Cleaning Starts in the OR

Why the OR Must Moisten All Instruments Immediately After Use The single biggest problem facing personnel in the decontamination area is receiving surgical instruments from the OR that have dried blood and organic debris on them. Trying to remove dried blood and organic debris from instruments is a huge challenge to reprocessing personnel. Organic debris and dried blood that remains on an instrument after reprocessing can be the source of a surgical infection. Recently, The Joint Commission (TJC) has started to take a hard look at the problem of O.R. staffs not soaking or spraying surgical instruments after use. To help combat this problem, when conducting their audits, TJC has started has started citing facilities for failing to start the instrument pre-cleaning process in the OR, after use and prior to transport. The issue of the OR staff not soaking or spraying instruments with an enzymatic detergent immediately after use (and certainly prior to transport) was a major topic of discussion earlier this month in the AAMI Member Discussion Group. The discussion concerning the lack of pre-cleaning in the OR started with a question from Helen asking if there are any publications or standards to cite when dealing with surgical techs who do not want to spray or soak instruments in the OR. ¹ Far too many CS/SPD managers and supervisors face the same problem in their facility as Helen does in her facility.  Getting the OR staff to buy into the need to begin the instrument pre-cleaning process at point-of-use in the OR is not an easy task. The AAMI member responses to Helen’s question are most informative and will give you some key points to use to help convince your OR team members to start to pre-clean instruments. In response to Helen, Kimberly said “You can reference section 6.3 thru 6.4 in AAMI ST79 (2017) that discusses point of use care of instruments. Similar information is also discussed in AORN's Guideline for Cleaning and Care of Surgical Instruments. What both references discuss is keeping the instruments moist after point of use cleaning is complete and until decontamination begins in SPD. This is to prevent the drying of debris on the instruments, making them more difficult to clean and to prevent the formation of biofilm. TJC is now scoring on whether the instruments are cleaned at the point of use - which can mean at the back table in the OR - and kept moist until decontamination begins. TJC is looking to see if you have a policy describing those actions and if you follow it. IAHCSMM also supports this position. AST has a standard of practice for decontamination of surgical instruments that also discusses point of use cleaning. Bottom line: if you aren't cleaning your instruments at point of use and using some standardized method per your policy to keep them moist until the decontamination process begins, then you can most definitely (and probably will) be cited by TJC when the time comes.” Kimberly² According to TJC’s website:

• Pre-cleaning applies to surgical instruments, devices and supplies that, based on manufacturer instructions for use (IFU), are intended to be reprocessed (meaning they are not single-use disposable items).
• When there are delays in the cleaning/decontamination reprocessing steps, gross soil should be removed at the point of use.
• Pre-cleaning at the point of use is required when soiled items cannot be immediately contained and transported to a decontamination area or soiled utility area. “Immediately” is described as “without delay.”
• Pre-cleaning at the point of use requires that visible bioburden is removed from the instruments prior to transport to a decontamination area where pre-cleaning or preparation for transport to a reprocessing area occurs.
• If a product is selected for pre-cleaning purposes, compliance should be based on the manufacturer’s IFU.
• When there are delays in instruments reaching decontamination in CS, items must be pre-cleaned and remain moist while awaiting transport to decontamination.
• Use of a pre-cleaning product or other acceptable method to keep instruments moist applies when there are delays in transporting instruments. ³

TJC’s website also states that if a healthcare facility selects a product for keeping instruments moist, then the facility should follow the manufacturer’s IFU. If for example the manufacturer’s IFU states that hinged instruments are to be in the open position, then TJC surveyors will cite the facility if this practice is not being consistently followed. ⁴ The need for the OR to moisten and pre-clean all instruments immediately after use is no longer just a suggestion. As the AAMI Member Discussion Group exchange points out, and TJC website confirms, TJC is now citing facilities that do not begin pre-cleaning surgical instruments at point-of-use (i.e., the back table in the OR). Not only is a lack of pre-cleaning a potential citation issue with TJC, more importantly, it is an issue for patient safety in your facility as well as for the longevity of the instruments.

1. AAMI Members Discussion Group Digest for Tuesday July 2, 2019
2. AAMI Members Discussion Group Digest for Wednesday July 8, 2019
3. https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=1552
4. Cite.