Pre-Cleaning: Part III

The Importance of Pre-Cleaning Instruments in the O.R. (Part III) Over the past year there has been increased emphasis and attention placed on pre-cleaning surgical instruments in the O.R. prior to transport to sterile reprocessing. In Part I and Part II of this series, we explored some of the factors driving this new, increased attention and emphasis on pre-cleaning surgical instruments at the point-of-use.  As we pointed out, this new emphasis is coming from many sources and organizations, including the Joint Commission. A recent post on AAMI’s member discussion board from an O.R. supervisor stated that after a recent Joint Commission survey, the hospital was told that instruments need to be cleaned at the point of use prior to going to SPD. This particular hospital had a practice of wiping instruments off and covering them with an enzymatic cleaner. However after the survey, per a consultant's recommendation, the hospital is now placing instruments in sterile water and cleaning all bio-burden from them prior to placing them in an enzymatic cleaner for transport to SPD.¹ The emphasis on pre-cleaning is in the Joint Commission’s survey of Ambulatory Surgery Centers (ASC) as well. Interestingly enough, the importance of pre-cleaning of surgical instruments is listed in the Infection Control Surveyor’s worksheet under “Practices to be Assessed.” Specifically, the ASC Joint Commission surveyor needs to determine if “Items are pre-cleaned according to manufacturer’s instructions.”² The Joint Commission’s worksheet on pre-cleaning correctly lists it as an “infection control” issue/problem. This is because the longer blood and organic debris are allowed to dry on an instrument, the greater the difficulty in removing it. Bioburden that remains on an instrument after reprocessing is a source of surgical infections and represents a very real infection control problem/challenge. When blood dries on a hard surface, it turns black in color. When blood dries on the black insulated shaft of a laparoscopic instrument, it becomes nearly impossible to see. When blood dries on the black handle of a surgical instrument, it too becomes practically invisible. Only through timely, complete and thorough pre-cleaning can this problem be eliminated. The Association of Surgical Technologists (AST) has developed a set of standards for the decontamination of surgical instruments. The AST standards emphasize the importance of pre-cleaning surgical instruments at the point-of-use. They recommend that: “The Certified Surgical Technologist (CST) in the first scrub role should keep the instruments free of debris and blood during the surgical procedure.

• The instruments should be wiped clean using a sterile, water-moistened sponge. Care must be taken that the sponge is not used on the tissues of the patient. 
• Instruments with lumens should be flushed with a sterile, water-filled syringe to remove blood and debris and prevent drying of the gross soil.
• Instruments that may not be used for the remainder of procedure (e.g., acetabular reamers used during a total hip arthroplasty) may be placed into a basin containing sterile water to soak.
• Saline must not be used, since the chloride ions can cause pitting and deterioration of the finish on the surface of the instruments.”³

 As we’ve shown in this three-part blog series, the importance of pre-cleaning cannot be overemphasized. Still, no amount of pre-cleaning can overcome the challenges posed by instruments that are difficult, if not impossible, to thoroughly decontaminate and clean, thus becoming the source of a surgical infection. So how do you reduce the risk of disease transmission in your facility from instruments whose cleaning challenges are problematic at best? You start by only using instruments whose cleaning IFUs have been validated by independent laboratory testing utilizing FDA testing protocols to ensure clean, sterile, moisture-free instruments for all of your patients. 1. AAMI Member Discussion Board, August 14, 2018 2. Joint Commissions Ambulatory Surgical Center (ASC) Infection Control Surveyor Worksheet (Rev: 142, Issued: 07-17-15) 3. “Standards of Practice for the Decontamination of Surgical Instruments” Association of   Surgical Technologists (AST) April 2009