening and adjusting. Most often, maintenance is determined by frequency of use. Work carefully with your repair service provider to develop a preventative maintenance program. Schedule maintenance a minimum of every 3-6 months. Instruments which may require more frequent sharpening or adjusting are: scissors, needle holders, hemostats, and orthopedic or spine instruments. [Another tip is to] carefully package and sterilize instruments. Instrumentation packaging is generally in a tray, bundle or single-instrument package. Packaging should be done in a way that achieves and maintains sterility until the point of use. Disassemble all removable parts and open-hinged instruments fully and in unlocked positions. Delicate and sharp instruments must be protected by arranging them in an appropriately sized tray. Using tip protectors that are steam and gas permeable will add protection.

ICT: How can a staff member be sure an instrument needs to be repaired, versus replaced?

Spectrum: We’ve developed a sharpness test kit to assist sterile processing professionals in determining if an instrument requires sharpening. The kit provides testing standards for many instruments, including scissors, arthroscopy punches, laparoscopic scissors, Kerrison rongeurs and more. Furthermore, the hospital’s instrument repair vendor should play a part in assisting with making these decisions. A good repair vendor will make sure that the instrument sets are being serviced with the patient’s safety in mind, thus removing instruments that don’t pass quality standards. Examples include instruments that are cracked, broken or have exceeded their useful life and can no longer be repaired. It is wise to follow the advice offered by your repair technicians when evaluating these instruments. You would never want to ignore their advice, only to find that the instrument fails in a critical surgical situation.

ICT: The details and applications of flash sterilization are often contested. Do you think it’s important for the industry to reach consensus, and do you think such consensus is likely?

Raven: I do believe that consensus is important, however, reaching it will be very difficult. “Flash sterilization” can mean completely different things to different people and the term “flash” is thrown around so often that it has taken on a meaning beyond the scope of its initial intent. Originally intended for “emergency use,” the use of flash sterilization is commonplace today. A flash cycle is far from a standard cycle and is not always the same cycle facility to facility. Too often, the cost of boosting inventory is used as justification for the overuse of flash sterilization. In many cases, however, there simply is no alternative. There is almost no motivation to reach a consensus except from users themselves. If there is going to be a change, it will happen because of the support and legwork of healthcare/hospital users.

SterilMed: Sterilization parameters are a function of load content, type of sterilizer and packaging methods used. Follow the guidelines set by the AAMI [Association for the Advancement of Medical Instrumentation] for weight and density of instruments. While flash sterilization can be used for an urgent need, use the same steps as if terminally sterilizing, to assure safety. Unwrapped flash sterilized items must be used immediately, since sterility assurance cannot be maintained. That said, impediments to safely and effectively cleaning instruments would depend on the process and the complexity of the instrument and the instrument manufacturers’ recommendations. Safely and effectively processing contaminated items is critical to a patient’s outcome and is no small task. Preservation of medical instrumentation that is both delicate and costly must be carried out by trained technicians who handle instruments. Much is being developed in the study of medical instrumentation today. The desired result is how to best process specific instruments and to determine handling procedures that avoid damage in the use, cleaning and wrapping for sterilization. The sooner the disinfection and decontamination takes place, the easier the process becomes. It would be highly desirable in the operating room (OR) to proceed with disinfection and decontamination immediately after using an instrument, if that is possible, to make the cleaning process safer. Detergent and water are typically used with enzymatic cleaners for soaking prior to cleaning and rinsing. Meticulous cleaning is dependent on good lighting, eyesight and careful examination. Many instrument manufacturers recommend and provide instrument processing instructions. It is critical to return instruments, sterile and in good working order, through a system, each with its own set of protocols. Instructions for cleaning a specialized instrument would be specific, concrete, individualized and unique. A course of studies of the best methods, based on the instruments and the manufacturer’s instructions, are available through the auspices of organizations such as the International Association of Hospital Central Supply and Materials Management (IAHCSMM) the American Association for the Advancement of Medical Instrumentation (AAMI), and others.

Cleaning Instruments Effectively: A How To

By Kathy Jorgensen

“Order and simplification are the first steps toward the mastery of a subject.” — Thomas Mann

That said, impediments to safely and effectively cleaning instruments would depend on the process and the complexity of the instrument and the instrument manufacturers’ recommendations. Safely and effectively processing contaminated items is critical to a patient’s outcome and is no small task.

Preservation of medical instrumentation that is both delicate and costly must be carried out by trained technicians who handle instruments. Much is being developed in the study of medical instrumentation today. The desired result is how to best process specific instruments and to determine handling procedures that avoid damage in the use, cleaning and wrapping for sterilization.

The sooner the disinfection and decontamination takes place, the easier the process becomes. It would be highly desirable in the operating room (OR) to proceed with disinfection and decontamination immediately after using an instrument, if that is possible, to make the cleaning process safer. Detergent and water are typically used with enzymatic cleaners for soaking prior to cleaning and rinsing. Meticulous cleaning is dependent on good lighting, eyesight and careful examination.

Many instrument manufacturers recommend and provide instrument processing instructions. It is critical to return instruments, sterile and in good working order, through a system, each with its own set of protocols. Instructions for cleaning a specialized instrument would be specific, concrete, individualized and unique. A course of studies of the best methods, based on the instruments and the manufacturer’s instructions, are available through the auspices of organizations such as the International Association of Hospital Central Supply and Materials Management (IAHCSMM) the American Association for the Advancement of Medical Instrumentation (AAMI), and others.

Proper Handling of Instruments

Regarding the method of sterilization with Ethylene oxide (EtO) — which Andersen systems employs — the preparation of items to be sterilized are by their very nature delicate, or perhaps mechanical, electrical or photographic, or contain filter material, contain or are plastic, rubber, latex, or consist of long, narrow lumens, or have components that have anodized coatings on aluminum or contain brass, certain foams or anything that is cellulosic, or anything else made of heat-, moisture- or pressure-sensitive materials. EtO can sterilize without denigrating or damaging those items.

Speaking from a standpoint of EtO and sterilization, Andersen Sterilizers (which have been used on every continent for 40 years), the small-unit dose, flexible-cycle loading and gentle nature of unique gas-diffusion technology is important in the hospital market.

Every certified surgical technologist (CST) would find the Andersen Key Operator test familiar. Andersen has offered a free operator training program for more than 25 years for all owners of our sterilizers. It begins with the question, “What four basic steps must be followed when preparing instruments for sterilization?” With the emphasis on basic, the correct answer is, “disassemble, wash, dry and wrap."

By removing all caps, plugs and stylets, the EtO will be allowed an unobstructed path to all surfaces of the instrument. Somewhat more specific instructions include the phrase “meticulously cleaned” and “air dried or towel dried to the most critical standard of cleanliness possible.”

Towel or air drying is important for EtO sterilization. The EtO molecule is extremely volatile and essentially rips through the cell wall and chemically alters a microorganism.

EtO can easily sterilize spores. However, if they are chemically dried or extremely desiccated due to exposure to low relative humidity, or exposure to heat and hot air, microorganisms could survive an EtO cycle. Washing is the usual method to humidify instruments. Yet, drying is important, since water molecules left on an instrument can harbor microorganisms.

If the cell wall is dried out using heat, which dehydrates or desiccates organisms, re-hydration must be carried out so that spores do not revert to a “super-dried” state. Taking care to prepare instruments that cannot be washed involves a re-hydration procedure that Andersen’s system is very well-equipped to handle.  Andersen uses a sealed, plastic sterilization bag that is essentially the “chamber.”The humidity will be retained in the bag by using a Humidichip®, a humidification device that comes with Andersen’s unit dose of gas, the sterilization bag, a Dosimeter and the 10.5 g of EO inside of the gas cartridge.

The sealed sterilization bag also allows the operator to open the cabinet at any time to add or remove bags as each one is ready. By the way, this method eliminates the EPA (Environmental Protection Agency) full-load requirement, since each bag is a full load.

Extending the life of instruments is the whole point when using EtO. Since it is compatible with almost everything, it readily penetrates narrow lumens and is extremely effective.

Kathy Jorgensen is general manager of H.W. Andersen Products of California, Inc.