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by Natalie Lind, CRCST, CCSMC, ACE
Anyone who is involved in reprocessing surgical instruments knows just how importantthat process is to the healthcare facility. Improperly processed instruments pose asignificant threat to patient outcomes. Failure to process instruments correctly can leadto nosocomial infections and possible patient injuries from damaged instruments. For thatreason, instrument reprocessing is one of the most important tasks that takes place withinthe central sterile department.
While patient safety is the primary reason for the emphasis on proper processingtechniques, there are also strong financial considerations. Instruments represent a largefinancial investment to any healthcare facility, and the goal of every processingdepartment must be to prolong the life of each instrument by ensuring that it receives theproper treatment during each step of its reprocessing.
For these reasons, departments constantly strive to develop instrument processingsystems that protect both their patient and the facility's investment. For these systemsto be effective, all employees must know the correct way to process every instrument. Thatis no easy task. New instruments are being introduced on a regular basis and as technologyadvances, the complexity of the instruments advances as well. The only way to keep up withprocessing requirements for complex instruments is to establish a system that specificallyaddresses each phase of reprocessing and the steps required for it to be successful.
Ideally, reprocessing considerations should be addressed before an instrument isselected and purchased. Part of the overall purchase decision should be the instrument'scleaning and sterilization requirements and the ability of the facility to meet thoserequirements. In some instances, instruments may be needed that "challenge" thefacility's cleaning and sterilization capabilities. Whenever those situations arise, thefacility must be prepared to allocate adequate resources to ensure that the instrument isprocessed correctly.
Once a decision has been made and an instrument has been purchased, a written planshould be developed that addresses the instrument's cleaning requirements. The plan shouldfollow the manufacturer's recommendations for cleaning and should also incorporate basicscientific principles of cleaning and instrument handling. The plan should incorporatecleaning methods available at the facility, for example, mechanical washers, etc. whenappropriate. This cleaning plan should also take into account the product's compatibilitywith chemicals used in the process and address any temperature or moisture considerationsthat may cause damage to the instrument.
Developing a processing plan before an instrument is put into use will eliminateconfusion, reduce the chance of processing errors, and identify any processing limitationsbefore the instrument is used. This processing plan can then be used as a training toolfor technicians who will be responsible for cleaning the instrument.
Technicians assigned to the decontamination area are often anxious about the specialtyinstruments that they are responsible for cleaning. Oftentimes, they are told howexpensive 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 cleaningspecialty instruments and may want to leave them for another shift, etc. In theirhesitancy to damage the instrument, employees may even fail to clean it thoroughly. Thebest way to ensure that technicians feel confident about cleaning specialty instruments isto create clear, concise, step-by-step directions for each instrument. This task need notbe overwhelming and is well worth the effort to protect both patients and the facility'sinvestment.
Rather than refer to the task at hand as a decontamination process, it might be betterto break the basic decontamination process down into smaller steps. Decontamination can bedefined as cleaning plus a biocidal process. So, a good reprocessing procedure shouldbegin by breaking the large task into several smaller ones. For example, the basiccleaning process can be broken down into six basic steps: sort, soak, wash, rinse, rinsewith special rinse water, and dry. These basic steps can apply to cleaning almost everyspecialty instrument.
Sort: During the sort process, the technician shoulddisassemble the instrument and disconnect any disposable parts that may remain with theinstrument. This phase should also include a separation of items that require specialprocessing. For example, the separation of immersible from non-immersible items, etc. Whenthe 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 grosssoil. It may actually be a soak process, or it may simply be the removal of gross soilwith a cleaning cloth or a rinse process. The goal should be to remove excessive soil thatmay impede the cleaning process.
Wash: Washing is the physical removal of soil. This process maybe accomplished manually or mechanically. The goal should be to remove both visible andinvisible 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 upcomingbiocidal process will be successful.
Rinse: The rinse process is designed primarily to flush awaysoil particles and detergent from the item being cleaned. The presence of either soil ordetergent residue will impede the biocidal process.
Special Rinse: Many facilities use a special rinse to preventdeposits from forming on instruments. This special rinse can increase the effectiveness ofupcoming processes and in some instances, may prolong the life of the instrument.
Dry: The dry phase of the basic cleaning process is oftenoverlooked, but it is an important part of cleaning. Failure to dry an instrumentthoroughly may impede the sterilization or disinfection process that is to follow.
By using this well known cleaning formula, facilities can design instrument cleaningprocedures that provide good information that is easy to read and follow.
The next step in decontamination is a biocidal process. Even if the instrument isslated for a future sterilization process, this step is imperative. This biocidal processhelps to lower the bioburden of the instrument, thereby increasing the chances that thesterilization process will be successful. It also makes the instrument safe to handle sothat 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 thedecontamination procedure is important. People are more likely to follow proceduresclosely if they understand the importance of each specific step. The goal should besimple: to create a cleaning procedure that makes sense.
This same approach can be used to establish protocols for disinfection andsterilization processes. Specific guidelines for chemical and temperature compatibilityshould be established. Simple, step by step instructions for instrument preparation shouldbe 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 bedone?
Assembly: What components are included in the set? What type oftray or pack should it be placed in? How should the instrument be placed within the set tofacilitate the sterilization process?
Packaging: What type of packaging should be used? How shouldthe package be labeled? Are special instructions needed?
Sterilization: What method of sterilization is used? Are thereany special processing requirements?
Storage and Distribution: What should be done with theinstrument after processing? Will it be stored in CS? If so, what is the exact storagelocation? Or will it be delivered directly to the user unit? Specialty instruments areoften one of a kind and are almost always very expensive. For those reasons, it isimportant to keep close track of the whereabouts of specialty instruments at all times.
Once a specialty instrument's reprocessing protocols have been established, the nextstep is to communicate them to employees. This process should start by providing a copy ofthe newly-written processing procedures to the staff. Many departments use processingbooks 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 trainingfrom staff inservices to individual or small group demonstrations. Whatever the chosenmethod of training, the goal should be to provide a simple, easy to follow, breakdown oftasks. By breaking down the large task into smaller ones, it creates a more manageableprocess for everyone.
Many companies will provide processing education for their specialty instruments. Forexample, they may provide literature, videotape education programs, or they may provide arepresentative that will come out to inservice the staff. Requests for this type ofsupport should be included in the initial purchase agreement.
After the initial staff training is accomplished, training resources should becataloged and maintained for use as new employees enter the system. Taking the time todevelop a specialty instrument training library can help alleviate future processingproblems. As medical technology increases, the number of specialty instruments will alsoincrease. Complex instruments will become an even greater part of every reprocessingsystem. As this takes place it is important to remember some important guidelines.
Develop Solid Processes: Use sound infection control theory andbasic foundations of decontamination and sterilization to build procedures that protectthe patient, employees, and the instrument.
Provide Adequate Training: Provide adequate training when a newspecialty instrument is introduced into the system and provide ongoing training as newtechnicians enter the workforce to ensure that reprocessing standards are met.
There are No Shortcuts: Complex instruments require more timeto process and the staff members assigned to specialty instrument reprocessing willrequire more training than they do for simple instrument processing. As technologyincreases, adequate resources must be allocated to meet the needs that these instrumentscreate.
Specialty instruments serve patients and healthcare providers by allowing advancedtechnology 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 keepup with change and meet the demands of new processing protocols. By taking the time todevelop a system that addresses these protocols, departments can better prepare themselvesto meet their patients' needs and to protect their facility's financial investment.
Natalie Lind, CRCST, CCSMC, ACE, is the Director of the Health Systems ProcessingPrograms at Northwest Technical College (East Grand Forks and Moorhead, Minn).
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