The field of instrument reprocessing is constantly evolving. We encourage all members of the sterile processing community to post their questions. Potomac Labs is committed to education, and we believe knowledge sharing within the sterile processing community-at-large will improve the safety of patients everywhere.
Advanced Instrument Processing Solutions
Education: Ask the Expert
The Potomac Labs team is pleased to present commonly asked questions encountered in sterile processing.
Charles Ciullo, our Director of Sterile Processing, is here to answer your questions.
Feel free to send us your questions–here’s how:
- Click the “ASK A QUESTION” button (right side of this screen)
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Looking forward to receiving your questions.
We’ve been told that the washer-disinfectors in our facility are supplied with treated but no one seems to know what kind of treated water it is. We are a small free standing surgical center so we have no maintenance department to ask, so how can we figure out what kind of treatment system we have?
Since any water treatment system requires preventive maintenance, either resin recharging in case of softened water, filter tank changes in the case of deionized water, or filter replacement in the case of reverse osmosis water, I highly suggest you first talk to the center’s director and make sure this is being done. If you have a water treatment system that is not being maintained it can do more harm than good, throwing the minerals it was filtering back into the water it was treating. Once you find out the company doing your PM’s, call them up and ask them what kind of water treatment system it is. You might even want to ask them to give you an analysis of your treated and untreated water the next time they come in. Since your detergent dosing ratios are highly dependent on your water quality it is good to know it (no matter what the company who makes your detergent claims, “effective in all water qualities” does not mean you would you use the same amount in hard water that you would use in deionized water).
Since it may take a while to get in touch with the company doing the service on your water system I am going to give you so clues to look for to help you determine what type of water treatment system you have.
If you can find them, check to see what type of piping is supplying water to your W/D, if the piping is copper you are probably only using softened water in your W/D. Deionized and Reverse Osmosis water are highly aggressive and will basically eat right through copper piping. If your water is DI or RO it the pipes it runs through will be PVC
If you can find the water treatment system in your facility try and compare it to the pictures I have supplied here as examples of each treatment modality.
A water softening system usually consists of two components a tank that does the softening and another that contains brine that is used to “regenerate” the resins in the softening tank. Again since softened water is not aggressive the pipes in and out of it will most likely be copper.
A water deionizing system usually consists of more than two filtering tanks one multimedia filter, and a cation and anion filter to remove the positive and negatively charged minerals in the water, these tanks need to be changed on a regular basis and since the resins they contain cannot be recharged on premises. Because pure water is a “universal solvent” the piping exiting a DI system will PVC and not copper, DI water would basically dissolve the copper piping in time, but does not dissolve PVC.
A Reverse Osmosis (also known as high purity water) system usually consists of a pre filter and then multiple filters filled with a coiled membrane that only pure water under “osmotic” pressure can pass through. Minerals and other substances dissolved in the water cannot pass through the pores in these filters they are washed “downstream” with the waste water. Because a smaller amount of “high purity water” is produced to the amount that becomes waste, RO systems normally have a holding tank to contain the “pure water”. As with Deionized water, Reverse Osmosis water is highly aggressive and the piping it passes through is PVC.
Our ASC is trying to figure out the correct standards for how often to change the water for cleaning instruments before reprocessing?
The water in the manual soak sink and ultrasonic cleaner should be changed when it becomes visibly soiled and at least once each shift. The soak sink and ultrasonic cleaner should be rinsed clean before refilling and at the end of the day or between shifts should be disinfected with a lint free cloth soaked in 70% alcohol.
If you are cleaning intraocular instruments, The American Society of Cataract and Refractive Surgery, The American Society of Ophthalmic Registered Nurses and AAMI ST79, Annex N all recommend that the water be discarded after EACH set cleaned. Also for intraocular instrument after cleaning and a tap water rinse all instruments should be rinsed in sterile, distilled or deionized water. This sterile water rinse should provide flow of water over and through the instruments, should not be done in a basin with agitation and should not be reused.
Always follow the cleaning chemistry manufacturers IFU for dosing/dilution ratios. Have your soak sink marked so that when you fill it to that mark you know the amount of water in the sink (e.g. 5 gallons) and dose your cleaning chemistry appropriately. The AAMI ST79 188.8.131.52 also recommends that you monitor and document the temperature of your soaking solution to make sure it stays in the correct temperature parameters suggested by the detergent manufacturer.
We have had our wash water tested and the silica level is low, yet we still have a snake skin pattern on our instruments after sterilization. Is the wash water the only source of silicates or can they be coming from somewhere else?
There are other sources of silicate deposits which I neglected to mention in my last post on them
One source is the steam in your autoclave. If water to the boiler is improperly treated, minerals that are dissolved in the water can be carried in the steam and deposit on instruments and the chamber of your autoclave. Silica is also added to some steam boiler systems to protect the boiler and piping from corrosion, if used in excessive amounts this treatment can be deposited on instruments by the steam containing it.
Another source of silicates is in the detergents you may be using. Sodium Silicate (meta-silicate) is sometimes used in cleaning chemistry as a complexing/chelating, buffering and emulsifying agent. As a complexing agent Sodium Silicate has a great affinity for metals and will bind with dissolved metals in water, thus acting as a water softener and preventing dissolved minerals from depositing on surfaces, it is also a great wetting agent and helps keep the components of detergents in emulsion. Many laundry detergents use Sodium Silicate in their formula for this reason and because it has an affinity for metals, tends not to bind to the fibers of clothing.
Another name for dissolved sodium silicate is Water Glass or Liquid Glass and this brings us to its other use. Sodium silicate can be added to the coolant system of a car to repair gaps in the head gaskets. When sodium silicate in solution reaches a temperature of 100°-105°C (212°-221°F) it adheres to the gaps in the head gasket in the form of glass, thus sealing these gaps. The glass that is formed here can only be re-melted at 810°C (1490°F). In the U.S. governments Car Allowance Rebate System “Cash for Clunkers” program, engines of cars traded in had to be disabled so they could not be reused or resold for parts. This was done by draining the oil from the car, replacing it with 2 liters of sodium silicate solution and then running the engine. When the engine got hot enough the sodium silicate would turn glass like and abraded the engine internals causing it to seize.
Given its affinity for metal and the fact that it turns to glass at the boiling point of water, you would wonder why it would be used in any cleaning chemistry for sterile processing, yet it is, because it is a relatively inexpensive substance. It is more common to find this in cart washer chemistry than those for instruments, but here the sodium silicate takes its toll on the washer more than the carts. After repeated uses the cart washer chamber begins to exhibit a coating that one would assume is calcium, but unlike calcium deposits it is not easily remove, even wire brushes have little effect on it. Also this coating begins to build up freezing the washer arm mechanism and plugging the spray nozzles. With continued use the cart washer will become inoperable.
Is there a standard format/template for procedures used in CSPD departments or does each facility make up their own?
The standard format for CSPD is that items always move from dirty to clean to low/intermediate/high level disinfection or sterilization, depending on the item and its use (non-critical items get low/intermediate level disinfected, semi-critical get high level disinfected, critical items get sterilized in accordance with Spaulding’s classifications of medical devices) to storage or end user and back to dirty.
Each step in the reprocessing cycle has its own subset of steps and parameters that must be met in order for the process to be performed properly. Also these processes must be verified to ensure that they are working correctly (e.g. biological monitoring of the sterilization cycle should be performed weekly, preferably daily, to ensure microbial kill).
Should we be using huck towels for instrument tray liners and wicking in our basin sets or would we be better off using disposable tray lines for this?
I personally would suggest you go with disposable tray liners. For as long as I can remember most of the institutions I have worked in used green huck towels as tray liners, as corner protection under heavy trays and wicking in basin sets etc.., we did it because it is what we had always done. Now new questions on this practice are arising with good reason. If your institution does not have its own laundry facility you send your laundry out to have it washed, do you know what the laundry facility uses to launder these towels? Is there any residual detergents left in these towels after they are laundered? Residual chemistry in huck towels can deposit on instruments during steam sterilization, many laundry facilities use a high alkaline detergent followed by an acid rinse, residue of the chemistries depositing on instruments can cause corrosion. The washing chemistry is not the only factor here, dye transfer from towels onto instruments also comes into play. I know many of us have seen plastic sterilization cases stained from the dyes in towels, if this dye is transferring onto the plastics cases and staining them, is it transferring onto the instruments too? (my guess here would be yes) Now you have these residual chemistries (detergent and dye) on your instruments and I’ve already stated they can cause corrosion of instruments, but they can also cause allergic reactions in those people sensitive to them, something you don’t want occurring at the surgical site.
Lastly there is the problem of lint. We have all been told that these towels are “lint free” but I assure you if you run a lint brush over them it is not coming off clean. What happens when lint, even the tiniest piece gets into the surgical site, the body reacts to it. Lint is a foreign body it doesn’t belong where it is so reactions such as granulomas and adhesion formation can occur. Also since a particle of lint is much larger than most bacteria, the body will react to it before it detects the bacterial cells allowing them time to replicate and cause major problems.
Sterile huck towels were originally just used to dry hands post scrub before gloving, we in healthcare are the ones who have repurposed them for a hundred other uses than they were originally designed without a second thought.
We have begun to notice what looks like little tiny holes with rings of rust colored metal around them. What would cause this to happen?
What you are seeing on your instruments is pitting corrosion. Pitting corrosion begins when the passivation layer of a stainless steel instrument is compromised, usually by a scratch. This sets up a situation where you have two different metals exposed, the chromium oxide passivation layer and the iron based steel. When these metals are exposed to an electrolyte, like sodium chloride solution or blood, the more active metal, in this case the stainless steel, begins to corrode at an accelerated rate, while the more noble metal (less active) corrodes at a much slower rate, through an electrical exchange between the two metals (also known as galvanic corrosion) To make things even more complicated the dissolved oxygen in this solution comes into play oxidizing the steel (rust). This chloride based corrosion increases with longer exposure to sodium chloride solution or blood, when exposed to halides (like povidone-iodine) and when instruments are not dried completely at the end of your W/D wash cycle. Even the chlorine in your tap water can increase the corrosion. If you use softened water in your W/D, “salt slippage” from it can hasten the corrosion process too. The rust ring you see around that tiny pin hole will give you an idea of the extent of the damage to your instrument, so that tiny hole can be hiding a large cave underneath it, and that cave is capable of harboring bio-burden, so it might be time to take that instrument and “kiss it goodbye” (if you have an instrument repair contract, check with them to see if your instruments are repairable)
There are a few ways to prevent this corrosion from happening. One is to clean instruments at point of use, by wiping them down with sterile water. I know you are thinking “yeah you tell the folks in the OR to do that”. I suggest you and your manager meet with the OR director tell them the problem you are experiencing (take pictures of the instruments) and quote them AORN PNDS:170;198 (Perioperative Nurse Data Set) “Keep instruments free of gross soil during surgical procedures” and from the same document “Cleaning and decontamination should begin as soon as possible after use. Preparation for decontamination should begin at point of use”. Explain the cause of this corrosion, how detrimental it is to instruments and how much it will cost to replace them.
On the SPD/CSSD side of this equation you must be just as diligent, as soon as instruments arrive in decontamination start cleaning them. The longer the sit, the more they will pit.Have your water quality assessed, I cannot stress this point enough. Water is the true cleaning agent in decontamination, detergents just facilitate the job. Water with too many contaminates leads to a bad cleaning process, excessive use of detergents and deposits on instruments. It is unfortunate that many institutions in the U.S. would rather spend money on detergents etc. instead of spending the money to make their water more aggressive (e.g. DI, RO water). If you use softened water in your W/D have the water checked to see whether or not you have “salt slippage”. Lastly make sure when your instruments come out of the W/D they are dry, if they are not have the dry cycle adjusted so they do exit the W/D dry.
I’ve included here a picture of pitting corrosion and a diagram of the process of chloride pitting so you can see how that tiny hole can be hiding a cave.
Our facility currently uses Class 5 Integrating Indicators in all our packs and steam sterilization cycles. Someone recently suggested we use Class 6 Emulating Indicators in our steam sterilizer because they are more accurate. Which do you believe to be the better one for us?
I suggest you stay with the Class 5 Integrating Indicators for now. Class 6 Emulating Indicators are cycle specific, so if the indicator says prevac, 270°F/132°C 4minutes, that Class 6 indicator can only be used in that cycle, not in any other. If you run a gravity load at 250°F/121°C for 30 minutes you will need a separate Class 6 indicator specific for that load. Although a Class 6 can be used as an internal indicator in packs, trays, and rigid containers, as can a Class 3, 4 or 5 CIs (Chemical Indicators) only a PCD (process challenge device) with a Class 5 integrating indicator and a BI (Biological Indicator) can be used to monitor implant loads and verify the lethality of your sterilization cycle when you do your weekly
(preferably daily!) testing. Yes you could use a Class 6 in the set with the implants, if you have one specific to that trays sterilization parameters, but in the case of an early release of implantable items for an emergency, before the BI results are available, only the results of a Class 5 CI can be used, because they mimic the biological response of the spore contained in the BI when exposed to the optimal saturated steam conditions.
Current Class 6 CI’s are formulated with a complex indicator ink that produce a color change when two or more of the chemical reactions the ink was formulated for are met. Each ink is formulated to respond to a specific cycle, so in that case you could say they are more accurate, because they will only change color when the cycle they are formulated for has met its sterilization parameters (time, temperature and saturated steam)
Class 5 CIs are formulated to react to 3 stated value temperatures 250°F/121°C, 275°F/135°C and one temperature in between (plus time and saturated steam) to mimic the death curve of a BI. Also the value of 250°F/121°C must be met for longer than 16.5 minutes to mimic this curve.
Again, because you will need a different Class 6 CI for each specific cycle you run in your facility, you will have to increase the amount of inventory you purchase. That and the fact that only Class 5 CIs are recognized for use with a BI PCD at the present time, I would have to suggest you stick with the Class 5 Integrating Indicators.
Our Surgical Center has been having a problem getting loaner instrument trays in a timely fashion. Sometimes we have to “cut corners” to get the trays processed for the surgical cases that needs them. What actions can we take to insure we get the trays in with enough time to process them properly?
Loaner instruments have been the bane of the Sterile Processing Department for what seems like an eternity. Every Sterile
Processing Technician , including myself, has a hundred or so horror stories of having to deal with them . I am going to skip my usual long crazy tirade here (yes I could really go nuts with this) and just start with my suggestions.
First, NEVER CUT CORNERS….NEVER! Ethically you are obligated to “do the right thing” by complying with the manufacturers IFU for cleaning and sterilization. If loaner instruments arrive at 10:00am and are needed for an 11:30am case, you “cutting corners” to get them done only placates the surgeon and the sales rep. who brought them in at the time they did, the patient, who is your main concern does not benefit from this at all. Ask yourself, would I want these instruments that have been improperly processed used on a member of my family or myself? I’m sure the answer will be NO. I understand that this means you will have to “take a stand” and explain your actions to the everyone who is expecting these instruments to be ready (yes, I know they will be screaming about it too), so calmly explain that it is your ethical obligation to “do the right thing” (see above) and ask them if they would want improperly processed trays used on them or their loved ones.
Now if this seems to be a reoccurring problem, which it probably is, I suggest before the problem arises again, get together with the staff from the OR, get your Infection Control person involved, talk to the director of your ASC, even get other surgeons involved (they will listen if you explain the legal ramifications of a Surgical Site Infection from improperly processed instrumentation) and work on getting a policy together and in your facilities policy and procedure manual to control this problem. Here I would suggest you use the IAHCSMM “Sample Policy and Procedure for Loaner Instrumentation”
as your template. This sample policy is wonderful and covers all the bases, from the responsibility of the OR staff, to the weight of instrument sets, to the responsibility of the sales reps pre and post surgery and of course the responsibility of the SPD/CSSD staff. Once the policy is complete and documented in your facilities manual, make sure that all the sales reps. who bring you loaner instruments get a copy of it so they know of it and then hold them to it. Without a policy in writing and in your facilities policy and procedure manual, your plight will be a losing battle, so get one started ASAP.
How do you measure technicians productivity and do you set a standard number of instruments they must process daily?
Every Sterile Processing manager wants productive technicians working for them, technicians that will get “the job” done right in the most efficient manner possible, while still adhering to the policies and procedures of the department. Productivity is normally measured by comparing the amount of goods and services produced to the inputs used in the production of those goods and services, simply put, Productivity = output divided by input.
That being said, anyone who has been in the trenches of sterile processing knows that the variables of processing instruments (and by number of instruments I have assumed you were talking about instrument sets/ trays and not individual instruments) has a very wide range. Instrument sets vary in complexity, an E.R. Suture Set has much fewer instruments than a D&C tray, and a D&C tray has fewer instruments than an Open Heart tray or a Total Hip tray. Also individual instruments themselves vary in complexity, some require disassembly to be processed properly, others do not. Now to make things even more difficult, some instrument manufacturers require extended cleaning or sterilization cycles for their instruments. Also the processing of instruments in different areas of the department varies in difficulty, it is normally more labor intensive to decontaminate the instruments in a D&C tray, than it is to reassemble and wrap said tray.
Since I have brought up the labor intensive decontamination area, a tray that is grossly contaminated or one where the soil has been allowed to dry on the instruments is much harder to clean, than the same tray that was opened in the OR, but not used, both trays are “dirty” and need to go through the decontamination process in the same manner (unstrung, box-locks open etc.) but one of those trays is going to take a heck of a lot more “elbow grease”(and perhaps some cussing) than the other.
The Prep and Pack area has its own set of challenges, we have all encountered the tray that, on assembly, we discovere was missing one very important instrument, and after searching high and low for it, we finally found what we were looking for, but it took time, enough time that we could have assembled two of the same trays had it been complete in the first place.
Now that I have again gone off on one of my little tangents, let me get back to the core point of your question and that is productivity. Here I would first like to suggest you obtain a copy of “ Management Basics for Sterile Processing, Nancy Chobin, R.N. AAS, ACSP,CSPDM https://www.sterileprocessing.org/bookform.htm and refer to Chapter 4, Productivity and Staffing which I am about to quote. First off the most important things needed for CS/SPD to be productive as a department is,
• A fully trained, educated, competent (and here I add Certified) Staff.
• A Certified management team to provide accountability and leadership during all shifts the department is open.
• The ability to provide ongoing continuing education to keep the staff current on all new information.
• Copies of all standards, guidelines and recommended practices that are relevant to CS/SPD processes.
• Adequate physical space and appropriate design to permit work to be performed efficiently.
• Adequateprocess equipment that is well maintained.
• Sufficient surgical equipment to reduce the “priority rushes” that often cause errors.
• Sufficient backup instruments to prevent the opening of complete sets to obtain one or two instruments.
• Specialty containers for delicate and microsurgical instruments to prevent damage in transit and processing.
• Team relationships within CS/SPD and with other departments.
• Support from the facility administration for the success of the department.
In order for individuals in the department to be productive you first need an environment that is conducive to productivity. Then if you want to set numbers of instruments or trays you expect to have processed by technicians have time studies done, taking into account all the variables I listed in the beginning of this answer. How long does it take to clean a D&C tray? How long does it take to clean one that is grossly contaminated? Remember that all services provided by the staff, even telephone coverage must be included in the time and output calculations.
Given the extreme variables of the job, (and the fact that time studies are not my specialty) I have always found it difficult to set productivity numbers for technicians in CS/SPD, it has always been plain as the nose on my face who was goofing off and who was diligently working. Also, if you promote a team environment in your department the rest of the team will not be happy with the employee who is not pulling their weight.
I do understand that you may need documentation of sub-par performance to initiate disciplinary action or you made need these calculations to justify OT or increased department staffing and that is why I have suggested the above reading.