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Back to Basics: Instrument Cleaning
CONTINUING EDUCATION
Back to Basics: Instrument Cleaning 1.0 www.aornjournal.org/content/cme
LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #17509 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme.
Conflict-of-Interest Disclosures
The contact hours for this article expire March 31, 2020. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to surgical instrument cleaning.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Kristi Van Anderson, BSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Van Anderson and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe the implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2017.01.001 ª AORN, Inc, 2017
292 j AORN Journal
www.aornjournal.org
Back to Basics: Instrument Cleaning 1.0 www.aornjournal.org/content/cme
LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN
ABSTRACT Adequately cleaning and processing surgical instruments may be challenging for perioperative team members; however, the cleaning and processing of instruments are critical steps in making instruments safe to use on patients and achieving an appropriately safe OR environment. Instruments that are cleaned properly have had organic debris and soil removed, rendering them ready for sterilization or disinfection. This Back to Basics article covers the basic steps and considerations for cleaning and processing instruments before sterilization. AORN J 105 (March 2017) 292-299. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2017.01.001 Key words: surgical instruments, instrument cleaning, instrument processing, biofilm, ultrasonic cleaner.
P
roper instrument cleaning is an essential step when processing surgical instruments to ensure patient safety. Consider the following scenario: Mrs G is a 65-year-old patient admitted to an outpatient surgery center for an orthopedic surgical procedure. During her procedure, the surgical technologist prepares the drill before use and notices that there are bone fragments in the drill bit from another patient. The drill bit had already touched other instruments that the surgeon used during Mrs G’s procedure. The instrument had not been properly cleaned, and Mrs G has been exposed to potentially infectious material. The nurse takes her to the postanesthesia care unit where she is recovering without problems. She is sitting up and waiting to see the surgeon. The surgeon notifies Mrs G of the instrument contamination. Mrs G becomes upset that she may be at risk of developing a surgical site infection. This scenario illustrates the importance of surgical instrument cleaning before sterilization as an essential step that requires careful execution. This Back to Basics article addresses instrument precleaning and cleaning as the first steps in ensuring that surgical instruments are safe and ready to use on patients. This article does not address sterilization, loaned instruments, evaluating or selecting instruments, prions, or personal protective
equipment. For evidence-based guidance on these topics, see AORN’s “Guideline for sterilization”1 and the “Guideline for cleaning and care of surgical instruments.”2
HOW-TO GUIDE Before beginning any process for cleaning surgical instruments, personnel should consult the instrument manufacturer’s instructions for use (IFU), which should be on-site and available in every facility.2 Manufacturers of reusable instruments and devices cleared by the US Food and Drug Administration provide validated cleaning and decontamination instructions and instructions on device processing between uses.2 Items cannot be assumed to be clean, decontaminated, or sterile unless the manufacturer’s IFU are derived from validation testing and the user has followed those instructions.2 Personnel should review the written IFU to determine the requirements for cleaning and processing the instruments and to make sure the required materials for cleaning are available at the facility.2 Examples of such requirements are the type of water for cleansing; instrument air; cleaning equipment; accessories; cleaning agents; lubricants; and procedures for handling, cleaning, disinfecting, testing, packaging, and sterilizing.3 Sterile-processing personnel should review these instructions periodically to make sure the
http://dx.doi.org/10.1016/j.aorn.2017.01.001 ª AORN, Inc, 2017
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facility is compliant with the IFU. Before the cleaning process begins, it is important to inspect the instruments for defects and ensure they are functioning correctly. Personnel should verify the following details for each instrument, as applicable, before cleaning:
screws are secure, moveable parts are freely moveable, cutting edges are sharp, tips are intact and aligned, ratchets hold properly, and insulation is intact.2
Biofilm Biofilm is a thin layer of microorganisms that can adhere to organic or inorganic surfaces together with the polysaccharides that the microorganisms secrete.2 Biofilm can form on instruments if blood or other organic materials are allowed to dry. Biofilm can be difficult to remove when allowed to dry; therefore, it is important to clean instruments as soon as possible after use.2 During the surgical procedure, the scrub person should remove gross soil from the instruments by wiping them with a sterile surgical sponge that has been moistened with sterile water.2 The scrub person should also use sterile water to irrigate instrument lumens.2 This step helps to remove gross soil so it does not dry on the instruments, which may subsequently affect disinfection and sterilization. Blood, organic debris, and saline are highly corrosive to instruments and may cause rusting and pitting if left to dry on the surface of instruments.4 Personnel may also spray an instrument cleaner on instruments to prevent debris from drying on instrument surfaces and to inhibit biofilm formation.2
Transporting Instruments Perioperative personnel should transport instruments to the decontamination area as soon as possible after use and should keep the instruments moist until they are cleaned.2 Personnel may place a towel moistened with water over the instruments to help prevent them from drying out during transport. If an instrument cannot be cleaned immediately after use, personnel should treat it with an instrument cleaner in accordance with the manufacturer’s IFU.5 Before transporting the instruments, personnel should discard liquids used to soak contaminated instruments at the point of use, and they should transport instruments in a container that is leakproof, puncture resistant, able to accommodate all of the contents, and 294 j AORN Journal
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labeled with a bright orange label containing a biohazard legend.6 If sterile or clean supplies remain on the case cart at the end of the procedure, personnel should remove them from the cart and return them to the proper storage area before placing any dirty items on the cart.5
CLEAN AND DECONTAMINATION AREAS The decontamination room where contaminated items are cleaned should be separated from areas where personnel handle clean items to avoid the risk of cross-contamination. Droplets and aerosols created when instruments are cleaned may cause any nearby clean items or surfaces to become contaminated. The sterile-processing area should have separate clean and decontamination areas that are separated by one of these three methods: a wall with a pass-through or door, a partial wall or partition that is at least 4 ft high and at least the width of the counter, or a wall with 4 ft of distance between the instrument-washing sink and the area where the instruments are prepared for sterilization.2 Sinks used for washing instruments should be separate from those used for hand hygiene, and decontamination equipment such as automated washers and ultrasonic cleaners should be available.2
Mechanical or Manual Cleaning Instrument manufacturer’s IFU contain instructions on cleaning instruments either by mechanical or manual methods.4 Sterile-processing personnel cannot mechanically clean devices such as power drills, delicate instruments, and cameras because of the risk of damaging them, so personnel must manually clean these devices.5 In preparation for manual cleaning, personnel should disassemble the instrument and open valves, ports, stopcocks, ratchets, and joints; use a cool water rinse before washing to help remove gross soil and wash away water-soluble blood proteins; submerge the instrument in a solution of detergent and water that is intended for cleaning surgical instruments, unless contraindicated in the manufacturer’s IFU, and use the type of water recommended by the instrument manufacturer’s IFU (eg, distilled, filtered);
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immerse instrument lumens in the cleaning solution in a vertical position and flush the lumens with the cleaning solution; use a brush to clean the length and diameter of the lumens to contact all surfaces; and change solutions used for cleaning before they become heavily soiled, when the temperature does not meet the temperature indicated in the manufacturer’s IFU, or as needed to help minimize bioburden.2,7 Mechanical cleaning is preferred over manual cleaning if the instrument manufacturer allows it. Mechanical cleaning methods such as using ultrasonic cleaners and washer disinfectors/decontaminators provide consistent detergent concentration, temperature control, and washing and rinsing processes, and reduce the risk of exposure to potentially infectious materials by health care personnel who are conducting the cleaning.8 Personnel should remove visible soil from instruments before placing them into an ultrasonic cleaner.5 Ultrasonic cleaners are an effective means of removing soil from hard-to-reach areas such as joints and crevices. Ultrasonic cleaners vary by design and intended use, so personnel should follow the manufacturer’s IFU closely, using only cleaning products that are compatible with the design of the ultrasonic cleaner. Using unapproved cleaning products may interfere with the cavitation process that ultrasonic cleaners use to remove debris. After ultrasonic cleaning is completed, personnel should thoroughly rinse instruments with distilled water, reverse osmosisefiltered water, or filtered water of a quality that will not cause stains or damage to the instruments nor cause recontamination.5 After each use, or at least daily, personnel should empty, clean, disinfect, rinse, and dry ultrasonic cleaners.5 Mechanical washer disinfectors/decontaminators also vary among manufacturer and model types, so personnel should closely follow the manufacturer’s IFU. Personnel should position surgical instruments and accessories in the washer in a manner that ensures the cleaning solution contacts all surfaces of the instrument.5 When using a mechanical washer disinfector/decontaminator, personnel should disassemble items with more than one part and confine small parts, place instruments in open mesh-bottom pans, open stopcocks and ports, remove stylets from instruments with lumens, ensure that ratchets are in the open position, place items that have a surface that will retain water on their edge, and
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Back to Basics: Instrument Cleaning
segregate insulated instruments and those with electrical cords from the sharp instruments.5 These steps help ensure contact between the instrument surfaces and the cleaning solution; this is a critical step for effective cleaning and decontamination.5
Inspecting Instruments After the cleaning and decontamination process, personnel should inspect instruments for
missing parts; presence of moisture; chipping or wear; cleanliness; integrity of the device and parts (eg, cords, cables), seals, and gaskets; corrosion, burrs, cracks, nicks, or pitting; correct functioning; correct alignment; sharpness of cutting edge; integrity of insulation; lens clarity; and any other defects.2
Inspecting instruments for these issues gives personnel an opportunity to identify soiled or damaged instruments and to remove them from service before they are used on a patient.
BENEFIT Precleaning and cleaning surgical instruments are the first steps in instrument processing. It is extremely important to be diligent when cleaning instruments. If instruments have been adequately cleaned according to best practices, then personnel have taken the first step toward providing surgical instruments that are safe for the patient. Cleaning removes any type of soil, including organic debris, so that sterilization of the instruments can be successful.
STRATEGIES FOR SUCCESS Personnel must take special precautions when cleaning certain instruments (eg, eye instruments) because of the risks of patient harm. One example is the risk of toxic anterior segment syndrome, which is an acute inflammation occurring in the anterior segment of the eye.2 Contaminated surgical instruments and supplies have been implicated as a cause of this condition, along with other factors including endotoxin residue on instruments, insufficiently dried instrument lumens, AORN Journal j 295
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insufficient instrument rinsing, use of reusable cannulated instruments, contaminated ultrasonic cleaners, dried debris and ophthalmic viscoelastic (OV) residue on instruments, detergent residue on instruments, and use of glutaraldehyde during processing.2 To help decrease the risk of toxic anterior segment syndrome for patients, personnel should follow best practices related to cleaning eye instruments, beginning in the OR.2 The scrub person should use sterile water to flush the aspiration and irrigation ports of the irrigation and aspiration handpieces and phacoemulsification ports, accessory tips, and tubing before disconnecting from the unit.9 Flushing immediately after use helps prevent OV material from drying and prevents buildup, which can be difficult to remove when cleaning.9 Immediately after the procedure, the scrub person should wipe instruments clean with sterile water using a lint-free sponge and flush or immerse instruments in sterile water according to the manufacturer’s IFU. Manufacturer’s IFU may vary, so personnel should review and follow specific cleaning instructions. Personnel should clean the instruments and lumens following the manufacturer’s IFU, rinse with a copious amount of water, and complete a final rinse and flush with distilled or sterile deionized water to help remove all of the detergent and residual enzymes.10 After manual cleaning, and if it is not contraindicated by the manufacturer’s IFU, personnel should disinfect the instruments by rinsing the lumens and wiping the instruments with 70% to 90% alcohol solution and allow them to dry before packaging them for sterilization.11 Personnel can also use ultrasonic cleaners, and should thoroughly rinse the instruments after the ultrasonic cleaning process before drying, inspecting, packaging, and sterilizing.12 Ophthalmic viscoelastic residue is very difficult to remove, so personnel must inspect instruments using magnification to facilitate detection of residual OV material.13 Sterile-processing leaders should employ an adequate number of personnel to perform the cleaning and sterilization process to ensure thorough and effective cleaning and sterilization according to evidence-based practices. Sufficient inventory is also essential to avoid requests for fast turnaround times that could jeopardize the time needed for proper instrument cleaning and sterilization.5 Laryngoscope blades and handles are also specialized instruments that personnel should clean and decontaminate because they are a potential source of contamination. Laryngoscope handles are classified as noncritical items because they contact intact skin.14 Personnel should clean 296 j AORN Journal
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Resources Instrument cleaning. AORN, Inc. https://www.aorn.org/ guidelines/clinical-resources/clinical-faqs/instrument -cleaning. Accessed October 12, 2016. Guidelines and Tools for the Sterile Processing Team [e-book]. Denver, CO: AORN, Inc; 2015. https:// www.aorn.org/guidelines/clinical-resources/publications/ ebooks/guidelines-tools-sterile-processing-team [fee required]. Accessed October 12, 2016.
laryngoscope handles and may either low-level disinfect after each use or high-level disinfect or sterilize them.2 In contrast, laryngoscope blades are semicritical items because they contact mucus membranes or nonintact skin. Personnel should clean the blades and either high-level disinfect or sterilize them after each use. Personnel should store blades in individual packages to minimize the potential for contamination.15
WRAP-UP Instrument cleaning is one of the most important processes when caring for surgical instruments and readying them for use in surgical procedures. Instruments that are cleaned properly have had organic debris and soil removed, rendering them ready for sterilization or disinfection. Sterilization and disinfection are negatively affected if bioburden and microorganisms remain on surgical instruments.1 Oil, soil, and other materials that remain on instruments shield microorganisms from coming into contact with the sterilant or may inactivate the sterilant.1 Adherence to evidence-based instrument cleaning practices can help ensure effective instrument sterilization, which can ultimately protect patients from adverse outcomes.
References 1. Guideline for sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017:865-892. 2. Guideline for care and cleaning of instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017:815-850. 3. Association for the Advancement of Medical Instrumentation. AAMI TIR30: A Compendium of Processes, Materials, Test Methods, and Acceptance Criteria for Cleaning Reusable Medical Devices. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2011. 4. Spry CC. Care and handling of surgical instruments. In: Tighe SM, ed. Instrumentation for the Operating Room: A Photographic Manual. 8th ed. St Louis, MO: Mosby, Inc; 2012:1-21. 5. Association for the Advancement of Medical Instrumentation. ANSI/ AAMI ST79: Comprehensive Guide to Steam Sterilization and
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6.
7.
8.
9.
10.
11.
Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2013. Occupational safety and health standards: Bloodborne pathogens. 56(235) Fed Regist. (December 6, 1991) 64004 (codified at 29 CFR x1910.1030). https://www.osha.gov/pls/oshaweb/owadisp .show_document?p_id¼10051&p_table¼STANDARDS. Updated April 3, 2012. Accessed October 12, 2016. Williamson JE. Brushing up on brush basics. Healthc Purch News. 2009;33(5). http://www.hpnonline.com/inside/2009-05/0905CS-Accessories.html. Accessed October 12, 2016. Association for the Advancement of Medical Instrumentation. AAMI TIR12: Designing, Testing, and Labeling Reusable Medical Devices for Reprocessing in Health Care Facilities: A Guide for Medical Device Manufacturers. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2010. Hellinger WC, Bacalis LP, Edelhauser HF, et al. Recommended practices for cleaning and sterilizing intraocular surgical instruments. J Cataract Refract Surg. 2007;33(6):1095-1100. Mamalis N, Edelhauser HF. Enzymatic detergents and toxic anterior segment syndrome. Ophthalmology. 2013;120(3): 651-652. Maier P, Birnbaum F, B€ohringer D, Reinhard T. Toxic anterior segment syndrome following penetrating keratoplasty. Arch Ophthalmol. 2008;126(12):1677-1681.
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Back to Basics: Instrument Cleaning 12. Cutler Peck CM, Brubaker J, Clouser S, Danford C, Edelhauser HE, Mamalis N. Toxic anterior segment syndrome: common causes. J Cataract Refract Surg. 2010;36(7):1073-1080. 13. Buchen SY, Calogero D, Tarver ME, Hilmantel G, Tang X, Eydelman MB. Evaluation of intraocular reactivity to organic contaminants of ophthalmic devices in a rabbit model. Ophthalmology. 2012;119(7):e24-e29. 14. Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, 2008. http://www.cdc.gov/hicpac/pdf/guidelines/disinfection_ nov_2008.pdf. Accessed October 12, 2016. 15. Laryngoscope blades and handlesdhow to clean, disinfect and store these devices. The Joint Commission. https://www.joint commission.org/standards_information/jcfaqdetails.aspx?Standards FaqId¼1201&ProgramId¼46. Accessed October 12, 2016.
Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, is the director of Evidence-Based Perioperative Practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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EXAMINATION
Continuing Education: Back to Basics: Instrument Cleaning 1.0 www.aornjournal.org/content/cme
PURPOSE/GOAL To provide the learner with knowledge of best practices related to surgical instrument cleaning.
OBJECTIVES 1. 2. 3.
Discuss common areas of concern that relate to perioperative best practices. Discuss best practices that could enhance safety in the perioperative area. Describe the implementation of evidence-based practice in relation to perioperative nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.
QUESTIONS 1.
2.
Biofilm is a thin layer of microorganisms that can 1. form on instruments if blood or other organic materials are allowed to dry. 2. adhere to organic or inorganic surfaces. 3. be difficult to remove when allowed to dry. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 When transporting instruments to the decontamination area, perioperative personnel should 1. allow instruments to dry before they are cleaned. 2. place a towel moistened with water over the instruments. 3. transport instruments in a leakproof container. 4. transport instruments while soaking them in liquid. 5. transport instruments in a container labeled with a biohazard legend. 6. keep instruments moist until they are cleaned. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
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3.
The decontamination room where contaminated items are cleaned should be separated from areas where personnel handle clean items, to avoid the risk of cross-contamination. a. true b. false
4.
When using a mechanical washer disinfector/decontaminator, personnel should 1. open stopcocks and ports. 2. ensure that ratchets are in the open position. 3. disassemble items with more than one part. 4. place instruments in open mesh-bottom pans. 5. remove stylets from instruments with lumens. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
5.
Laryngoscope blades are classified as _________ items, and personnel should clean them and either __________ or sterilize them after each use. a. semicritical; low-level disinfect b. semicritical; high-level disinfect c. noncritical; low-level disinfect d. noncritical; high-level disinfect
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LEARNER EVALUATION
Continuing Education: Back to Basics: Instrument Cleaning 1.0 www.aornjournal.org/content/cme
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2.
Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High
3.
Describe the implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
5.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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Back to Basics: Instrument Cleaning 1.0 www.aornjournal.org/content/cme
LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #17509 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme.
Conflict-of-Interest Disclosures
The contact hours for this article expire March 31, 2020. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to surgical instrument cleaning.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Kristi Van Anderson, BSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Van Anderson and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe the implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2017.01.001 ª AORN, Inc, 2017
292 j AORN Journal
www.aornjournal.org
Back to Basics: Instrument Cleaning 1.0 www.aornjournal.org/content/cme
LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN
ABSTRACT Adequately cleaning and processing surgical instruments may be challenging for perioperative team members; however, the cleaning and processing of instruments are critical steps in making instruments safe to use on patients and achieving an appropriately safe OR environment. Instruments that are cleaned properly have had organic debris and soil removed, rendering them ready for sterilization or disinfection. This Back to Basics article covers the basic steps and considerations for cleaning and processing instruments before sterilization. AORN J 105 (March 2017) 292-299. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2017.01.001 Key words: surgical instruments, instrument cleaning, instrument processing, biofilm, ultrasonic cleaner.
P
roper instrument cleaning is an essential step when processing surgical instruments to ensure patient safety. Consider the following scenario: Mrs G is a 65-year-old patient admitted to an outpatient surgery center for an orthopedic surgical procedure. During her procedure, the surgical technologist prepares the drill before use and notices that there are bone fragments in the drill bit from another patient. The drill bit had already touched other instruments that the surgeon used during Mrs G’s procedure. The instrument had not been properly cleaned, and Mrs G has been exposed to potentially infectious material. The nurse takes her to the postanesthesia care unit where she is recovering without problems. She is sitting up and waiting to see the surgeon. The surgeon notifies Mrs G of the instrument contamination. Mrs G becomes upset that she may be at risk of developing a surgical site infection. This scenario illustrates the importance of surgical instrument cleaning before sterilization as an essential step that requires careful execution. This Back to Basics article addresses instrument precleaning and cleaning as the first steps in ensuring that surgical instruments are safe and ready to use on patients. This article does not address sterilization, loaned instruments, evaluating or selecting instruments, prions, or personal protective
equipment. For evidence-based guidance on these topics, see AORN’s “Guideline for sterilization”1 and the “Guideline for cleaning and care of surgical instruments.”2
HOW-TO GUIDE Before beginning any process for cleaning surgical instruments, personnel should consult the instrument manufacturer’s instructions for use (IFU), which should be on-site and available in every facility.2 Manufacturers of reusable instruments and devices cleared by the US Food and Drug Administration provide validated cleaning and decontamination instructions and instructions on device processing between uses.2 Items cannot be assumed to be clean, decontaminated, or sterile unless the manufacturer’s IFU are derived from validation testing and the user has followed those instructions.2 Personnel should review the written IFU to determine the requirements for cleaning and processing the instruments and to make sure the required materials for cleaning are available at the facility.2 Examples of such requirements are the type of water for cleansing; instrument air; cleaning equipment; accessories; cleaning agents; lubricants; and procedures for handling, cleaning, disinfecting, testing, packaging, and sterilizing.3 Sterile-processing personnel should review these instructions periodically to make sure the
http://dx.doi.org/10.1016/j.aorn.2017.01.001 ª AORN, Inc, 2017
www.aornjournal.org
AORN Journal j 293
Spruce
facility is compliant with the IFU. Before the cleaning process begins, it is important to inspect the instruments for defects and ensure they are functioning correctly. Personnel should verify the following details for each instrument, as applicable, before cleaning:
screws are secure, moveable parts are freely moveable, cutting edges are sharp, tips are intact and aligned, ratchets hold properly, and insulation is intact.2
Biofilm Biofilm is a thin layer of microorganisms that can adhere to organic or inorganic surfaces together with the polysaccharides that the microorganisms secrete.2 Biofilm can form on instruments if blood or other organic materials are allowed to dry. Biofilm can be difficult to remove when allowed to dry; therefore, it is important to clean instruments as soon as possible after use.2 During the surgical procedure, the scrub person should remove gross soil from the instruments by wiping them with a sterile surgical sponge that has been moistened with sterile water.2 The scrub person should also use sterile water to irrigate instrument lumens.2 This step helps to remove gross soil so it does not dry on the instruments, which may subsequently affect disinfection and sterilization. Blood, organic debris, and saline are highly corrosive to instruments and may cause rusting and pitting if left to dry on the surface of instruments.4 Personnel may also spray an instrument cleaner on instruments to prevent debris from drying on instrument surfaces and to inhibit biofilm formation.2
Transporting Instruments Perioperative personnel should transport instruments to the decontamination area as soon as possible after use and should keep the instruments moist until they are cleaned.2 Personnel may place a towel moistened with water over the instruments to help prevent them from drying out during transport. If an instrument cannot be cleaned immediately after use, personnel should treat it with an instrument cleaner in accordance with the manufacturer’s IFU.5 Before transporting the instruments, personnel should discard liquids used to soak contaminated instruments at the point of use, and they should transport instruments in a container that is leakproof, puncture resistant, able to accommodate all of the contents, and 294 j AORN Journal
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labeled with a bright orange label containing a biohazard legend.6 If sterile or clean supplies remain on the case cart at the end of the procedure, personnel should remove them from the cart and return them to the proper storage area before placing any dirty items on the cart.5
CLEAN AND DECONTAMINATION AREAS The decontamination room where contaminated items are cleaned should be separated from areas where personnel handle clean items to avoid the risk of cross-contamination. Droplets and aerosols created when instruments are cleaned may cause any nearby clean items or surfaces to become contaminated. The sterile-processing area should have separate clean and decontamination areas that are separated by one of these three methods: a wall with a pass-through or door, a partial wall or partition that is at least 4 ft high and at least the width of the counter, or a wall with 4 ft of distance between the instrument-washing sink and the area where the instruments are prepared for sterilization.2 Sinks used for washing instruments should be separate from those used for hand hygiene, and decontamination equipment such as automated washers and ultrasonic cleaners should be available.2
Mechanical or Manual Cleaning Instrument manufacturer’s IFU contain instructions on cleaning instruments either by mechanical or manual methods.4 Sterile-processing personnel cannot mechanically clean devices such as power drills, delicate instruments, and cameras because of the risk of damaging them, so personnel must manually clean these devices.5 In preparation for manual cleaning, personnel should disassemble the instrument and open valves, ports, stopcocks, ratchets, and joints; use a cool water rinse before washing to help remove gross soil and wash away water-soluble blood proteins; submerge the instrument in a solution of detergent and water that is intended for cleaning surgical instruments, unless contraindicated in the manufacturer’s IFU, and use the type of water recommended by the instrument manufacturer’s IFU (eg, distilled, filtered);
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immerse instrument lumens in the cleaning solution in a vertical position and flush the lumens with the cleaning solution; use a brush to clean the length and diameter of the lumens to contact all surfaces; and change solutions used for cleaning before they become heavily soiled, when the temperature does not meet the temperature indicated in the manufacturer’s IFU, or as needed to help minimize bioburden.2,7 Mechanical cleaning is preferred over manual cleaning if the instrument manufacturer allows it. Mechanical cleaning methods such as using ultrasonic cleaners and washer disinfectors/decontaminators provide consistent detergent concentration, temperature control, and washing and rinsing processes, and reduce the risk of exposure to potentially infectious materials by health care personnel who are conducting the cleaning.8 Personnel should remove visible soil from instruments before placing them into an ultrasonic cleaner.5 Ultrasonic cleaners are an effective means of removing soil from hard-to-reach areas such as joints and crevices. Ultrasonic cleaners vary by design and intended use, so personnel should follow the manufacturer’s IFU closely, using only cleaning products that are compatible with the design of the ultrasonic cleaner. Using unapproved cleaning products may interfere with the cavitation process that ultrasonic cleaners use to remove debris. After ultrasonic cleaning is completed, personnel should thoroughly rinse instruments with distilled water, reverse osmosisefiltered water, or filtered water of a quality that will not cause stains or damage to the instruments nor cause recontamination.5 After each use, or at least daily, personnel should empty, clean, disinfect, rinse, and dry ultrasonic cleaners.5 Mechanical washer disinfectors/decontaminators also vary among manufacturer and model types, so personnel should closely follow the manufacturer’s IFU. Personnel should position surgical instruments and accessories in the washer in a manner that ensures the cleaning solution contacts all surfaces of the instrument.5 When using a mechanical washer disinfector/decontaminator, personnel should disassemble items with more than one part and confine small parts, place instruments in open mesh-bottom pans, open stopcocks and ports, remove stylets from instruments with lumens, ensure that ratchets are in the open position, place items that have a surface that will retain water on their edge, and
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Back to Basics: Instrument Cleaning
segregate insulated instruments and those with electrical cords from the sharp instruments.5 These steps help ensure contact between the instrument surfaces and the cleaning solution; this is a critical step for effective cleaning and decontamination.5
Inspecting Instruments After the cleaning and decontamination process, personnel should inspect instruments for
missing parts; presence of moisture; chipping or wear; cleanliness; integrity of the device and parts (eg, cords, cables), seals, and gaskets; corrosion, burrs, cracks, nicks, or pitting; correct functioning; correct alignment; sharpness of cutting edge; integrity of insulation; lens clarity; and any other defects.2
Inspecting instruments for these issues gives personnel an opportunity to identify soiled or damaged instruments and to remove them from service before they are used on a patient.
BENEFIT Precleaning and cleaning surgical instruments are the first steps in instrument processing. It is extremely important to be diligent when cleaning instruments. If instruments have been adequately cleaned according to best practices, then personnel have taken the first step toward providing surgical instruments that are safe for the patient. Cleaning removes any type of soil, including organic debris, so that sterilization of the instruments can be successful.
STRATEGIES FOR SUCCESS Personnel must take special precautions when cleaning certain instruments (eg, eye instruments) because of the risks of patient harm. One example is the risk of toxic anterior segment syndrome, which is an acute inflammation occurring in the anterior segment of the eye.2 Contaminated surgical instruments and supplies have been implicated as a cause of this condition, along with other factors including endotoxin residue on instruments, insufficiently dried instrument lumens, AORN Journal j 295
Spruce
insufficient instrument rinsing, use of reusable cannulated instruments, contaminated ultrasonic cleaners, dried debris and ophthalmic viscoelastic (OV) residue on instruments, detergent residue on instruments, and use of glutaraldehyde during processing.2 To help decrease the risk of toxic anterior segment syndrome for patients, personnel should follow best practices related to cleaning eye instruments, beginning in the OR.2 The scrub person should use sterile water to flush the aspiration and irrigation ports of the irrigation and aspiration handpieces and phacoemulsification ports, accessory tips, and tubing before disconnecting from the unit.9 Flushing immediately after use helps prevent OV material from drying and prevents buildup, which can be difficult to remove when cleaning.9 Immediately after the procedure, the scrub person should wipe instruments clean with sterile water using a lint-free sponge and flush or immerse instruments in sterile water according to the manufacturer’s IFU. Manufacturer’s IFU may vary, so personnel should review and follow specific cleaning instructions. Personnel should clean the instruments and lumens following the manufacturer’s IFU, rinse with a copious amount of water, and complete a final rinse and flush with distilled or sterile deionized water to help remove all of the detergent and residual enzymes.10 After manual cleaning, and if it is not contraindicated by the manufacturer’s IFU, personnel should disinfect the instruments by rinsing the lumens and wiping the instruments with 70% to 90% alcohol solution and allow them to dry before packaging them for sterilization.11 Personnel can also use ultrasonic cleaners, and should thoroughly rinse the instruments after the ultrasonic cleaning process before drying, inspecting, packaging, and sterilizing.12 Ophthalmic viscoelastic residue is very difficult to remove, so personnel must inspect instruments using magnification to facilitate detection of residual OV material.13 Sterile-processing leaders should employ an adequate number of personnel to perform the cleaning and sterilization process to ensure thorough and effective cleaning and sterilization according to evidence-based practices. Sufficient inventory is also essential to avoid requests for fast turnaround times that could jeopardize the time needed for proper instrument cleaning and sterilization.5 Laryngoscope blades and handles are also specialized instruments that personnel should clean and decontaminate because they are a potential source of contamination. Laryngoscope handles are classified as noncritical items because they contact intact skin.14 Personnel should clean 296 j AORN Journal
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Resources Instrument cleaning. AORN, Inc. https://www.aorn.org/ guidelines/clinical-resources/clinical-faqs/instrument -cleaning. Accessed October 12, 2016. Guidelines and Tools for the Sterile Processing Team [e-book]. Denver, CO: AORN, Inc; 2015. https:// www.aorn.org/guidelines/clinical-resources/publications/ ebooks/guidelines-tools-sterile-processing-team [fee required]. Accessed October 12, 2016.
laryngoscope handles and may either low-level disinfect after each use or high-level disinfect or sterilize them.2 In contrast, laryngoscope blades are semicritical items because they contact mucus membranes or nonintact skin. Personnel should clean the blades and either high-level disinfect or sterilize them after each use. Personnel should store blades in individual packages to minimize the potential for contamination.15
WRAP-UP Instrument cleaning is one of the most important processes when caring for surgical instruments and readying them for use in surgical procedures. Instruments that are cleaned properly have had organic debris and soil removed, rendering them ready for sterilization or disinfection. Sterilization and disinfection are negatively affected if bioburden and microorganisms remain on surgical instruments.1 Oil, soil, and other materials that remain on instruments shield microorganisms from coming into contact with the sterilant or may inactivate the sterilant.1 Adherence to evidence-based instrument cleaning practices can help ensure effective instrument sterilization, which can ultimately protect patients from adverse outcomes.
References 1. Guideline for sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017:865-892. 2. Guideline for care and cleaning of instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017:815-850. 3. Association for the Advancement of Medical Instrumentation. AAMI TIR30: A Compendium of Processes, Materials, Test Methods, and Acceptance Criteria for Cleaning Reusable Medical Devices. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2011. 4. Spry CC. Care and handling of surgical instruments. In: Tighe SM, ed. Instrumentation for the Operating Room: A Photographic Manual. 8th ed. St Louis, MO: Mosby, Inc; 2012:1-21. 5. Association for the Advancement of Medical Instrumentation. ANSI/ AAMI ST79: Comprehensive Guide to Steam Sterilization and
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6.
7.
8.
9.
10.
11.
Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2013. Occupational safety and health standards: Bloodborne pathogens. 56(235) Fed Regist. (December 6, 1991) 64004 (codified at 29 CFR x1910.1030). https://www.osha.gov/pls/oshaweb/owadisp .show_document?p_id¼10051&p_table¼STANDARDS. Updated April 3, 2012. Accessed October 12, 2016. Williamson JE. Brushing up on brush basics. Healthc Purch News. 2009;33(5). http://www.hpnonline.com/inside/2009-05/0905CS-Accessories.html. Accessed October 12, 2016. Association for the Advancement of Medical Instrumentation. AAMI TIR12: Designing, Testing, and Labeling Reusable Medical Devices for Reprocessing in Health Care Facilities: A Guide for Medical Device Manufacturers. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2010. Hellinger WC, Bacalis LP, Edelhauser HF, et al. Recommended practices for cleaning and sterilizing intraocular surgical instruments. J Cataract Refract Surg. 2007;33(6):1095-1100. Mamalis N, Edelhauser HF. Enzymatic detergents and toxic anterior segment syndrome. Ophthalmology. 2013;120(3): 651-652. Maier P, Birnbaum F, B€ohringer D, Reinhard T. Toxic anterior segment syndrome following penetrating keratoplasty. Arch Ophthalmol. 2008;126(12):1677-1681.
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Back to Basics: Instrument Cleaning 12. Cutler Peck CM, Brubaker J, Clouser S, Danford C, Edelhauser HE, Mamalis N. Toxic anterior segment syndrome: common causes. J Cataract Refract Surg. 2010;36(7):1073-1080. 13. Buchen SY, Calogero D, Tarver ME, Hilmantel G, Tang X, Eydelman MB. Evaluation of intraocular reactivity to organic contaminants of ophthalmic devices in a rabbit model. Ophthalmology. 2012;119(7):e24-e29. 14. Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, 2008. http://www.cdc.gov/hicpac/pdf/guidelines/disinfection_ nov_2008.pdf. Accessed October 12, 2016. 15. Laryngoscope blades and handlesdhow to clean, disinfect and store these devices. The Joint Commission. https://www.joint commission.org/standards_information/jcfaqdetails.aspx?Standards FaqId¼1201&ProgramId¼46. Accessed October 12, 2016.
Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, is the director of Evidence-Based Perioperative Practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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EXAMINATION
Continuing Education: Back to Basics: Instrument Cleaning 1.0 www.aornjournal.org/content/cme
PURPOSE/GOAL To provide the learner with knowledge of best practices related to surgical instrument cleaning.
OBJECTIVES 1. 2. 3.
Discuss common areas of concern that relate to perioperative best practices. Discuss best practices that could enhance safety in the perioperative area. Describe the implementation of evidence-based practice in relation to perioperative nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.
QUESTIONS 1.
2.
Biofilm is a thin layer of microorganisms that can 1. form on instruments if blood or other organic materials are allowed to dry. 2. adhere to organic or inorganic surfaces. 3. be difficult to remove when allowed to dry. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 When transporting instruments to the decontamination area, perioperative personnel should 1. allow instruments to dry before they are cleaned. 2. place a towel moistened with water over the instruments. 3. transport instruments in a leakproof container. 4. transport instruments while soaking them in liquid. 5. transport instruments in a container labeled with a biohazard legend. 6. keep instruments moist until they are cleaned. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
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3.
The decontamination room where contaminated items are cleaned should be separated from areas where personnel handle clean items, to avoid the risk of cross-contamination. a. true b. false
4.
When using a mechanical washer disinfector/decontaminator, personnel should 1. open stopcocks and ports. 2. ensure that ratchets are in the open position. 3. disassemble items with more than one part. 4. place instruments in open mesh-bottom pans. 5. remove stylets from instruments with lumens. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
5.
Laryngoscope blades are classified as _________ items, and personnel should clean them and either __________ or sterilize them after each use. a. semicritical; low-level disinfect b. semicritical; high-level disinfect c. noncritical; low-level disinfect d. noncritical; high-level disinfect
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LEARNER EVALUATION
Continuing Education: Back to Basics: Instrument Cleaning 1.0 www.aornjournal.org/content/cme
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2.
Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High
3.
Describe the implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
5.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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