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There’s a rule of thumb that states that you want to start full decontamination
of instruments within an hour of their use. Otherwise, the patient soil tends to become more and more difficult to remove as it coagulates and dehydrates. In a perfect world, instruments would appear at decontam well within that one-hour window and you, the
technician, would be waiting for them with all your other work already done, ready to get them clean.
In the words of Shrek (add Scottish accent), “LIKE THAT WOULD EVER HAPPEN.”
The real world of sterile processing is made up of delayed delivery of
instruments from the points of use, of backups at decontam, of patient soil or “bioburden” dried on the instruments resulting in rework (our instruments are so nice, because we process them twice), etc. Any improvement in this situation is desired and sometimes,
small actions have large, positive impacts on the work that must be done.
According to a
research
article titled, "A proposed cleaning classification system for reusable medical devices to complement the Spaulding classification",
cleaning, defined as the removal of soil to the extent necessary for further processing or for intended use, is essential, and it has been demonstrated repeatedly in the literature that cleaning failures are a root cause of failing decontamination process
of reusable medical devices.
Also, Wilder’s first law of processing, “Every step in the reprocessing
process should ALMOST make the next steps unnecessary.”
And, Wilder’s corollary, “Each cleaning step shall use appropriate measures
to achieve the best results for the cleaning being done at that moment.”
What are the steps?
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Wipe down
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Pretreatment
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Soak
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Brush
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Sonic (if possible)
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Washer disinfector (if possible)
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Disinfect/Sterilize
So, pretreatment. How do you do it and what does it do?
Ideally, any instrument used on a patient should be wiped down with a
clean, lint-free cloth moistened with sterile water at the point of use to remove the grossest of the gross soil on the instrument. Why sterile water? If you somehow create an aerosol, you don’t want it to compromise the sterile field. If far from the sterile
field, you can use critical water.
If you can maintain the instruments in a moist environment, it will take
longer for the patient soil to dry, making it easier to remove the soil when it gets to Decontam. There are a number of ways to do this. One is the time-honored practice of covering the instruments with a moistened towel. This is good while the wetness of
the towel lasts but suffers from lack of contact with the instruments below the top level of the pile in the return tray. So the ones on top stay moist, but the ones below may not stay as moist.
Immersion. Bad idea. You don’t want to be transporting liquid biohazard
from point of use to where the instruments are processed. What if it spills? We don’t want to increase the odds of having “cleanup on aisle three” for biohazard liquids in a healthcare institution. It’s hard enough to ensure that infectious agents are contained
without enabling for this kind of trouble.
So, we come back to pretreatment. This approach provides moisture to
keep the load cleanable and can assist in loosening soil on the instrument due to the formulation of the pretreatment.
How do you use these? You spray the instruments with them. Not just the
top of the pile, but each instrument on both sides of it as after wipe down as it is delivered to the tray for return to sterile processing for its cleaning and disinfection/sterilization.
How do these work? These are sprays. Some contain enzymes, which are
present in the spray to assist in breaking down patient soil in transit from point of use to Decontam. Moisture retention due to the formulation of the pretreatment spray (surfactants, which solubilize the soil, and moisturizing agents/humectants) helps to
keep the soil from coagulating and hardening. This allows subsequent cleaning steps to have less of a challenge and therefore limits the possibility of patient soil/bioburden remaining on the instruments.
Let’s have a look at the different parts of a transport spray and what
they do to accomplish this.
These sprays are generally formulated to be compatible with all materials
you might find in a surgical instrument. This includes aluminum, anodized surfaces, stainless steel and engineering plastics. So there should not be any worry about material compatibility. But it is worth asking the question as to whether the manufacturer
has data to support this claim.
Surfactants are molecules that bind to both polar molecules like water
and non-polar molecules like biological residues. These hold moisture and soil together so that the soil doesn’t dry out and become (more) difficult to remove. Since they bind to water, when you soak the instrument in the first step in decontamination, their
presence makes the otherwise insoluble biological molecules soluble and helps these residues to go into the soak solution and not stay on the instruments. Surfactants are part of the answer to the question as to how you keep the instruments moist.
Humectants are molecules that inhibit the evaporation of water. A simple
example is a film of oil on top of a puddle of water. The water is covered and can’t evaporate. The humectants used in pretreatment sprays are more-sophisticated examples of the same principle, except that they work at a micro level, encapsulating water and
the surfactant/soil mix on a molecular basis.
Enzymes can be your friend or be problematic. Enzymes are biological
molecules that digest specific parts of the soil. Protease digest protein, lipases digest lipids, amylases digest carbohydrates. Typically, enzymes don’t do much to dissolve soil at room temperature, with higher temperatures being required to get a rapid,
effective reaction with the soil. But we are not talking about complete cleaning here. We are talking about helping to break up biological residue/soil en route to Decontam and a fair amount of time to do it. So, yes, enzymes help things along.
But, what could possibly go wrong with enzymatic pretreatment sprays?
Ophthalmic instruments. We don’t want to use enzymes on ophthalmic instruments because of the link to TASS (toxic anterior segment syndrome) in ophthalmic surgery. Non-enzymatic sprays are a must for use in ophthalmic applications. And if you are doing both
ophthalmic and non-ophthalmic procedures, why take a chance on mixing this up at some poor patient’s expense?
It is my hope that this helps you understand the why of using pretreatment
sprays. We have come a long way in product formulation to make them more effective and the viewpoint of the users have changed from 15 years ago, when a nationally-known SPD manager told me that they just create more bioburden. They don’t, and they never did.
They make soil removal easier. And that’s the name of this game.
Jonathan A. Wilder, Ph.D
Managing Director
Quality Processing Resource Group, LLC
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