Infection Control Today - 04/2002: Optimum Cleaning and Disinfection of Surgical Instruments

April 1, 2002

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Optimum Cleaning and Disinfection of Surgical Instruments

By Ruth A. LeTexier, RN, BSN, PHN

Surgical
instruments are used every day in the perioperative setting. The surgeon selects
specific tools to perform intricate maneuvers in order to accomplish optimal
patient outcome. Part of this outcome is based upon the assumption that all
instruments used for surgical intervention are precisely cleaned or
decontaminated in preparation for the sterilization process to prevent infection
or harm to the patient.

Cleaning is the single most important step in making a medical device ready
for reuse.

Without adequate cleaning, many disinfection and sterilization processes are
ineffective.1 Cleaning is critical in removal of gross debris,
prevention of cross contamination and protection of the healthcare worker (HCW)
in the processing area. Cleaning is considered to be the removal of visible
dirt, soil, organic matter or other foreign material from an instrument or
object. Cleaning generally means the removal of, rather than the killing of,
microorganisms.1 There are basic principles of washing instruments,
whether by hand or machine:

  • Use a cool-water rinse to remove gross debris.
  • Fat or protein sediments and debris dried to the instrument surface may
    require an enzyme detergent soak.
  • Water temperature should be less than 140 degrees Fahrenheit.
  • Choose a detergent compatible with the makeup of the surgical instrument.1

Decontamination is a term used to describe the process by which contaminants
are removed, using specific solutions designed to render the blood and organic
debris harmless, then a process such as disinfection or sterilization will kill
microorganisms to render items safe to handle. To be most effective,
decontamination must occur as soon as possible following the use of the surgical
instruments.

Some institutions support the idea of an enzymatic detergent added to the
water in a splash basin to begin the breakdown of organic debris as a presoak
method. One expert in the field of sterilization and processing does not support
the notion of presoaking in the perioperative area with the enzyme detergent,
but advocates the use of sterile water to keep the blood and body fluids, which
lead to corrosion, from being left to dry on the instrument.

The majority of surgical instruments are made from stainless steel. The
alloys have specific properties that make them resistant to corrosion when
exposed to blood, body fluids, cleaning solutions, sterilization and the
atmosphere. Iron alloys in the 400 series (low in chromium and high in carbon)
are most commonly used for the fabrication of surgical instruments.2

Enemies of the surgical instrument are present in the surgical wound and
tools are exposed on a daily basis. Blood, tissue, body fluid residue, synovial
fluid, peritoneal fluid, fat, pus, bile, urine and gastric acids all contribute
to pitting, staining and discoloration of the surgical instruments. Other
enemies include washing instruments with inappropriate solutions such as dish or
laundry soap, bleach (sodium hypochlorite), disinfectants and non-approved
solutions, all of which contribute to metal corrosion.

Once surgical instruments have entered the central sterile (CS) processing
area and are sorted, they may be cleaned manually or mechanically. Types of
mechanical cleaners include the ultrasonic cleaner, the washer-decontaminator,
the washer-sterilizer and the washer-disinfector. With the exception of the
ultrasonic cleaner, all may be used to remove debris from the instruments and
render them safe for handling but not for immediate reuse. It is the
disinfection process that eliminates many or all pathogenic microorganisms, with
the exception of bacterial spores, from inanimate objects and surfaces.

The Association for Professionals in Infection Control and Epidemiology (APIC)
has established that organic debris and microbial bioburden should be removed
before processing by high-level disinfection or sterilization. Surgical
instruments are classified as critical items in that they present a high risk of
infection to the patient if contaminated with microorganisms, including
bacterial spores. Sterilization is required for critical items.2

To minimize organic build-up or reduce bioburden on the instruments, best
practices in the perioperative setting would include keeping the instruments as
free as possible of blood and organic debris during the surgical procedure.
Association of periOperative Registered Nurses (AORN) recommended practices for
care and cleaning of surgical instruments dictate that instruments should be
kept free of gross soil during the surgical procedure.2

Common methodology includes:

  • Lap or gauze sponges moistened with sterile water should be used during
    the surgical procedure to wipe the instruments and remove organic debris and
    blood.
  • Lumens of suction or cannulas should be flushed with water to remove
    blood/fluids, which may dry and adhere to the surface.
  • A nonfibrous sponge should be used to wipe off microsurgical, ophthalmic
    and other delicate tips (this sponge prevents snagging and breaking of
    gentle tips, and potential lint is decreased).1
  • Once the procedure has ended, hinged instruments should be opened and
    placed in a splash basin of sterile water to soak.
  • Sharp, cutting, delicate or power instruments are managed separately to
    avoid damage to the surgical tools.
  • Instruments that are too large to be contained in a basin may be covered
    with a towel soaked in water to keep the organic debris and blood from
    drying on the instrument surface.

Removal of debris from instruments in the field will:

  • Reduce the number of microorganisms on the device.
  • Reduce the nutrient material that might support pathogenic growth.
  • Minimize the risk of environmental exposure from aerosolization or
    spillage.
  • Decrease the possibility of device damage from organic debris: blood,
    saline, iodine or radiologic dyes.
  • Cancel the need to vigorously clean a device to remove encrusted debris.3

Proper care of instruments during an operative procedure, coupled with
meticulous methods of cleaning and disinfection, ensures patient safety for all
surgical interventions. It is a shared responsibility between the surgical
department and the central processing department to reduce and destroy microbes
and prevent cross contamination or risk to the patient.

Ruth A. LeTexier, RN, BSN, PHN, is the director of surgical technology at
Northwest Technical College in East Grand Forks, Minn.