STARTING POINT Surgical instruments that aren't clean can't be sterilized, making effective decontamination the first, and perhaps most critical, step of the sterilization process.

It all starts in the OR. Yes, the real dirty work may take place in sterile processing, but decontamination begins in the operating room, at the point of use, where OR personnel should prepare soiled instruments and devices for reprocessing. How?

• By wiping instruments down and removing bioburden so biofilms don't begin to form. Biofilms, a resistant layer of microorganisms that tightly adhere to surfaces and can't be removed easily, can begin to form in as little as 10 minutes.
• By keeping like instruments together by set. If you expect to get those instruments back quickly, you'll save the reprocessing staff valuable minutes if you transport the set organized and intact.
• By keeping them moist and covered for the trip to SPD. Any biohazard — in this case, dirty instruments — should be transported in a closed, covered, puncture-resistant container.
• By disassembling instruments composed of more than one piece (trocars, depth gauges or laparoscopy instruments, for example) in order for cleaning solutions to contact all surfaces. If cleaning solutions can't reach all a device's surfaces, organic material and debris can be retained.

BIOFILM BLOCKER Keep instruments moist until they're cleaned to prevent bioburden from drying and adhering.

Perioperative personnel's role
Much has been written about SPD's role in decontaminating instruments. But what about the steps your OR team must take before the instruments get to sterile processing? What about the operating room's part in the care and handling of devices, during and immediately following the case?

I was a scrub tech for 7 years before I became a nurse. I can still remember how instruments would often arrive at sterile processing from the OR: mismatched, caked in blood ... and needed back ASAP. This only made the reprocessing department's already difficult job all the more challenging — both in terms of reprocessing instruments as they should be and getting them back to the OR when they should be. Here are a few truths I tried to drill into the OR team's mind:

1. Preparation for instrument decontamination begins at the point of use. Don't wait for the procedure to end to start cleaning instruments. The scrub person should remove gross soil from instruments by wiping the surfaces with a sterile surgical sponge moistened with sterile water during the surgical procedure. Removing gross soil as soon as possible reduces the amount of microorganisms on the instruments. Besides being highly corrosive to instrument surfaces, blood, organic material, debris, and saline can also result in corrosion, rusting and pitting when allowed to dry on surgical instruments. This in turn reduces the efficacy of the subsequent sterilization process.

Hint: It helps to have a basin of sterile water on the field. In some cases, a larger basin in a ring stand may be necessary for larger instruments like broaches or reamers that collect large amounts of bone and tissue. Another hint: Make sure you use sterile water and not saline to wipe down instruments, as prolonged exposure to saline can cause rusting, corrosion and pitting on stainless steel instruments.

2. Periodically irrigate lumens with sterile water. As we've said, biofilms can form on almost any surface in a short amount of time. And once biofilm forms, you need direct friction and oxidizing chemicals to remove it. Biofilms are especially problematic in lumens because we can't see inside of most lumens, making it difficult to adequately remove biofilms once they've formed. The simple solution: Periodically irrigate lumens with sterile water (not saline) throughout the surgical procedure in order to remove gross soil and reduce the risk of biofilm formation. Irrigation of lumens throughout a procedure merely requires an extra vessel containing sterile water and a syringe.

3. Keep instruments moist. In preparation for transport to the decontamination area, you want to keep instruments moist until they can be cleaned. This will prevent blood, organic materials and debris from drying and forming biofilm. There are several ways to do this: Place a towel moistened with water (not saline) on top of the instruments, place the instruments inside a package designed to maintain humid conditions, or pre-soak them with an instrument spray or gel designed for pretreatment (enzymatic solution, for example).

If you use a pre-soaking solution, be sure to consult the manufacturer's written recommendations for the correct dilution, temperature and soak time. Note: If you use liquids to soak contaminated items on the sterile field, discard the liquid before you transport items to decontam. The contaminated liquid can be suctioned into a canister or a waste management system, or disposed of down a drain, depending on your facility's options and policy. If it's not possible to dispose of the contaminated liquid, you must transport the solution in a leakproof container marked as biohazard to the decontamination area for disposal.

4. Stack instruments wisely. What happens if you place delicate and other easily damaged instruments under heavier instruments during transport to the decontamination area? Crunch. Protect your fiber-optic cords, rigid endoscopes and microsurgical instruments from damage. Either place them on top of heavier instruments or segregate them into separate containers. Similarly, before you transport sharp instruments to decontam, you should separate them and place them in a puncture-resistant container. The OSHA Bloodborne Pathogens Standard requires the safe disposal of contaminated sharps (suture needles and scalpel blades, for example) to protect healthcare workers from the risk of bloodborne pathogen transmission.

5. Safely transport instruments to decontam. Transport soiled instruments to the decontam area as soon as possible after the procedure is completed. Remember that you must contain instruments during transport to prevent injury, exposure to blood, body fluids, or other potentially infectious materials, and instrument damage. The container must be closed (bins with lids or enclosed transport carts, for example), leakproof, puncture-resistant and large enough to contain all contents. Containers must be marked with a biohazard label or otherwise indicate that the contents are hazardous (a red container, for example).

Waiters and dishwashers
Some OR personnel have a that's-not-my-job mentality. We're waiters, not dishwashers. And that's wrong, as well as dangerous. The OR and SPD share in the responsibility. Together, they can ensure a safe and efficient decontamination process.