Achieving a consistent level of performance

by Sanat Mohanty

According to a 2008 report by the Centers for Disease Control and Prevention (CDC), there are more than 46 million surgical procedures performed each year, including approximately five million gastrointestinal endoscopies. Consider the number of surgical instruments used and it becomes clear they are a major investment for healthcare providers.

Instrumentation also is a primary front for infection prevention because instruments come into contact with body fluids and other matter that could potentially introduce or transmit pathogens to patients. Proper cleaning, handling, sterilization and storage of surgical instrumentation not only protects facilities’ investments in instrumentation but also helps ensure patient safety.

However, the wide variety of biological soils and the complicated configuration of surgical instruments can make cleaning a challenge. Blood, fat, mucus and other soils become trapped in serrated surfaces, hinges and on other surfaces, and can be particularly difficult to remove when dried on instruments. Blood contains chlorides and extended contact with instrumentation can result in corrosion of stainless steel. To prevent this, instruments should be processed as soon as possible to help reduce the risk of damage. Solving this issue requires a combined program consisting of mechanical and chemical treatments that includes the right products and equipment suited to the individual facility’s needs. Training also is critical to make sure that staff is following best practices for instrument cleaning and using products to their best effect.

Evaluating the Current Decontamination Process

A good first step before implementing any changes is to conduct a baseline study to identify areas where the sterile processing department is succeeding and where it is struggling. In many cases, issues such as persistent soils are a result of several factors from pre-cleaning to automated washing so it is important to be thorough.

The baseline evaluation should measure environmental factors that could inadvertently impact the performance of the cleaning chemistry and equipment as well as gaps in handling and procedure. Within automated washers, water quality, hardness, pH and temperature can all affect the way detergents and equipment work. For example, minerals in hard water can clog spray heads. In addition, if water temperatures are set too high, they could be hardening remaining protein-based soils onto instrumentation surfaces rather than dissolving them.

Selecting the Right Cleaning Products

There are a wide variety of chemical treatments available today that are designed to remove organic soils from the surface of surgical instruments including several types of enzymatic cleaners. Enzymatic detergents are very effective at removing organic matter because of their ability to speed up chemical reactions. They are suited for this application because they begin working to digest biological soils such as blood, fibrin, mucus, oils and fats, on contact.

Enzymes are specific in terms of the type of soil they remove, so consider the most prevalent types of soils on instruments when evaluating detergent formulations. Products formulated with high levels of protease are particularly well suited for instrument reprocessing because of their ability to act on protein-based soils.

Enzymatic detergent formulations also work best under certain environmental conditions such as specific temperature ranges, pH levels and washer settings, and in combination with other chemical ingredients. Each enzyme type has an optimal temperature at which its catalytic activity is at its greatest. Wash temperatures that are too high for a specific enzyme can disable its ability to cause a reaction, while wash temperatures that are too low also reduce cleaning ability. In general, the products that perform best contain relatively high and stable enzyme levels and have been engineered to work at specific temperature ranges.

Establishing Standard Practices and Training

Ensuring that staff are following standard procedures based on best practices from the Association for the Advancement of Medical Instrumentation (AAMI) and using products correctly is as important as the equipment and products being used. To help facilitate this, consider what can be implemented to make it easier for a procedure to be consistently followed:

• Add regular training and evaluation sessions—Though new staff members are trained when they are first hired, best practices bear repeating so people remember to follow the proper process. Enlist experienced staff members to support training by referencing their personal experiences, for example if they have ever had to rewash instrumentation numerous times because they skipped a portion of the manual washing. Also review material data safety sheets with staff so that they are aware of proper handling, usage, potential hazards, first aid measures, personal protective equipment that should be worn and storage of the chemistries they are using.
• Post visual reminders—Reinforce proper cleaning processes by posting step-by-step cards near the appropriate work area.
• Install automatic chemistry dispensers—The benefit of automating product dispensing is that it helps ensure the correct dilution rate and product mix. Using too little product can result in poor performance while using too much can lead to waste. Consult with your supplier to ask if they offer an automated chemistry dispensing system.
• Create stations for specific processes—Create designated work areas for specific processes like manual cleaning to help streamline the workflow in SPD. If there is enough space, consider dedicating sections so that staff are able to perform the proper procedures without having to move from work surface to work surface.

In instrument reprocessing, as in any department, there are no magic bullets that can solve every issue. However, taking a comprehensive approach that includes understanding the department’s current processes, water quality and soil types to determine the best solution, sterile processing can improve outcomes with improved products, processes and training to achieve a consistent level of performance.

Sanat Mohanty is a senior program leader at Ecolab Healthcare working on instrument reprocessing technologies. He holds a PhD in Chemical Engineering. He can be reached at sanat.mohanty@ecolab.com.