Cleaning surgical instruments, the most important part of the decontamination process, begins as soon as an instrument leaves the surgeon's hand. Pass these 4 steps to your nurses and techs so they realize that properly sterilizing the tools of their trade is a total team effort that starts in the OR.

Step 1: Pre-treat.
In the same way that you'd pre-treat a stain on your favorite shirt before it's laundered, you must handle soiled instruments in a manner that will inhibit the drying of any contaminants that have accumulated on them, yet will not damage the instruments themselves. This can be accomplished as soon as is practically possible after the conclusion of a surgical procedure by wrapping instruments in a moist towel or by applying a commercially prepared gel or foam product designed specifically to inhibit the growth of microorganisms.

Step 2: Get 'em moving.
The container that holds these treated instruments should then be transported to the decontamination area immediately. In this day and age, "immediately" sometimes falls prey to the "as soon as I can" mentality, but moving instruments to central sterile must be a priority.

Upon arrival in the decontamination area, the instruments should be sorted, separated and appropriately taken apart to ensure that all surfaces of the instruments will be in contact with the cleaning solution.

Step 3: Pre-soak and rinse.
This frequently neglected step will make the cleaning process easier and more effective. Soak instruments in tap water or (if allowed by manufacturers' instructions) in one of the many pre-soaking solutions available on the market, including enzymatic, disinfectant or detergent products. Keep in mind that after pre-soaking, it is imperative to rinse the instruments in order to remove any loose contaminants or residual solution before proceeding.

Step 4: Wash.
Considering all the challenges that new technology has brought to bear on the sterile processing technician, "wash" truly is a four-letter word. There are many instruments which, to put it simply, don't seem like they were designed to be cleaned. They may have long, narrow channels, for example. They cannot be taken apart. They harbor multiple nooks and crevices. Or they were constructed from uneven surfaces, heat-sensitive parts or electrical components.

Fortunately, there are methods of washing to address each issue: manual, ultrasonic and mechanical. Each uses a detergent solution that has been specifically formulated for how it is to be used and in what conditions. The solutions are not interchangeable. In addition, the solution that is used must be safe and effective to use in accordance with all of the items you'll clean, so consult each manufacturer's directions as well as those of the solution before beginning the process. Each solution should be carefully evaluated before use to ensure an effective decontamination process.

• Manual. The process of washing instruments by hand with warm water, detergent and friction, was once believed to be the best method of cleaning, yet it has become a method that many sterile processing departments work to avoid. This method has seen a resurgence, however, with the influx of newer technology, since it can be used to clean heat-sensitive devices, power equipment and delicate instruments that would not survive mechanical cleaning methods.

The three-sink method is considered the gold standard for manual washing. It consists of the following steps:

• the first sink (or bin), which contains water and a detergent solution, for active washing;
• the second sink, which contains water, for rinsing; and
• the third sink, which contains distilled, de-ionized or reverse osmosis water, for a final rinse.

Manual cleaning can also be used to augment the decontamination of difficult-to-clean items prior to a mechanical cleaning cycle. You should, of course, always follow a manufacturer's instructions for the proper cleaning of specialty devices, such as ophthalmic instrumentation.

• Ultrasonic. These cleaners use high-frequency sound waves that pass through the tap water and solution in which instruments are immersed to create very fast vibrations. These vibrations create bubbles, and the bubbles' implosions create a vacuum that sucks the debris out of the cracks and crevices of the immersed instruments. (This process is called cavitation.)

When using ultrasonic cleaners, keep the following factors in mind:

• Instruments' lumens should be flushed prior to the cleaning.
• Sort instruments by the metal they're made of, since cleaning different types of metals together in an ultrasonic cleaner may result in corrosion.
• Because tap water contains gases, run an empty cycle before instruments are inserted in order to de-gas the fluid and ensure ideal ultrasonic activity.
• Change frequently the water and fluid - perhaps as often as twice a day - and check often the cleaner's filters and drains for debris and routinely test the machine for effectiveness according to the manufacturer's directions.

Recently, many manufacturers have incorporated specially designed irrigation ports into ultrasonic cleaners to assist in washing difficult-to-clean items. The flushing of lumens that these devices provide can improve the removal of contaminants and residual material. Any items that can be cycled through an ultrasonic cleaner - in accordance with its cleaning instructions and the directions for the cleaning system's optimal operation - should be. Then, for best results, instruments that can withstand mechanical cleaning should be run through a mechanical washing cycle.

• Mechanical. This washing equipment includes such combination machines as washer-sterilizers, washer-decontaminators, pass-through washers and tunnel washers, which disinfect instruments through timed exposure to hot water. Their multiple steps include a high-volume spray rinse, a solution wash, a second rinse, a final rinse with distilled, de-ionized or reverse osmosis water and a steam heat cycle. Some models even provide lumen flushing or lubricant cycles.

The quality of mechanical washers has improved greatly in recent years. As a result, it's easy for users to become complacent with their operation. But the mechanical washing process must be regularly verified by posting outcome measures for comparison at the inspection table, although products capable of alerting sterile processing technicians of problems prior to the machinery's use are commercially available.

Stay vigilant
The cleaning of surgical instruments is the most important part of the decontamination process. As a result, cleaning is the most important component of infection prevention in sterile processing. The more a facility's staffing and economic pressures push central sterile to "do more with less," the greater the likelihood that soiled instruments will sit longer before they are processed. In facilities that do not have well-monitored procedures for cleaning, multiple possibilities exist for errors to fall through the cracks and for staff to miss important steps in the process. Don't let them happen at your facility.