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.