Cleaning Surgical Instruments & Minimizing the Risk of Infection
What is being done to minimize the risk of using dirty or unsterile surgical instruments? The sophistication of surgical instruments has increased over the years, and as a result, hospitals must take a closer look at the efficiency of their sterile processing department (SPD). Typically, the more sophisticated the instrument, the more extensive the cleaning and sterilization process. Proper cleaning of surgical instruments is not a straightforward task; rather, it is a more complicated process involving multiple parties.
How does this impact healthcare organizations, surgical staff, and patients?
Regularly auditing current systems and processes related to cleaning surgical instruments is critical to patient safety. There is a clear rise in nationally reported incidents where improperly cleaned instruments were used on multiple patients, exposing them to the risk of a surgical site infection (SSI).
Cleaning Surgical Instruments
Not only does improper cleaning and disinfection of surgical instruments impact patient safety, but it also puts healthcare organizations at great financial risk. While there are many steps that can be taken to reduce such risk, below are three main points to consider implementing.
1. Ensure errors are reported. The focus to date has been on SPD decontamination practices and not necessarily the proper reporting on errors made in the department.
2. Effective cleaning of instruments at point of use (POU). This has proven to be a key component of ensuring instruments are successfully cleaned in SPD. Removing debris or fluid before it dries on the surface of the surgical instrument can improve the effectiveness of cleaning. Point-of-use cleaning practices ensure that bioburden is reduced, which supports:
● Reduction in microorganisms ● Increased longevity of instruments ● Faster processing turnaround
3. Comprehensive training for surgical staff. Very little detail has been published on the point-of-use actions and competencies for surgical techs to follow.
According to a 2015 survey from the New England Journal of Medicine,“4,614 patients (37.5%) met the criterion for review of healthcare-associated infection by receiving antimicrobial agents for the treatment of an infection or receiving antimicrobial agents for which the rationale was not documented. This percentage was lower than that of patients who met the same review criterion in the 2011 survey (39.9%, P<0.001).”
While the 2015 survey reported fewer patients with infection, every day, there are emerging cases of patients with a healthcare-associated infection. The CDC reports about one in 31 hospital patients have at least one associated infection on any given day.
The Importance of Cleaning Surgical Instruments & Defined Responsibility in the SPD
It is critical that healthcare organizations stay current with guidelines and best practices for proper decontamination, especially as industry dynamics, governance, and technology swiftly evolve. From referencing operational manuals to purchasing the right equipment for your SPD, leaders must recognize their department is crucial to the success of the OR. Healthcare organizations must also acknowledge the need for regular audits in order to prevent infections, provide quality patient care, and reduce operational costs.
Best Approaches: Cleaning Surgical Instruments at the Point of Use
If allowed to dry, blood, bodily fluids, and saline can damage surgical instruments. It can also be increasingly difficult to decontaminate the instruments effectively and to remove dried debris or fluid on a surgical instrument, which is why cleaning at the site of use is paramount. Cleaning surgical instruments and spraying before transport is also a crucial step in preventing infection, but there are additional best practices surgical staff should follow.
1. Wipe surgical instruments down during the surgical procedure as needed with sterile sponges and sterile water. 2. Ensure sharp instruments are separated from other instruments. 3. Never place heavier surgical instruments on top of more delicate instruments. 4. Instruments with multiple parts should be disassembled and arranged in an organized way, and care should be taken to keep the set together. 5. Microsurgical instruments should be kept in separate containers from other instruments to prevent damage. 6. Instruments should be moistened and covered with a towel if there is a delay in the start time.
Immediate-Use Steam Sterilization (IUSS) Recommendations
The Association for the Advancement of Medical Instrumentation (AAMI) recommends immediate-use steam sterilization of surgical items be considered only if all the following conditions are met:
1. Duties ensure proper cleaning, decontamination, inspection, and arrangement of surgical instruments into the sterilizing trays or other containment devices before sterilization. 2. The physical layout of the department ensures the direct delivery of sterilized items to the point of use. 3. Standard operating procedures are developed, followed, and reviewed regularly to ensure aseptic handling and personnel safety during the transfer of the sterilized items from the sterilizer to the point of use. 4. The surgical item is needed for use immediately after flash sterilization.
Support for Cleaning at the Point of Use
Proper point-of-use care of instrumentation is supported by both the Association of periOperative Registered Nurses (AORN) and the Association of Surgical Technologists (AST) who have both published protocols reflecting the standards and recommended practices as published in the AAMI ST-79, section 6.3.
Keeping Surgical Instruments Clean—It’s Everybody’s Responsibility!
Cleaning surgical instruments properly is a joint effort. As stated by the Pennsylvania Patient Safety Advisory, “The operating room and its patients depend on the reprocessing department; operating room services cannot exist without an adequate flow of quality surgical instruments and equipment. Efforts can be considered to unify departments and processes around the care and maintenance of mission-critical items, such as surgical instruments, devices, and equipment.”
Surgical instruments come in all shapes and sizes, making them increasingly difficult to adequately disinfect and sanitize. Failing to follow manufacturer guidelines for sterile processing standards can result in infections, financial loss, and harm to patients. It takes both OR and SPD actions to control and prevent hospital-associated infections.
Randy Heiser is the President of Sullivan Healthcare Consulting. Randy has been a hospital consultant since 1983 and has specialized in perioperative consulting since 1992. He has directed more than 500 surgery department operational improvement studies (and participated in an additional 350) in programs ranging from small community hospitals and freestanding surgery centers to some of the largest university hospitals in the U.S. He was instrumental in the design, development and implementation of the Surgery Benchmark Program that has been used by more than 280 hospitals. He has also participated in the design of several proprietary surgery scheduling information systems currently available in North America.