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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.
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Our facilities Washer/disinfector cycle is approximately 50 minutes long and many times we run into problems when trays are needed that are still in the washer. Is there any way to shorten the wash time without compromising the cleanliness of the instruments?
Here I would like to first say that if there are trays in the washer that are needed for cases, your facility…
A) Probably needs to increase the inventory of those trays (how a facility can expect to do 15 carpal tunnel cases etc… in a limited amount of time with only 5 trays is ridiculous. The first 5 patients get properly washed and terminally sterilized trays, the remaining 10 don’t? Where is the continuity of care here?)
B) If you do have sufficient inventory, yet still seem to have trays that are needed for cases in the washer, then someone needs to speak to the OR scheduling department. Obviously cases are being booked too close together.
C) If scheduling nor insufficient inventory are the cases then, trays are not being delivered to decontamination from the OR in a timely fashion, so I suggest you speak to the Nursing Director in the OR explain your predicament. Instruments that are allowed to sit with debris on them are harder to clean and more prone to corrosion.
If any of the above factors are the reason trays are still in the washer when they are needed I would also suggest you get your infection control department involved in this problem, since they will be your best advocates here.
When it comes to shortening the time instruments are in the washer/disinfector, the only possible place I can see doing that is in the dry time part of the wash cycle, and doing it there will necessitate you employing some chemistry help before hand. Instrument manufacturers, as well as washer/disinfector and cleaning chemistry manufacturers validate the cleaning parameters stated in their Instructions For Use. When you follow the IFU you are doing so to ensure the efficacy of your cleaning process. If the IFU states that you should run said instruments in the ultrasonic for 20 minutes and you do not do so, you are processing the instruments off label. This holds true for the automated washing of your instruments. If you machine is validated pre-wash time is 4 minutes and the validated wash time is 10 minutes and you remove the pre-wash all together and shorten the wash time by 5 minutes are you following the IFU?
I stated before that you can shorten the wash cycle in the dry time part of the total cycle but you would need the help of chemistry to do that, so let me explain. If you add a rinsing aide ( http://www.potomaclabs.com/deconex-64.php ) in the final thermal rinse of your wash cycle you can lessen your dry time. Rinse aides are basically made of surfactants and lubricants, the introduction of a rinse aide in the rinse water cause the water to bead off surfaces while mildly lubricating the instruments. This means by the end of the thermal rinse your instruments will not be as wet and you can cut the dry time up to 50%. Having dry instruments is important at the end of a wash cycle to help prevent corrosion of the instruments this not only uses a lot of energy but also is one of the dry time can be one of the longest parts of the wash cycle. The only remedy for that is to make them “less wet” before hand and to do that you need a rinse aide.
We have a new CSSD department and some of our instruments are getting a rainbow colored stain on the gold handles and bluing of the stainless steel. Have you ever had this issue? Or do you know the cause?
In reference to the stains on your instruments I would first suggest you have an analysis done of the water you are using in your department. Rainbow stains (annealing colors) and bluing of instruments is caused by a high silicate level in your water. These silicates deposit on the instruments and cause the staining. These stains can be exacerbated by the use of a high alkaline detergent. High silicate levels in your water also tend to stain the chamber of your washer-disinfector a gold color, so if this phenomenon is occurring it is further evidence of a silicates. Poorly formulated detergents can be another source of silicates, since certain silicates are used as builders in detergents. It may be fine to use them in laundry detergents, but their use in instrument reprocessing detergents can be detrimental (please see…http://www.potomaclabs.com/education/2013/07/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/).
Also because water vapor can carry dissolved minerals, poor steam quality can be another source of silicate staining, although in this case the silicate stains will leave more of a “snake skin pattern” on the instruments. If these stains are appearing after the instruments have been autoclaved I would suggest having you steam quality checked.
These stains are not harmful if caught in time and can be removed from your instruments with a surgical stain removing soaking bath. Stains in the chamber of your washer-disinfector can be removed by running a full empty wash cycle with this same surgical stain remover, in accordance with the manufacturer’s Instructions For Use (IFU) on dosing ratios and run time (http://www.potomaclabs.com/deconex-34gr.php).
We have a lot of problems cleaning the soil off of the Bi-polar and Mono-polar surgical instruments at our facility, do you have any suggestions?
The problem of cleaning eschar off of electrosurgical instruments has been an issue since these instruments first started being used. As you know these instruments are used to cauterize tissue to minimize the amount of bleeding at the surgical site. This is done by passing an electrical current through the instrument either through opposing tips with different electrical charges or through a mono-polar tip that passes the current through the patient to a grounding pad. In the case of mono-polar cauterization the tip of the instrument touching the tissue does the brunt of the work, while the weakened electrical charge passes through the patient to the grounding pad. (I hope that everyone is checking the insulation on their electrosurgical laparoscopic instruments after each use, since a break in the insulation can cause a “misfire” during a surgical procedure. Electrical current can pass through breaks in the insulation, and if this break is close to any other organ the current will take the closest route out of the instrument, damaging tissue that was not meant to be cauterized). When these tips cauterize, tissue, blood and body fluid are basically cooked onto the instrument. This burned on tissue or Eschar (your new $50.00 word) should be removed AT POINT OF USE. Many surgical “kits” come with a little scouring pad that the surgical tech should use to remove the eschar AT POINT OF USE. Each time the instrument is used the eschar should be removed, but we’ve all seen those bipolar forceps with layer upon layer of burned on blood and tissue come into decontamination. I have capitalized and underlined “at point of use” twice now for a reason, The Association of Surgical Technicians, AORN, and AAMI all state in their recommended best practices that “The cleaning of instruments should begin during the surgical procedure to prevent drying of blood, soil and debris on the surface and within lumens.”(AST RSOP for the Decontamination of Surgical Instruments, Standard of Practice I). If you are constantly receiving electrical surgical instruments with layers of eschar on them, then someone in the OR is not doing their job correctly. Here I would suggest you get together with your manager arm yourself with photographs of the instruments as evidence and written recommended best practices, the A.S.T. version is readily available on line and set up a meeting with the Director of the OR.
Now as far as the removal of eschar from electrosurgical instruments, my first recommendation would be the use of a stiff plastic brush, soak your instruments as recommended in their IFU preferably in a high quality multi-enzymatic detergent (see our deconex® Power Zyme http://www.potomaclabs.com/power-zyme.php). Brush them under the soak water surface to remove the eschar. If staining from the burned on tissue is still a problem, and the material you are cleaning is stainless steel, I would suggest you use a surgical stain remover (deconex® 34GR is great for the removal of both organic and inorganic stains on surgical instruments and Washer/Disinfectors http://www.potomaclabs.com/deconex-34gr.php) again refer to the IFU of the product you are using.
One more suggestion I would like to make is that if you are in a larger institution and have more than one washer, you dedicate one of your washers for instruments that are difficult to clean. Use a two component cleaning chemistry system in your washer (deconex® Twin pH10/Twin Zyme http://www.potomaclabs.com/deconex-twin.php) Two component cleaning chemistries like the “Twin system” employee both an enzymatic detergent and a mildly alkaline detergent that when combined in the washer/disinfector form an extremely effective cleaning system and have demonstrated efficacy in cleaning hard to clean instruments like the DaVinci Endowrist instruments.
We’ve been told that the washer-disinfectors in our facility are supplied with treated water, 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, 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 184.108.40.206 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.
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.