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

Optimum Cleaning and Disinfection of Surgical Instruments

By Ruth A. LeTexier, RN, BSN, PHN

Surgicalinstruments are used every day in the perioperative setting. The surgeon selectsspecific tools to perform intricate maneuvers in order to accomplish optimalpatient outcome. Part of this outcome is based upon the assumption that allinstruments used for surgical intervention are precisely cleaned ordecontaminated in preparation for the sterilization process to prevent infectionor harm to the patient.

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

Without adequate cleaning, many disinfection and sterilization processes areineffective.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 visibledirt, soil, organic matter or other foreign material from an instrument orobject. 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 contaminantsare removed, using specific solutions designed to render the blood and organicdebris harmless, then a process such as disinfection or sterilization will killmicroorganisms to render items safe to handle. To be most effective,decontamination must occur as soon as possible following the use of the surgicalinstruments.

Some institutions support the idea of an enzymatic detergent added to thewater in a splash basin to begin the breakdown of organic debris as a presoakmethod. One expert in the field of sterilization and processing does not supportthe 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, whichlead to corrosion, from being left to dry on the instrument.

The majority of surgical instruments are made from stainless steel. Thealloys have specific properties that make them resistant to corrosion whenexposed to blood, body fluids, cleaning solutions, sterilization and theatmosphere. 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 andtools are exposed on a daily basis. Blood, tissue, body fluid residue, synovialfluid, peritoneal fluid, fat, pus, bile, urine and gastric acids all contributeto pitting, staining and discoloration of the surgical instruments. Otherenemies include washing instruments with inappropriate solutions such as dish orlaundry soap, bleach (sodium hypochlorite), disinfectants and non-approvedsolutions, all of which contribute to metal corrosion.

Once surgical instruments have entered the central sterile (CS) processingarea and are sorted, they may be cleaned manually or mechanically. Types ofmechanical cleaners include the ultrasonic cleaner, the washer-decontaminator,the washer-sterilizer and the washer-disinfector. With the exception of theultrasonic cleaner, all may be used to remove debris from the instruments andrender them safe for handling but not for immediate reuse. It is thedisinfection process that eliminates many or all pathogenic microorganisms, withthe 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 removedbefore processing by high-level disinfection or sterilization. Surgicalinstruments are classified as critical items in that they present a high risk ofinfection to the patient if contaminated with microorganisms, includingbacterial spores. Sterilization is required for critical items.²

To minimize organic build-up or reduce bioburden on the instruments, bestpractices in the perioperative setting would include keeping the instruments asfree as possible of blood and organic debris during the surgical procedure.Association of periOperative Registered Nurses (AORN) recommended practices forcare and cleaning of surgical instruments dictate that instruments should bekept 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 withmeticulous methods of cleaning and disinfection, ensures patient safety for allsurgical interventions. It is a shared responsibility between the surgicaldepartment and the central processing department to reduce and destroy microbesand prevent cross contamination or risk to the patient.

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