5 Steps to Better, Safer Decontamination

Decontamination, the first step in the sterilization process, may also be the most important, because no sterilization system can reliably penetrate caked on biological material. To decontaminate medical devices effectively, you need a thorough knowledge of the various types of cleaning processes, the properties and design of the items you are cleaning, and the safety precautions you need to take. In this article, I'll review five vital steps that will ensure your decontamination processes are up to par.

1 Pre-clean thoroughly
Left alone, blood and other debris can dry and coagulate on the surfaces of surgical instruments very rapidly, making cleaning nearly impossible. So remember that timing is everything when it comes to decontamination. It's critical to start the decontamination process immediately after the surgeon is finished with the device, particularly if the device is complex.

To remove dirt before it dries and begin the cleaning process as soon as possible, always have a basin or tray containing an enzyme solution ready at the surgical site. Place instruments directly into the basin as soon as the surgeon is finished with them. An alternative may be to use a spray-on pre-cleaner that may help to dissolve the soil immediately, making it easier to remove later.

A few notes:

• Do not rely on the practice of placing a wet towel over the instruments and hoping this will keep the soil from drying. It won't.

• It is critical that the enzyme solution get into all nooks, crannies and lumens, so make sure you open scissors and jaw-type devices and disassemble complex devices before placing them into the solution (Figure 1).

• Disassemble air-powered devices and immerse the components into the enzymatic solution. Follow the manufacturer's recommendations for any pre-decontamination treatment of items that cannot be immersed.

• Many multi-lumened scopes require that you place them into special cleaning devices that flush debris out of the lumens; do this as soon as possible after use.

• Separate delicate instruments (such as some ophthalmic instruments) from general surgical instruments to prevent damage. Most manufacturers of these instruments can furnish you with specially designed trays, which you can use to protect the instruments from damage during transport, decontamination and sterilization.

If for any reason, you cannot use or do not want to use an enzymatic solution to pre-clean your items, then you should have a sink close at hand. As soon as possible, hold the items under a faucet and douse them abundantly with running tap water to remove as much of the gross debris as possible. Then place them into a covered tray containing tap water.

2 Transport with care
Use a closed cart to move contaminated instruments from surgery to the decontam area (Figure 2). If this is not possible, use containers that you can close or seal to prevent aerosolation and/or splashing of the contaminated contents into the environment. Place soiled linen into strong all-plastic bags or in plastic-lined hamper bags so that liquids can't leach out of the bag (Figure 3).

3 Design a safe facility
The ideal decontamination area will have the following characteristics:

• - It should be physically separate from all other areas.

• - It should have its own air circulation system that changes the room air a minimum of 10 times per hour. The air should be pressurized so that it always exhausts to the outside, rather than recirculating.

• - The floor, walls, ceiling and work surfaces should be made of non-porous materials that will not support mold growth. It's important to wash down these surfaces frequently (Figure 4).

• - Because the area is potentially a high-humidity area, the room must have adequate floor drains and some sort of humidity control. Clean up any spills immediately to prevent slips and falls. You can treat floors to prevent slipping (Figure 5), but make sure they remain easy to clean and maintain.

• - The area should have adequate lighting, with no shadowed or dark areas. Lighting fixtures should be recessed so as to not provide a haven for bacteria to grow.

• - The area should be restricted to only those staff members who work there.

4 Wear proper attire
The attire worn in the decontamination area should protect staff from contamination by the items and the relatively hostile environment. A few suggestions:

Head coverings: Provide moisture-resistant disposable or reusable head coverings for your staff. Don't use hairnets. They may be comfortable, but they don't offer enough protection.

Gloves: Surgical gloves might be appropriate for hand washing very delicate instruments, but as a general rule workers should wear thicker, more durable gloves. The gloves should have cuffs that are long enough to prevent water from coming over the wrist and into the glove (Figure 6). Wash and decontaminate gloves at least daily, and discard them immediately if you find holes or cracks.

Eye protection: If there is a possibility of splashing or aerosol creation when handling contaminated instruments, goggles, or preferably, face shields that protect the eyes, nose and mouth are a necessity. Do not rely on ordinary eyeglasses-they don't provide enough eye protection.

Gowns: Workers should wear gowns, coveralls or aprons with sleeves that prevent moisture strike-through over surgical attire. Cover shoes with either disposable or reusable waterproof boots.

Make sure all attire is easy to put on and take off. Workers should remove protective clothing before leaving the decontam area and place it in appropriate containers for either disposal or reprocessing. Do not, under any conditions, take attire home for laundering!

Use OSHA guidelines and your own common sense when making decisions on what precautions are necessary to protect employees. The more automated the process, the less the need for personal protection.

5 Use the right equipment
If you have a small surgical facility, you may elect to perform all your decontamination by hand. If so, you'll need only a sink and an assortment of cleaning brushes and tools (Figure 7). If you're in a large, busy facility, however, you may want to automate the entire process. Several different devices may help you do this productively, effectively and safely. A rundown of what's available:

Cart washers will handle your case carts, transport carts, and other mobile equipment much the same as a car wash. Insert the cart in one end, start the washer, and wait for it to come out clean on the other end. If you need to clean mobile equipment and don't have an automatic cart washer, you may want to equip an area of your decontamination room with a power washer and drain, depending on your volume and the types of services that you offer (Figure 8). Please note that some portable equipment cannot withstand either a cart washer or a power washer; if this is the case, you'll need to wipe down the equipment by hand (Figure 9).

Single-chamber washers operate basically the same as your home dishwasher (Figure 10). You will need to separate the items and place them in special baskets that allow the high-pressure water to reach all surfaces. Some washers include attachments for special items such as scopes. Single-chamber washers differ in their degree of automation. Some simply wash and rinse. Others are fully automatic, featuring everything from power doors to operator- selected cycles, to automatic loading and unloading. Pay close attention to the manufacturer's claims regarding the unit's ability to remove microorganisms, and religiously follow instructions regarding how to operate the equipment and what detergents and disinfecting chemicals to use.

Tunnel washer/sterilizers may be appropriate for very high-volume facilities (Figure 11). These devices index and automate the various steps of pre-rinsing in cold water, detergent hot-water washing, ultrasonic cleaning, instrument lubrication, sterilization, and drying. It's questionable if the sterilization cycle is necessary. Some users believe that if the washer/sterilizer doesn't clean exceptionally well, the sterilization process will bake on whatever the cleaning cycle misses. However, if you are more comfortable having your instruments decontaminated and sterilized before you run them through the standard packaging and sterilization process, they may be worth the cost. In most cases, however, you just need automatic equipment that provides very good cleaning.

Ultrasonic cleaners may be useful for instruments with difficult-to-clean surfaces, like serrated tips and box locks. There is some controversy about where in the cleaning cycle you should use ultrasonic cleaning. I believe you should use these devices after you have washed the instruments and removed most of the soil and debris. Then use the ultrasonic cleaner to remove the very last bit of contamination.

After thorough rinsing, you may dip instruments in a water-soluble lubricant designed for sterilization. A lubricant (often called "instrument milk" because of its milky color and consistency) may lubricate instruments with hinges or moving parts and provide surface protection. Always follow the manufacturer's instructions for use. Under no circumstances should you use mineral oil or other oil-based lubricants.

Whatever decontamination methods you employ, and whatever devices you choose, don't skimp on time or equipment for this important step. The health of your patients and staff depends on it.

Dan Mayworm is the former president of Mayworm Associates, Inc. and publisher of The Journal of Healthcare Resource Management and Infection Control & Sterilization Technology. He is the former president of Tower Products, Inc., a manufacturer of packaging materials for the medical device industry. Mr. Mayworm has served as president of the Health Industries Association and as an executive committee member of the Health Industry Manufacturers Association, and has given expert testimony before both the House and Senate subcommittees.

If you have an infection prevention question that you would like Mr. Mayworm to answer in this column, fax it to 610-240-4919, snail mail it to Outpatient Surgery Magazine, 3 Beryl Road, 2nd Floor, Paoli, PA 19301, or e-mail Mr. Mayworm at [email protected].