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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 secretionson surgical instruments can result in retained microorganisms representingbioburden. The use of saline as a rinse agent can cause deterioration of theinstrument surfaces. Sterile water should be used to irrigate and keepinstruments free of gross soil. Corrosion, rusting and pitting occur when bloodand other debris are allowed to dry on the surgical instruments. Instrumentsthat are cannulated or have lumens can become obstructed with organic material.
Ideally, the initial cleaning of instruments should begin immediatelyfollowing the completion of the surgical procedure. This initial step isintended to occur wherever the surgical procedure is performed. When surgicaland other invasive procedures are occurring in multiple locations in ahealthcare facility, how is the central sterile (CS) processing manager able toensure that the process is consistent?
In the assessment and evaluation of work practices, it is common to findmultiple methods of instrument decontamination. For example, using washersterilizers in operating rooms is sometimes the first step in instrumentcleaning. In reality, instruments subjected to a washer sterilizer without firstbeing rinsed and the gross soiling removed, have baked-on protein at thecompletion of the cycle. When these instruments arrive in the CS department forinspection and assembly, they must be cleaned again -- a much more difficulttask the second time around.
This is the situation we faced in a recent assessment and reorganization ofwork practices. The hospital owned two washer disinfectors; one was located inthe CS department and the other was outside of the surgical suite in a soiledutility room. The operating room (OR) staff was using the washer sterilizers inthe sub-sterile areas to decontaminate instruments after use. The washerdisinfector in the surgical suite was unused since its location was not readilyaccessible to OR personnel. OR personnel believed they were attaining the samestandard by using washer sterilizers rather than the washer disinfector. Thepractice of nursing personnel decontaminating instrumentation at the completionof the surgical procedure also impacted room turnover and throughput in the OR.
Our initial plan was to move the washer disinfector from the OR suitelocation to the decontamination area of the CS. This proposal required costlyfunding for architectural and utility changes and would have delayed the changein process. Our second proposal involved leaving the washer decontaminator inits location and developing process changes for post case instrument management.We developed an action plan that outlined the steps in the process changes wewere proposing:
1. Form a group consisting of CS and OR personnel who perform instrumentmanagement functions.
2. Assess the current situation to determine how instruments are handled atthe 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 currentprocess.
4. Discuss the differences between washer sterilizers and washerdisinfectors.
5. Evaluate the traffic and logistics of transporting contaminatedinstruments from the surgical suite to the soiled utility room where the washerdisinfector is located.
6. Assess the conditions of "confine and contain." Determine howinstruments are confined at the point of use in order to be transferred to theplace 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 staffedand determine the human resources needed.
10. Develop procedure for immediate post-case handling of surgicalinstrumentation.
11. Develop the assignment responsibilities for CS personnel performing ORdecontamination.
12. Communicate the plan to each group of departmental personnel and addresstheir concerns, such as immediate turnover needs and instrument inventorylimitations.
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 processin the OR suite from 9 a.m. to 7 p.m. Monday through Friday. The CS department'sstaffing plan was adjusted to provide a designated individual for thisassignment and training was provided regarding instruments that could toleratemoisture and heat versus those requiring manual cleaning. The soiled utilityroom, where the washer disinfector is located, was stocked with personalprotective equipment (PPE). Closed carts previously used to transport cleaninstruments to central sterile were re-designated as "soiled instrumentcarts" and placed in sub-sterile areas. At the completion of the surgicalprocedure, the scrubbed person was asked to:
1. Remove the gross soil from the instruments using a sponge moistened withsterile 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 ontop.
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 anenzyme spray.
9. Place the soiled instruments in the closed cart in the substerile area forpick-up by CS personnel.
Documenting this process and sharing it with OR and CS personnel ensured thatthe 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; areduction in the rework of cleaning instruments with baked-on protein; a fasterturn-around of instrument sets for reuse by OR personnel; a reduction in ORturnover time; and reduced instrument breakage and repairs.
Susan Bisol, RN, MSN, CNOR, is a senior consultant for Cardinal HealthConsulting Services, specializing in perioperative management. Rodd Bogue, CST,is the central sterile processing department manager at St. Charles Hospital inPort Jefferson, N.Y.