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step or the subsequent reprocessing steps may not be effective.


Steps of the Cleaning Process:1 • Sorting: items such as utensils, basins, sharps, non-immersible items, and powered equipment are grouped sepa- rately to facilitate the cleaning process and help prevent damage to instru- ments.


• Disposal: used single-use instruments and other items are removed from the basins and trays of soiled reusable instruments.


• Pre-rinsing/pre-soaking: reusable devices are moistened and/or soaked in a cleaning solution to loosen soil on the surfaces of items. Although general detergents can be used, enzyme deter- gents are preferred for this process.


•Washing: each device is cleaned manu- ally or mechanically, following the manufacturer’s instructions for use (IFU) and using a process specifically designed for surgical instruments.


• Rinsing: critical water (water treated by deionization, reverse osmosis, or distillation) is used to remove all soils and solutions.


•Drying: using a non-linting cloth, instrument air and/or medical device drying systems, devices are thoroughly dried to prevent potential recontamina- tion from residual moisture.


•Inspection: once cleaned and dried, each device is examined with bright light and magnifying tools to ensure that it is, at the very least, visually clean. Sterile processing staff understand that the decontamination station is no ordinary sink. All soiled items that come into this space must be handled as if they repre- sent a significant health risk (also known as standard precautions) because of the potentially infectious materials that may be on the items waiting to be processed. Moreover, manual cleaning is a double- edged sword because in addition to following their department’s written policies and procedures (which typically align with national standards), techni- cians must follow the specific IFU pro- vided by device manufacturers to safely reprocess each device. Some instructions may require 20 or more individual steps to completely clean the surgical instru- mentation and skipping even a single step in the process could leave soil behind. In addition, the process must be performed consistently on each device, and by every


SELF-STUDY SERIES


technician, to assure optimal decontami- nation results. Surgical instrument design varies greatly, and technicians must use the proper cleaning tools for each device. The most basic cleaning tool, the cleaning brush, comes in 10 or more different styles, a variety of lengths and diameters, and has bristles made of stainless steel, copper, or soft nylon. Using the wrong cleaning brush can damage devices or may not remove all soil. A common brushing error is using an abrasive cleaning brush on soft metal or plastic instrumentation. The resulting surface scratches create pits and groves that trap soils and microorganisms and impede the next step in the process (disinfection or sterilization).


Consequences and contributors to poor cleaning Any failure to effectively clean surgi- cal instruments before placing them in a mechanical washer or sending them over to the clean side for inspection and assembly can present risks to the patients we as healthcare professionals all serve. Surgical site infections (SSIs) due to improperly cleaned surgical instruments can be deadly to patients. A 2012 study from the National Center for Biotechnol- ogy Information reported a spike in surgi- cal site infections related to dirty surgical instruments. In this study, 20% of the patients became sick, and Staphylococcus sp. bacteria were found on the instru- ments and in the surgical packaging.2


In


addition to infections, foreign materials such as bone and blood can cause allergic reactions or inflammation, and can poten- tially lead to anaphylactic shock. Factors that can negatively impact the cleaning process include water quality, water temperature, cleaning chemistries, type of soil, human factors, and poor quality assurance. For example, medical devices such as endoscopes with lumens and robotic arms with channels must be manually cleaned to ensure that the lumen/channel is clean and free of any debris. If the department has hard water that is not treated (water quality), the chemistry they use may not work as effec- tively. If the wrong cleaning chemistry is used for the soils on the device (cleaning chemistries, soil type), some soils may not be fully removed. Then, if the lumens are not thoroughly flushed with critical or deionized water (water quality), pyro- gens and biofilm can collect inside the


lumen. If these cannulated items aren’t properly inspected after cleaning (qual- ity assurance, human factors), bioburden may be missed and may become fixed onto internal surfaces during the steril- ization process. Any residual soils can lead to bacterial colonies called biofilms forming within the instruments. Those biofilm-covered surface areas will not receive sterilant during the sterilization cycle and will retain organisms within the biofilm that can infect the next patient on whom the device is used.


In addition to these direct risks, there are indirect risks and consequences that can negatively impact the surgical department and the hospital’s bottom line. SSIs can cost hospitals valuable time spent notifying patients, correcting poor habits, and re-educating staff. They can also cause lost operating room time which can also affect revenue. According to an article published by Eloquest Healthcare, “While costs of an SSI vary widely based on the degree of infection and the site of surgery, the estimated average cost of an SSI can be more than $25,000, increasing to more than $90,000 if the SSI involves a prosthetic implant. Overall, SSIs cost the US healthcare system an estimated $3.5 to $10 billion annually.”3 The impact of patient infections does not stop with the patient and costs asso- ciated with treating that patient. As the lawsuit filed by 7 patients of Adventist Hospital in Denver shows, infectious out- breaks caused from improperly cleaned surgical instruments can impact hospitals financially and reputationally. The 7 patients alleged that their surgical site infections were caused by dirty instru- ments. Investigation by state officials confirmed 7 instances in which dirty instruments were found in the operating room.4


Even if the hospital settles the lawsuit before it goes to trial, community distrust could drive patients, and their revenue, away from the facility.


Developing a robust manual cleaning process Because a department’s manual cleaning functions have a direct impact on the health and safety of patients, it’s essen- tial that every SPD establishes a robust manual cleaning protocol.


Physical setup


A best-practice protocol begins with an optimal workspace. First and foremost,


hpnonline.com • HEALTHCARE PURCHASING NEWS • March 2022 47


Self-Study Test Answers: 1. D, 2. A, 3. B, 4. A, 5. C, 6. C, 7. A, 8. D, 9. D, 10. C


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