INSIDE JOB The manual cleaning of flexible endoscopes requires the correct style and size of brush to remove bioburden from internal channels.

Lumened instruments are notoriously difficult to clean and can pose a major patient safety risk if their channels and surfaces aren't properly flushed and brushed between uses. The alarming truth: Improperly cleaned instruments can't be disinfected or sterilized, and mistakes continue to be made during this important first step in proper instrument reprocessing. (Exhibit A: The recent carbapenem-resistant Enterobacteriaceae [CRE] outbreaks at several facilities across the country that were linked to improperly cleaned duodenoscopes). That's why even the most dedicated techs in central sterile need regular reminders about proper manual cleaning protocols. Here are some key points to emphasize.

1. Start at the bedside
Cleaning at the point-of-use helps remove gross debris and flushes lumens before instruments arrive at central sterile. Keeping instruments moist immediately after use basically ensures that blood, tissue and other bodily fluid doesn't dry on surfaces and in channels to make manual cleaning even more difficult. It can also help keep instruments in better shape by reducing the amount of corrosion and pitting that bodily fluid can cause. Cleaning at the bedside is a step that's often overlooked, because facilities place an emphasis on turning over rooms quickly instead of making pre-cleaning a priority.

Here's how to do it correctly: After instruments are used in the OR or procedure room, wipe them down with a moistened towel or sponge to remove gross soil. Lumens should be flushed using a syringe and an enzymatic detergent, which starts breaking down bioburden. Enzymatic solutions are considered best practice, although flushing with water is also acceptable. The instruments should be kept either under a moist towel or soaked in a neutral pH enzyme detergent until they're brought to sterile processing.

New gel and foaming enzymatic detergents are specifically designed to make pre-cleaning even simpler by keeping instruments moist without having to fill a basin for soaking. These options form protective barriers that keep instruments wet for longer periods of time. Special transport sacks are also available to keep instruments moist after use and are especially helpful in busy sterile processing departments where techs might not be able to clean lumened devices as soon as they arrive.

WIPE DOWN Proper instrument cleaning begins immediately after use in the OR or procedure room.

2. Follow the instructions for use
It's something you hear over and over again: Follow the instrument manufacturer's instructions for use to ensure the item is reprocessed properly. It's a simple directive that can actually be incredibly difficult for busy techs to follow.

Instructions for use are often poorly written, difficult to understand or suggest the use of detergents or devices that a facility might not have. In addition, most techs are under strict time constraints and pressure to turn around instruments as soon as possible. Because manufacturers' instructions for use are typically tedious and detailed — consider that the reprocessing directions for some flexible endoscopes include more than 100 steps — it's easy for techs to inadvertently skip over essential parts of the manual cleaning process.

Pay close attention to your techs' knowledge of the proper way to handle devices with hard-to-clean lumens, mating surfaces and moving parts. If they're having difficulty with a specific instrument, consider bringing in a rep from its manufacturer for a demonstration on the correct way to reprocess the device. And if issues persist, check to see if there's an alternative and easier-to-clean instrument that provides the same clinical benefit.

3. Use the right equipment
Techs should manually clean lumened devices, even if the instruments are going to be placed in an automated washer. During this step, be sure techs are using the correct brush to scrub the inside of the lumen. Information on the size and style of the brush is usually found in instrument manufacturers' instructions for use. The brush size should be the same diameter as the lumen. If it's too small, it won't create enough friction to clean the lumen properly; if it's too large, the bristles won't fit correctly inside the instrument. Some facilities try to standardize the brushes that are used in the sterile processing department, so they have to stock only 2 or 3 types and sizes. That may work for 95% of your instruments, but it's essential to have brushes that fit all of your lumened devices. Consider expanding your brush inventory, so your techs can effectively clean the other 5%.

Many facilities also rely on automated washers, whether they're integrated into automated endoscope reprocessors (AERs) or ultrasonic washers designed for lumened instruments. For the vast majority of these washers, you can purchase additional attachments that connect to lumened devices and force water and detergent through their channels. Though the purchase of the attachments is an added cost, it's well worth the expense. Without these attachments, there's no guarantee that cleaning fluid is being flushed through lumened devices with enough pressure to hit all of the internal surfaces. Some techs place the devices in various positions within automated washers to force fluid through the channels, but that practice isn't nearly as effective as purchasing the attachments that are designed specifically to flush channels properly.

4. Verify complete cleaning
Though cleaning verification is becoming more common, it remains the single biggest missed opportunity in proper instrument reprocessing. If your techs are cleaning dozens of lumened instruments each day, consider investing in a borescope that can look inside channels for missed debris. A borescope can cost several thousand dollars, and busy processing departments often need more than one to keep up with the heavy volume, but the scope easily pays for itself if it prevents just a single infection. In addition to a borescope, you should also consider keeping lighted magnification devices on hand that techs can use to inspect instruments after cleaning.

For a more precise look at your cleaning processes, use chemical cleaning verification tests to routinely check for traces of missed bioburden. These tests feature indicators that are pulled through the lumen to test for the presence of residual soil. They come in different formats and are available for nearly all lumened instruments, including endoscopes. Some of the most common tests measure levels of protein, hemoglobin or adenosine triphosphate (ATP). Keep in mind that ATP tests measure bioluminescence, which is produced by living cells. These tests work well if your instrument is being reprocessed relatively quickly, but if it's sitting for several hours or even days before reprocessing, ATP tests may miss residual debris trapped inside lumens. While it's impractical for techs to use chemical cleaning verification tests each time they clean an instrument, you can implement a program where these tests are used routinely on different types of instruments, and their various features, to ensure your cleaning processes are effective and working well.

5. Seek out continuing education
Debate continues about whether sterile processing techs need to be certified to properly care for the complex instruments they're asked to handle. Certification is a good start, but it won't completely solve the reprocessing issues that continue to occur. Instead, you need to focus on keeping your techs educated on the correct way to clean and sterilize instruments. Consider giving them the time and financial support they need to attend classes and conferences, so they can stay current on the latest reprocessing advances and technologies. The price you'll pay for improperly cleaned instruments will far exceed any investment you make in ensuring surgery's dirtiest job is done right each and every time. OSM