Centralizing Instrument Decontamination
By Susan Bisol, RN, MSN, CNOR and Rodd Bogue, CST
When instrument decontamination is decentralized in a healthcare facility, any number of variations can occur. Inadequate cleaning of blood and secretions on surgical instruments can result in retained microorganisms representing bioburden. The use of saline as a rinse agent can cause deterioration of the instrument surfaces. Sterile water should be used to irrigate and keep instruments free of gross soil. Corrosion, rusting and pitting occur when blood and other debris are allowed to dry on the surgical instruments. Instruments that are cannulated or have lumens can become obstructed with organic material.
Ideally, the initial cleaning of instruments should begin immediately following the completion of the surgical procedure. This initial step is intended to occur wherever the surgical procedure is performed. When surgical and other invasive procedures are occurring in multiple locations in a healthcare facility, how is the central sterile (CS) processing manager able to ensure that the process is consistent?
In the assessment and evaluation of work practices, it is common to find multiple methods of instrument decontamination. For example, using washer sterilizers in operating rooms is sometimes the first step in instrument cleaning. In reality, instruments subjected to a washer sterilizer without first being rinsed and the gross soiling removed, have baked-on protein at the completion of the cycle. When these instruments arrive in the CS department for inspection and assembly, they must be cleaned again -- a much more difficult task the second time around.
This is the situation we faced in a recent assessment and reorganization of work practices. The hospital owned two washer disinfectors; one was located in the CS department and the other was outside of the surgical suite in a soiled utility room. The operating room (OR) staff was using the washer sterilizers in the sub-sterile areas to decontaminate instruments after use. The washer disinfector in the surgical suite was unused since its location was not readily accessible to OR personnel. OR personnel believed they were attaining the same standard by using washer sterilizers rather than the washer disinfector. The practice of nursing personnel decontaminating instrumentation at the completion of the surgical procedure also impacted room turnover and throughput in the OR.
Our initial plan was to move the washer disinfector from the OR suite location to the decontamination area of the CS. This proposal required costly funding for architectural and utility changes and would have delayed the change in process. Our second proposal involved leaving the washer decontaminator in its location and developing process changes for post case instrument management. We developed an action plan that outlined the steps in the process changes we were proposing:
1. Form a group consisting of CS and OR personnel who perform instrument management functions.
2. Assess the current situation to determine how instruments are handled at the completion of the surgical procedure.
3. Ask questions to understand how the methods of removal of gross soil, chemical and fluid use, and thermal disinfection are occurring in the current process.
4. Discuss the differences between washer sterilizers and washer disinfectors.
5. Evaluate the traffic and logistics of transporting contaminated instruments from the surgical suite to the soiled utility room where the washer disinfector is located.
6. Assess the conditions of "confine and contain." Determine how instruments are confined at the point of use in order to be transferred to the place where decontamination occurs.
7. Discuss the use of the washer decontaminator in the OR.
8. Determine the resources needed and who will manage this process.
9. Determine the hours each day that this function will need to be staffed and determine the human resources needed.
10. Develop procedure for immediate post-case handling of surgical instrumentation.
11. Develop the assignment responsibilities for CS personnel performing OR decontamination.
12. Communicate the plan to each group of departmental personnel and address their concerns, such as immediate turnover needs and instrument inventory limitations.
13. Plan for a start date to trial the proposed changes.
14. Revisit the process to make any necessary changes.
The group was formed and followed the action plan steps. Within four weeks, CS personnel were prepared to take over the instrument decontamination process in the OR suite from 9 a.m. to 7 p.m. Monday through Friday. The CS department's staffing plan was adjusted to provide a designated individual for this assignment and training was provided regarding instruments that could tolerate moisture and heat versus those requiring manual cleaning. The soiled utility room, where the washer disinfector is located, was stocked with personal protective equipment (PPE). Closed carts previously used to transport clean instruments to central sterile were re-designated as "soiled instrument carts" and placed in sub-sterile areas. At the completion of the surgical procedure, the scrubbed person was asked to:
1. Remove the gross soil from the instruments using a sponge moistened with sterile water.
2. Irrigate all instruments with lumens with sterile water.
3. Open instrument box locks, restringing instrument sets whenever possible.
4. Disassemble instruments with removable parts.
5. Place scissors, lightweight instruments and microsurgical instruments on top.
6. Place heavy retractors and/or other heavy instruments in a separate tray.
7. Separate all reusable sharp instruments from the general instrumentation.
8. Place the instruments in a mesh bottom container and spray them with an enzyme spray.
9. Place the soiled instruments in the closed cart in the substerile area for pick-up by CS personnel.
Documenting this process and sharing it with OR and CS personnel ensured that the process would be consistent for on-call or late cases performed after 7 p.m. during the week and on the weekends.
The results were: A consistent standard of instrument decontamination; a reduction in the rework of cleaning instruments with baked-on protein; a faster turn-around of instrument sets for reuse by OR personnel; a reduction in OR turnover time; and reduced instrument breakage and repairs.
Susan Bisol, RN, MSN, CNOR, is a senior consultant for Cardinal Health Consulting Services, specializing in perioperative management. Rodd Bogue, CST, is the central sterile processing department manager at St. Charles Hospital in Port Jefferson, N.Y.