Reprocessing Specialty Instruments

June 1, 2000

Inside Central Sterile

Reprocessing Specialty Instruments

by Natalie Lind, CRCST, CCSMC, ACE

During the sort process, the technician should disassemble the
instrument and disconnect any disposable parts that may remain with the instrument.

Anyone who is involved in reprocessing surgical instruments knows just how important
that process is to the healthcare facility. Improperly processed instruments pose a
significant threat to patient outcomes. Failure to process instruments correctly can lead
to nosocomial infections and possible patient injuries from damaged instruments. For that
reason, instrument reprocessing is one of the most important tasks that takes place within
the central sterile department.

While patient safety is the primary reason for the emphasis on proper processing
techniques, there are also strong financial considerations. Instruments represent a large
financial investment to any healthcare facility, and the goal of every processing
department must be to prolong the life of each instrument by ensuring that it receives the
proper treatment during each step of its reprocessing.

For these reasons, departments constantly strive to develop instrument processing
systems that protect both their patient and the facility's investment. For these systems
to be effective, all employees must know the correct way to process every instrument. That
is no easy task. New instruments are being introduced on a regular basis and as technology
advances, the complexity of the instruments advances as well. The only way to keep up with
processing requirements for complex instruments is to establish a system that specifically
addresses each phase of reprocessing and the steps required for it to be successful.

Ideally, reprocessing considerations should be addressed before an instrument is
selected and purchased. Part of the overall purchase decision should be the instrument's
cleaning and sterilization requirements and the ability of the facility to meet those
requirements. In some instances, instruments may be needed that "challenge" the
facility's cleaning and sterilization capabilities. Whenever those situations arise, the
facility must be prepared to allocate adequate resources to ensure that the instrument is
processed correctly.

Once a decision has been made and an instrument has been purchased, a written plan
should be developed that addresses the instrument's cleaning requirements. The plan should
follow the manufacturer's recommendations for cleaning and should also incorporate basic
scientific principles of cleaning and instrument handling. The plan should incorporate
cleaning methods available at the facility, for example, mechanical washers, etc. when
appropriate. This cleaning plan should also take into account the product's compatibility
with chemicals used in the process and address any temperature or moisture considerations
that may cause damage to the instrument.

Developing a processing plan before an instrument is put into use will eliminate
confusion, reduce the chance of processing errors, and identify any processing limitations
before the instrument is used. This processing plan can then be used as a training tool
for technicians who will be responsible for cleaning the instrument.

Technicians assigned to the decontamination area are often anxious about the specialty
instruments that they are responsible for cleaning. Oftentimes, they are told how
expensive the instrument is, how it is a one of a kind instrument, or how delicate it is.
With this introduction, it is no wonder that many technicians shy away from cleaning
specialty instruments and may want to leave them for another shift, etc. In their
hesitancy to damage the instrument, employees may even fail to clean it thoroughly. The
best way to ensure that technicians feel confident about cleaning specialty instruments is
to create clear, concise, step-by-step directions for each instrument. This task need not
be overwhelming and is well worth the effort to protect both patients and the facility's

Rather than refer to the task at hand as a decontamination process, it might be better
to break the basic decontamination process down into smaller steps. Decontamination can be
defined as cleaning plus a biocidal process. So, a good reprocessing procedure should
begin by breaking the large task into several smaller ones. For example, the basic
cleaning process can be broken down into six basic steps: sort, soak, wash, rinse, rinse
with special rinse water, and dry. These basic steps can apply to cleaning almost every
specialty instrument.

Sort: During the sort process, the technician should
disassemble the instrument and disconnect any disposable parts that may remain with the
instrument. This phase should also include a separation of items that require special
processing. For example, the separation of immersible from non-immersible items, etc. When
the sort process is complete, the instrument should be reduced to its simplest components.
At that point, it is ready for processing.

Soak: The soak process is designed to loosen and remove gross
soil. It may actually be a soak process, or it may simply be the removal of gross soil
with a cleaning cloth or a rinse process. The goal should be to remove excessive soil that
may impede the cleaning process.

Wash: Washing is the physical removal of soil. This process may
be accomplished manually or mechanically. The goal should be to remove both visible and
invisible soil and to reduce the bioburden of the instrument to the lowest level possible.
By lowering the instrument's bioburden, technicians increase the chance that the upcoming
biocidal process will be successful.

Rinse: The rinse process is designed primarily to flush away
soil particles and detergent from the item being cleaned. The presence of either soil or
detergent residue will impede the biocidal process.

Special Rinse: Many facilities use a special rinse to prevent
deposits from forming on instruments. This special rinse can increase the effectiveness of
upcoming processes and in some instances, may prolong the life of the instrument.

Dry: The dry phase of the basic cleaning process is often
overlooked, but it is an important part of cleaning. Failure to dry an instrument
thoroughly may impede the sterilization or disinfection process that is to follow.

By using this well known cleaning formula, facilities can design instrument cleaning
procedures that provide good information that is easy to read and follow.

The next step in decontamination is a biocidal process. Even if the instrument is
slated for a future sterilization process, this step is imperative. This biocidal process
helps to lower the bioburden of the instrument, thereby increasing the chances that the
sterilization process will be successful. It also makes the instrument safe to handle so
that the risk of pathogen exposure is reduced for the instrument assembly technicians.
Another important part of this process should be to explain why each step in the
decontamination procedure is important. People are more likely to follow procedures
closely if they understand the importance of each specific step. The goal should be
simple: to create a cleaning procedure that makes sense.

This same approach can be used to establish protocols for disinfection and
sterilization processes. Specific guidelines for chemical and temperature compatibility
should be established. Simple, step by step instructions for instrument preparation should
be developed. These guidelines should address the following:

Inspection: What process is used to inspect the instrument?
Should it be tested? If so, how is that testing performed, and how often should it be

Assembly: What components are included in the set? What type of
tray or pack should it be placed in? How should the instrument be placed within the set to
facilitate the sterilization process?

Packaging: What type of packaging should be used? How should
the package be labeled? Are special instructions needed?

Sterilization: What method of sterilization is used? Are there
any special processing requirements?

Storage and Distribution: What should be done with the
instrument after processing? Will it be stored in CS? If so, what is the exact storage
location? Or will it be delivered directly to the user unit? Specialty instruments are
often one of a kind and are almost always very expensive. For those reasons, it is
important to keep close track of the whereabouts of specialty instruments at all times.

Once a specialty instrument's reprocessing protocols have been established, the next
step is to communicate them to employees. This process should start by providing a copy of
the newly-written processing procedures to the staff. Many departments use processing
books or computer data bases to keep this information readily accessible to staff.

The next step is to provide training. There are many ways to accomplish this training
from staff inservices to individual or small group demonstrations. Whatever the chosen
method of training, the goal should be to provide a simple, easy to follow, breakdown of
tasks. By breaking down the large task into smaller ones, it creates a more manageable
process for everyone.

Many companies will provide processing education for their specialty instruments. For
example, they may provide literature, videotape education programs, or they may provide a
representative that will come out to inservice the staff. Requests for this type of
support should be included in the initial purchase agreement.

After the initial staff training is accomplished, training resources should be
cataloged and maintained for use as new employees enter the system. Taking the time to
develop a specialty instrument training library can help alleviate future processing
problems. As medical technology increases, the number of specialty instruments will also
increase. Complex instruments will become an even greater part of every reprocessing
system. As this takes place it is important to remember some important guidelines.

Develop Solid Processes: Use sound infection control theory and
basic foundations of decontamination and sterilization to build procedures that protect
the patient, employees, and the instrument.

Provide Adequate Training: Provide adequate training when a new
specialty instrument is introduced into the system and provide ongoing training as new
technicians enter the workforce to ensure that reprocessing standards are met.

There are No Shortcuts: Complex instruments require more time
to process and the staff members assigned to specialty instrument reprocessing will
require more training than they do for simple instrument processing. As technology
increases, adequate resources must be allocated to meet the needs that these instruments

Specialty instruments serve patients and healthcare providers by allowing advanced
technology to play a greater role in healthcare. Their use will increase in the future.
Specialty instruments pose a challenge to reprocessing departments as they strive to keep
up with change and meet the demands of new processing protocols. By taking the time to
develop a system that addresses these protocols, departments can better prepare themselves
to meet their patients' needs and to protect their facility's financial investment.

Natalie Lind, CRCST, CCSMC, ACE, is the Director of the Health Systems Processing
Programs at Northwest Technical College (East Grand Forks and Moorhead, Minn).

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