Proper Sterilization of Instruments is Essential to Patient
Safety
Eileen A. McLachlan, RN, HEM, COHN
APIC Ambulatory Section, 2004 Chair
Kaiser Permanente
E-mail: eileenmclachlan@juno.com
More and more minor surgeries are being performed in ambulatory care
settings, and that means there is a greater need for staff in these
areas to reprocess instruments. Established ambulatory surgery centers
generally have both central sterile supply areas and staff members
trained to properly clean and sterilize instruments. In other ambulatory
care settings, however, there can be confusion about what must be
sterilized and a lack of knowledge about the proper steps required to
appropriately clean and sterilize instruments. Even where tabletop
sterilizers are readily available, there is often confusion about how to
properly maintain and use such equipment.
What follows is a brief discussion of the essential steps for
ensuring patient safety by properly sterilizing instruments. A
competency tool can be found here.
Per E. H. Spaulding's classification scheme, critical items-any
object that enters sterile tissue or the vascular system-must be
sterilized. This includes most surgical instruments used in the
ambulatory setting.
Many steps are required to ensure that instruments are appropriately
sterilized. These include pre-cleaning, cleaning, milking, inspection,
packaging, wrapping, autoclaving and maintaining the autoclave.
Pre-cleaning needs to be done at the point of use to prevent the
drying of organic material. This can be accomplished by either wiping
the instrument with a wet cloth or placing the instrument in an
enzymatic cleaner.
Cleaning includes many steps. Staff should wear appropriate PPE and
follow approved procedures to prevent BBP exposure. They must be sure
all instrument surfaces, including hinges, are scrubbed with an approved
enzymatic cleaner and thoroughly rinsed. If an ultrasonic machine is
used, care should be used to be sure all manufacturers' recommendations
are followed.
Milking: After cleaning, instruments with moveable parts should be
immersed in a milk solution and removed without rinsing. All instruments
should be inspected before wrapping. It is important to ensure that
hinged instruments open easily and that the jaws are properly aligned.
Sharp instruments should be inspected for sharpness. All instruments
should be inspected for cracks, chips or worn spots. Any instruments
found with defects should be removed from service and sent for
repair.
After inspection, instruments should be wrapped in a single pouch of
an appropriate size. All instruments should be in the open position with
any curved tips pointed in the same direction. A steam indicator should
be placed in the center of the pack with one end visible when the pack
is opened. The packet should be secured with steam indicator tape and
labeled with the date of sterilization, the load number and the initials
of the person preparing the package.
Autoclaving should be done following manufacturer's directions,
ensuring that packs are loaded in a manner that allows for free steam
and air circulation. A log should be kept that details each time the
autoclave is run, every time a biological indicator is sent and every
time maintenance is performed. Staff should be able to verbalize the
recall/resterilization procedure in case of failure of the biological
indicator, visible condensation seen in a package, steam indicators that
do not appropriately change color, and package integrity concerns or
compromised storage and handling conditions.
A competency checklist can facilitate teaching and ensure compliance
with these standards. A competency checklist can be found at http://www.apic.org//AM/Template.cfm?Section=Infection_Connection&Template=/CM/ContentDisplay.cfm&ContentFileID=2103.
Since implementation of this checklist, we have seen real improvement
with the cleaning and sterilization process.
Spaulding, E.H. Chemical disinfection of medical and surgical
materials. In: Lawrence CA, Block SS, eds. Disinfection, sterilization
and preservation. Philadelphia: Lea & Febiger, 1968:517-31.
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