THIS WAY IN Central service worker Tangela Celious loads a pass-through washer-decontaminator on the decontamination room side.

Decontamination is arguably the most important job taking place in your sterile processing department. It's also one of the most important steps in preventing surgical site infections. How well do you know the necessary practices involved? Read on for a review.

Immediate action
The care and handling of surgical instruments between the point of use and the high-level disinfection or sterilization process plays a critical role in inhibiting the transmission of infectious bacterial and viral organisms from patient to patient. Instruments must be thoroughly cleaned and rinsed for the subsequent steps to be effective. As any reprocessing tech will tell you, "It can't be sterile if it's not clean."

Instrument cleaning, as defined by the International Association of Healthcare Central Service Materiel Management, is the removal of all visible soil and other foreign material. Decontamination is the removal or reduction of infectious organisms. These processes must begin in the OR or procedure room as soon as possible after a surgeon is done using an instrument. They are a component of room turnover as well as a team effort.

A nurse or tech scrubbed into a procedure can use sterile water from the field to remove blood and tissue from instruments as the case progresses. When the procedure is completed, instruments should be kept moist by covering them with a damp towel or by applying a commercially available enzymatic foam or gel. These preliminary steps aim to keep blood, tissue and other gross contaminants from drying on the instruments, which can be difficult to remove and may increase the time it will later take to wash them.

Let's Stamp Out SSIs, Part 7

This Month: Decontamination
September: Patient Warming
October: Autoclaving and Flashing

You should wipe flexible endoscopes down after use with a detergent-solution-soaked cloth, and flush their suction channels with the solution and air. Once the case is concluded, transport instruments to the decontamination room without delay.

POINT OF CARE For sterile processing to be effective, cleaning and decontamination must begin as soon as instruments are out of surgeons' hands.

Proper preparation
Your reprocessing team should be prepared with the proper personal protective equipment, which includes a face mask (either with a built-in protective eye shield or with goggles), a bouffant hair cover, a water-resistant gown with sleeves that cover all the way to the hands, water-resistant gloves and shoe covers. The shoes themselves should be water-resistant, too.

The quality of the gloves is an important consideration. We've found that strong, general-purpose utility gloves that overlap the cuffs of the gown's sleeves and that are resistant to cuts and tears offer an added level of protection from sharps: Gelpi retractors, picks, Senn retractors and other hazards of instrument sets.

"The first and most important step in decontamination is thorough cleaning and rinsing," the Association for the Advancement of Medical Instrumentation outlines in its Comprehensive Guide to Steam Sterilization. Doing it efficiently demands that attention be paid to "the quality of the water; the quality, concentration and type of detergent or enzymatic cleaner; an acceptable washing method; proper rinsing and drying; correct preparation of the items to be processed by cleaning equipment; time temperature parameters; load capacity of the equipment; and operator performance."

Are your water, cleaning supplies, equipment, protocols and staff training up to standards? Good. When instruments arrive in the decontamination room, you're ready to sort, separate and disassemble them for manual, ultrasonic or mechanical washing, each of which has its own method and specially formulated detergent solution.

The manufacturers' instructions for the instruments, solutions and ultrasonic or mechanical washers will indicate which method is advised for which items. Draft a departmental protocol so that reprocessing staff can consult a single source for decontamination guidance, and be sure to update it in the event that manufacturers revise their instructions.

Hands on
Manual cleaning is most commonly accomplished through a 3-sink method. Instruments are washed in a sink full of warm water and detergent solution, rinsed in a sink of water, and final-rinsed in a sink of distilled or de-ionized water.

Washing by hand is without a doubt labor-intensive. But it's useful for items that can't handle mechanical cleaning, such as heat-sensitive, delicate or powered devices, or that would benefit from pre-cleaning, such as endoscopes and other channeled, lumened, jointed, complex instruments.

While automatic endoscope reprocessors, which have gained widespread use, have been designed to take scopes from their arrival in central sterile through high-level disinfection, most reprocessing standards still recommend manual pre-cleaning in order to ensure the removal of biofilm.

Ultrasonic vibrations
Lumened items and other fine instruments should be sorted for cleaning in an ultrasonic washer. They are immersed (after lumens have been flushed with water) in a mixture of tap water and an enzymatic solution that helps to break down tissue and fats that accumulate on instruments during a procedure. The washer generates high-frequency sound waves that pass through the liquid. The vibrations of these ultrasonic waves create bubbles, which implode to create vacuums that remove debris from inner surfaces, a process called cavitation.

In order to prolong the life of and prevent damage to your instruments, instruct your reprocessors to sort ultrasonic-bound devices by like metals. Mixing different types of metal instruments — stainless steel and titanium, for instance — in a single ultrasonic cycle can result in corrosion.

At our facility, we've had success using a single-enzyme solution. We've also tested out multi-enzymatic solutions for effectiveness. Whichever option you choose, be sure to seek the input of your central sterile staff. Since they'll have the most contact with these cleaning products, their views on effectiveness and even how the solution smells are important factors. Also, be sure that they change the water and fluid frequently, and keep the ultrasonic washer's filter and drain clear of debris.

Mechanical options
If you're not scrubbing a reusable instrument by hand, and it's not being decontaminated by way of ultrasonic immersion, then it will be going into a mechanical washer-decontaminator, of which you have several options. Various manufacturers make instrument washers and cart washers alongside their sterilizer equipment lines.

Even though they run on the basis of timed exposures to hot water and detergent through spraying, washing, rinsing and steam heating, mechanical washer-decontaminators are by no means just glorified dishwashers. Their wash cycles handle everything from delicate anesthesia instrumentation to basins and urinals to heavily soiled orthopedic tools.

Instrument washers can be divided into 2 types: low- and high-impingement. In low-impingement washers, instruments are washed and rinsed by water that rains down on them. The wash cycle usually employs a basic detergent that has a high pH level, while the rinse water is mixed with an acidic or otherwise low pH solution, in order to prevent the instruments from pitting.

Most washer-decontaminators in the United States have traditionally been of the high-impingement type. These machines rely on the force of water shooting from nozzles to remove debris and tissue. They usually use pH-neutral detergents along with enzymatic solutions to assist in washing instrumentation.

Cart washers are designed to decontaminate the case carts used to pick supplies for a surgery and then transport used instruments to central sterile when it's over. But they can also be used to clean instrument containers, basins and urinals. This use frees up your washer-decontaminators to clean instruments that demand their specific cycles, resulting in a more efficient sterile processing operation.

In the past, most detergents for washer-decontaminators were delivered in 30-gallon drums. More recently, however, manufacturers have begun packaging concentrated solutions in 2-, 5- and 15-gallon containers. One company has even developed tablets that can be diluted and pumped into the washers. By switching over to the 2-gallon concentrated solutions, we've enabled any member of our staff to change the detergent when it's needed, not limiting the job to the ones who can hoist the drum. In addition to improving central sterile's workflow efficiency, it also ensures that all instruments get cleaned uniformly.

Follow up
No matter which method of decontamination you've used — manual, ultrasonic or mechanical — it's important to make sure that the cleaned items are dry after the final rinse, in order to prevent biofilm from forming on their surfaces. When the bioburden is thoroughly removed from the instruments, they're clear for sterilization. While there are no biological, chemical or mechanical tests mandated for monitoring the decontamination process the way there are for sterilization, quality control is still paramount in providing safe, sterile instruments for surgery.

Make sure you've got the right chemistry (that is, your staff is using the appropriate detergents, enzymatic solutions or lubricants for the task at hand). Check your ultrasonic washers and washer-decontaminators on a daily basis. Study their printouts to ascertain that the proper solutions are being used, the right temperatures are being met, each part of the cycle is occurring for the right length of time and all parts are functioning properly. Use cleaning verification products to monitor the effectiveness of your machines. Conducting periodic inspections of instrument sets during assembly and acting on customer feedback can ensure that surgical patients get sterile instruments and the best care.