WASHING MACHINE Investing in automation helps standardize the decontamination process.

You know the drill: If an instrument isn't properly cleaned, it can't be properly sterilized. But the problem with the decontamination process is that each instrument might require a different set of cleaning instructions, and even the cleaning agents themselves can have considerable variations. When you add in the need to scrub tiny nooks and crannies on complex tools, it can make the task seem downright impossible. Focusing on the following factors can help standardize the process, make cleaning easier for your reprocessing techs and help reduce the risk of human error.

1. Point-of-use cleaning
Decontamination should always start at the point of use. At our hospital, after the physician is finished using a surgical instrument, it gets handed off to a nurse or tech responsible for pre-cleaning. Surgical instruments are wiped down to remove gross soil and then sprayed with an enzymatic cleaner.

Some facilities just rinse instruments in water or throw a wet towel on top and consider this first step satisfied. However, enzymatic sprays specifically designed for this task boost your decontamination process, because the solutions start removing bioburden as soon as they contact the instrument, which makes cleaning it even easier for techs down the line. Some sprays can even keep instruments moist for up to 72 hours, a benefit that we rely on at our facility since some of our off-campus clinics send their instruments to our central sterile department once a day.

Make sure the enzymatic spray you use is non-aerosol, which lets your staffers safely spray instruments immediately after use in the OR, even if a patient is still in the room.

2. The right cleaning agent
After used instruments are pre-cleaned, they are brought to the decontamination area in a closed container or cart. This starts our assembly line process to get the instruments ready for sterilization.

We start by placing the instruments into mesh baskets where we rinse off the enzymatic pre-cleaning solution. This step is crucial — we use one type of enzymatic cleaner for the point-of-use cleaning and different agents for the pre-soaking and washing steps in the decontamination area. You don't want the chemistries of the different enzymatic solutions to mix or dilute the next step's agent, which could compromise the decontamination process or leave a chemical residue behind.

ELBOW GREASE Refer to instruments' instructions for use to determine the size and type of cleaning brushes you need.

The type of cleaner and enzymes you need depends on your instrument manufacturers' instructions for use (IFUs). There are several different types of enzymes available in detergents:

• Protease enzymes treat proteins such as blood, mucous, feces and albumin. They take large insoluble molecules and break them down into smaller, more water-soluble compounds that are easier to clean and rinse away.
• Lipase enzymes break down fatty deposits and lipids. Though the fat and oil molecules they attack aren't as large as proteins, they tend to be insoluble in water. Lipase can make these molecules more water-soluble for better removal.
• Amylase enzymes catalyze starches. While they are less common in enzymatic detergents used on surgical instruments, they can be found in agents marketed for "heavy duty" cleaning.

Besides the type of enzymes used, there are a few other things to look for in your detergent that can help streamline the process. For example, our pre-wash soak solution has a 2-minute soak time, which is relatively short compared with some others on the market. It can also work in any temperature of water, which eliminates techs having to check and log the temperature during each wash. If you want to take it a step further, there are also automated sink-filling systems on the market that let techs simply push a button to fill the sink with the correct concentration of detergent and the correct volume and temperature of water.

3. Meticulous manual cleaning
After the initial soak, we manually scrub some of our trickier-to-clean instruments, such as those with lumens. Smaller facilities may rely purely on this step to clean instruments, though we use an automatic washer to more efficiently remove bioburden (more on that later).

Don't overlook the importance of manual cleaning, even if you're using an automatic washer. Start by determining which instruments require manual cleaning, and the specific tools needed to perform the task, by reviewing the instruments' IFUs. Making IFUs easy to access — by collecting them in a binder, displaying them on posters or posting them online — ensures techs always have the information they need to accurately clean devices.

In the IFUs, you'll find the type of cleaning agent to use as well as the size and style of brush to clean with. We typically use a soft bristle brush in various sizes, depending on the instrument. Note that you should never use a metal brush, as it can be too abrasive and remove the instruments' protective oxidized coating. You also want to ensure that staff are wearing the proper PPE during the cleaning process, including gloves, gown and eye protection.

Manual cleaning is a precise process. Because of that, techs should receive regular education, and some states even require certification in order to work in central sterile departments. To ensure our techs are up to snuff, we hold yearly competency exams and conduct regular education sessions when we receive a new product or device.

SPRAY PAN Enzymatic cleaners break down bioburden for easier removal.

4. Automatic cleaning
An automatic instrument washer can be a worthy investment for facilities looking to standardize their decontamination process. Washers allow you to automate the decontamination of medical instruments and scopes. There are several different styles on the market, including single-chamber washers that wash and disinfect instruments, ultrasonic washers for hard-to-clean or delicate instruments, cart washers, multi-chamber washers that process high volumes of instruments, conveyor belt systems and compact washers.

After our instruments are soaked and rinsed, they're loaded into an automatic washer, which coats the instruments with an enzymatic solution. Again, an instrument's IFUs must be followed, so the instrument is taken apart properly and placed into the washer correctly so that all surfaces are exposed to the solution.

We're in the process of moving to a new facility. For that central sterile area, we purchased new washers that offer a few new features, including a treated water system. Since many newer instruments recommend using treated water for a final rinse to avoid leaving tap water residue behind after drying, washers now use reverse osmosis to rinse instruments in pure water. While not yet a standard for decontamination, using treated water for the final rinse is a major trend that's worth considering.

5. Cleaning confirmation
We perform quality checks on our washers regularly to make sure they're cleaning instruments correctly, and also perform cleaning verification tests on our instruments. Our method relies on identifying adenosine tri-phosphate (ATP) on the surface of the instrument, a compound found in all organic matter. We just swab a surface of the instrument after cleaning and slide it into a handheld meter, which tells us in less than a minute whether there's any bioburden on the surface. You can also use swabs that change color to indicate the presence of bioburden.

Our decontamination process follows the same national standards set for all surgical facilities, but giving our techs the right resources, reducing unnecessary variations in the process and offering regular education helps ensure properly sterilized instruments are returned to the OR. OSM