Advanced Instrument Processing Solutions

Stainless Steel cleaner is great for cleaning the exterior of your washer, (or polishing your stainless steel refrigerator at home) but it is not a good choice for cleaning the interior wash chamber of the W/D.

Those white deposits on your chamber are from hard water and primarily composed of calcium carbonate (let’s think eggshells or chalk here).

Stainless Steel cleaner, even those that claim to be water based, contain mineral oil and silicone.

So basically when you use a Stainless Steel cleaner on the interior of the washer chamber, you are just coating this calcium carbonate with mineral oil and silicone. It may look good when you are done but after a few wash cycles you will have washed most of this coating away and in the meantime added some more calcium carbonate coating to your washer chamber.

Now let’s think of those eggshells or chalk I mentioned before if you put mixture of mineral oil and silicone on chalk, how easy it that going to be to wash off? It just seeps into the porous chalk and may take a few washes to remove with water and detergent, but where is it going? Into the wash water…do you see where I’m going with this?

Ok, so how do you remove the deposit properly?  Calcium carbonate is a base (alkali) when it comes in contact with an acid there will chemical reaction that will break down this alkali (and weaken the acid too). Try this…next time you are at home making eggs, take a piece of eggshell and put it in a glass with plain white vinegar.  You will begin to see bubbles form on the eggshell, this is the reaction between the acid and the alkali….if you leave the eggshell in the vinegar long enough it will totally break down. You need to reproduce this same chemical reaction in your W/D to remove the deposits. This can be done one of two ways, once a week you can run a de-liming in an otherwise empty full cleaning cycle or you can add an acid rinse to one of the rinse cycles following your detergent wash cycle. If you have any questions on whether or not this will harm your instruments, please see my answer to the question “We only use a neutral pH enzymatic detergent in our facility, why would we want to use an acid rinse in our W/D….?”

One thing I neglected to mention was the fact that if you have these hard water deposits on the W/D chamber walls, there will be deposits on and in the spray arms of your W/D and on the heating element. Deposits here are even more detrimental than on the chamber walls. When deposits form on the holes in the spray arms they become clogged, this eventually impedes both the spray of water out of the arms and their impingement, I have seen washer arms clogged so bad that there is not enough water pressure coming from them to make them turn, I assure you, nothing is getting cleaned properly there. Also these deposits on the heating element in the W/D make it more difficult for the element to heat the water, as the deposits become thicker, the heating element has to get hotter to heat the water, the deposits may get so bad that the heating element burns out trying to heat the water to the right temperature.

So do your Washer Disinfector a favor by de-liming it weekly or better yet using an acid neutralizer in one of the post wash rinse cycles and save the Stainless steel polish for the exterior.

There are multiple and varied substances that can cause the
inflammation of Toxic Anterior Segment Syndrome, but in the case of intraocular
surgical instruments the cause is most likely debris left from inadequate
cleaning, residues from improperly dosed or rinsed cleaning chemistries,
endotoxins from manual soak or ultrasonic cleaning chambers, lint from towels
used to protect instruments or trays, and inorganic salts deposited from the
steam in your sterilizer.

First I would like to suggest that you obtain a copy of the
“Recommended Practices for Cleaning and Sterilizing of Intraocular Surgical
Instruments” from the American Society of Cataract and Refractive Surgery and
the American Society of Ophthalmic Registered Nurses and familiarize yourself
with it.

That being said let me begin with saying that the care of
these (and any other surgical instrument for that matter) begins at the point
of use, keeping instruments free of debris and moist, with sterile, distilled
or de-ionized, water during the procedure will help insure your technicians
will be able to clean and sterilize them properly when the procedure is
finished. Also the sooner the instruments are decontaminated, once the
procedure is finished, the easier they will be to clean. Since Ophthalmic
Viscosurgical Device Solutions can harden in minutes, I would suggest the use
of disposable cannulas and tubing whenever possible. Any non-disposable
cannulas (or instruments) that come in contact with these solutions should be
flushed and keep moist with copious amounts of sterile water to prevent deposits.

Once the instruments arrive in decontamination cleaning
should begin immediately. Always follow the instrument manufacturers IFU when
it comes to cleaning these instruments. If enzymatic detergents are
contraindicated for cleaning, do not use them, if they can be used, I would
suggest using a neutral pH enzymatic detergent that is both color and fragrance
free (please see my answer to the question “We prefer an enzymatic detergent
with coloring and fragrance…” for further discussion on this matter). Always
follow the detergent manufacturers IFU, when it comes to the dosing of their
detergent in solution for cleaning. If you have an ultrasonic cleaner, only use
it with those instruments that can be cleaned in it.

When it comes to the cleaning of ophthalmic instruments, it
is highly recommended, weather in the manual soak sink or ultrasonic cleaner,
that you change the cleaning solution between each tray, to avoid the deposit
of debris from previous trays on instruments. Also more frequent cleaning and
disinfection of the chamber of your ultrasonic cleaner and soak sink is highly
recommended to prevent the build-up of bacterial endotoxins which can deposit
on instruments.

Once the instruments have been cleaned with detergent,
rinse them with copious amounts of water to remove any detergent residue, tap
water may be used here unless contraindicated by either the equipment or
detergent manufacturer. This should be followed by a final rinse with sterile,
distilled or de-ionized, water. This rinse should provide flow over and through
the instruments. The final rinse water should not be reused and agitation of
instruments in a basin of sterile water should not be used since any debris
could redeposit this way.

Following the final rinse all lumened instruments should be
dried with medical grade compressed air.

When assembling instrument sets, closely inspect all
instruments for defects or debris, a lighted magnifying glass is highly
recommended here. If you normally use huck-towels to line your instrument sets,
please make sure that they are both lint and detergent residue free. Call your
linen provider to find out what chemistry is used to wash these towels because
a highly alkaline detergent may transfer chemicals from the towels to the
instruments during sterilization, I have even seen the dye from new huck-towels
transfer to trays so find out from your linen supplier if they have ever had
any incidence with this problem.  A
better choice for tray liners are the specially made disposable dye and residue
free paper liners you can get from many sterilization supply companies.

Since dissolved
inorganic salts in the steam of your autoclave can deposit on your instruments
and my trigger inflammation, have the quality of your steam checked, at least
on a yearly basis.

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)
• Include your name
• Institution
• City & State
• Contact email (we won’t post your contact info–it’s just to alert you when an answer has posted)
• Click “SEND”

Looking forward to receiving your questions.

The classification of masks and respirators is a complex subject with multiple classifications for a variety of working situations, so I am going to just focus on those that pertain to working in decontamination. Let me begin with the fact that you do not need a respirator for decontamination. Although respirators would offer you great protection from aerosolized particulates, they must be fit tested and worn properly to be effective. Furthermore, the more filtration they provide, the harder they become to breathe through. Respirators are best for use in patient rooms where respiratory isolation is indicated.

I did state that a mask for decontamination should be fluid resistant, and when searching for masks, you will see different resistance qualifications and wonder what they might refer to, so I will give some examples here to help out.

If you see BFE > 99%:
This qualification is based on testing done by the ASTM (ASTM F2101-01) for Bacterial Filtration Efficiency, the material being tested is mechanically subject to 3 micron droplets of liquid aerosol containing Staphylococcus aureus at a flow rate of 28.3 L/min, and a material of this classification is capable of filtering out more that 99% of this aerosol. (Make sure this BFE rating is based on the ASTM F2101-01 testing and not on the older Modified Greene and Vesely Test, where a human subject says the word “Chew” and “Sing” distinctly at 10 second intervals for 1 minute through the material being tested in a closed container. The container is then cultured and a bacterial count is taken but there is no specific organism counted).

If you see PFE > 95%:
This qualification is based on Submicron Particulate Filter efficiency testing done by the ASTM (ASTM F2299).This test uses 0.1micron latex spheres at a flow rate 0.5 to 25cm/s the particles are counted with a light scattering photometer before and after passing through the material being tested, so a PFE>95% would mean that more than 95% of these spheres were filtered by the test material.

NIOSH Particulate Filtration Efficiency testing for respirators, (yes I know I said you don’t need a respirator for decontamination) is much more stringent. For healthcare purposes N series respirators apply (N here = Not resistant to oil, the other two classifications are R- Resistant to oil and P-Oil Proof would include oil in their testing aerosol). The challenge here is ~0.3microns liquid sodium chloride aerosol at flow rate of 85L/minute. A collection of at least 95% of this by the material gives the respirator an N95 rating, at least 99% collection would be an N99 and anything 99.7% and over gives the material an N100 rating.(These N,R and P classifications truly only apply to respirators and not face masks)

If the masks make the claim ASTM F1862 120mmhg Fluid Resistance:
This is the actual fluid resistance of the mask based on ASTM testing. In this challenge, a high velocity stream of synthetic blood is aimed at the material being tested at different pressures (80mmHg, 120mmHg and 160mmHg) to replicate blood exiting a puncture wound at a variety of blood pressures. An 80mmHg rating would be a Low fluid barrier classification, 120mmHg would be a Medium and 160mmHg a High.

Another thing you might see is a Differential Pressure Test (Delta P or ∆P) number:
The lower the number here the more breathable the mask is but, the more breathable the mask is the less protection it offers.

Now if this is not complicated enough ASTM F2100-11 has prescribed new mask standards for fluid resistant face masks as follows:

ASTM Level 1
Low Fluid Resistance     80mmHg
Filtration Efficiency      BFE>95%
PFE>95% @ 0.1micron
Breathability-∆P             <4.0mm H2O/cm2
Flame Spread                   Class 1 (low flammability)

ASTM Level 2
Moderate Fluid Resistance 120mmHg
Filtration Efficiency       BFE>98%
PFE>98% @ 0.1micron
Breathability-∆P              <5.0mm H2O/cm2
Flame Spread                    Class1 (low flammability)

ASTM Level 3
High Fluid Resistance 160mmHg
Filtration Efficiency        BFE>98%
PFE>98% @ 0.1 micron
Breathability-∆P               <5.0mm H2O/cm2
Flame Spread                     Class 1 (low flammability)

Wow that’s a lot of information… So now the choice is yours, but if it were up to me, knowing that surgical masks truly do not provided the optimum protection that a respirator does, I would at least choose one that provided me with the most protection, like an ASTM level 3 Mask, or at least one that had all those qualities.

First, you need to lower the temperature on your wash cycle to the optimum high point of your detergent. Most of the enzymes in an enzymatic detergent will begin to denature over 145°F.

Let’s explore a few scenarios where your washer was set previously to a higher temperature:

1. If your wash cycle was set at a temperature over 160°F, it was probably set up for an alkaline detergent which work best at higher temperatures. 
2. If you were previously using another enzymatic detergent at a high temperature and experiencing poor results, these high wash temperatures would most likely be the cause. 
3. If you were using a two detergent system, your wash cycle would only work properly at the higher temperature if you were following the enzymatic detergent wash by an alkaline one. Following the enzyme wash cycle with a plain neutral pH detergent wash cycle at that high of a temperature, would have just been cooking any leftover soil onto your instruments.

With the aforementioned in mind, if you don’t know how to change the temperature on your washer, please have your service tech come in and show you how! All too often, I encounter facilities where no one knows how to adjust the parameters on their washer. This is a very important piece of “know how.” For example, if you’re testing your washer’s cleaning efficacy according to AAMI recommendations, and it appears you are not using enough chemistry to do the job, how are you going to adjust the dosing if you don’t know how to? Don’t become dependent on your service tech for these minor adjustments—a service call takes time, and it’s down time you can’t afford. Besides, learning how to adjust your machine will ensure you are in control in following recommendations and optimizing your cleaning ability.

Furthermore, if you work at a larger facility with a number of shifts, it’s my belief that at least one person on every shift should know the codes to change the parameters. You wouldn’t own a car without knowing how to put gas in it or an oven that only ran at one temperature, right? And you probably know how to change the parameters on your sterilizer for those “wonderful” extended cycles… so why wouldn’t you know how to do the same with your washers?

I know… I went off on a tangent again… but I hope I answered your question and wish you all a wonderful holiday!

First, I recommend you review our blog answers under the “hard water category.” That being said, it has been my experience that most institutions use tap water in their washer-disinfector, all the way up to the final thermal rinse. If the facility has the ability, they will use either de-ionized or reverse osmosis water in this final thermal rinse. Depending on where you live and the time of year, your tap water can contain a lot of dissolved minerals which can end up depositing on your instruments and in your machine’s wash chamber, eventually damaging both. An acid rinse will neutralize these minerals and keep them from forming deposits.

Now, there are certain instruments that cannot be exposed to an acid rinse (such as plated copper instruments); however, these instruments would not fare well in an alkaline wash either. Always check the manufacturer’s recommendations and instructions for cleaning.

The majority of the instruments you run through your washer are surgical grade stainless steel. These instruments have a layer of passivation that helps protect them from corrosive substances. This layer is not added to them, like a layer of electro-plating. Instead, passivation is formed by dipping the instruments in an acid bath which removes the Nickel and Iron from the top part of the instrument surface. The metal that remains is Chromium, which reacts with the acid to form Chromium Oxide–the passivation layer. This layer is very tough and protects the instrument from corrosion, but this layer is also very thin and can be easily damaged. Once this layer is damaged, corrosive substances can make their way to the steel below. It is, however, possible to reinforce this layer of passivation, and one of the means is to expose these instruments to an acid rinse in the wash cycle.

So to answer your question, the acid rinse will not harm your surgical instruments. In fact, it will strengthen and keep them free from corrosive deposits at the same time. Furthermore, the acid rinse will also keep your washer disinfector chamber free of deposit formations.

OSHA Bloodborne Pathogens Standard 29CFR-1910.1030 states:
Gowns, Aprons, and Other Protective Body Clothing. Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure anticipated.190.1030(d)(3)(xi)

So what does that mean to you as a sterile processing technician? Because you deal with liquids in decontamination, your gown choice should be impervious to liquids!

ANSI/AAMI PB70 “Liquid Barrier Performance and Classification of Protective Apparel and Drapes Intended for Use in Health Care Facilities” classifies gowns (and drapes) used for protective apparel into four levels: these levels are based on fluid penetration tests as defined by the AATCC (American Association of Textile Chemists and Colorist) and the ASTM (American Society for Testing and Materials International):

Level 1 Gowns: Are generally best used for contact isolation and not for decontamination. They allow less than 4.5g of liquid penetration under normal atmospheric conditions (based on AATCC 42 test for fabrics resistance to rain penetration)

Level 2 Gowns: Are best for small bedside procedures. They allow less than 1.0g of liquid penetration (AATCC 42 test) and are resistant to liquid penetration up to 20cm of water pressure (AATCC 127 test) 

Level 3 Gowns: Are the gowns that ANSI/AAMI suggests for use in decontamination. They offer increased barrier protection and are resistant to strike through. They allow less than 1.0g of liquid penetration (AATCC 42) and are resistant to penetration up to 50cm of water pressure (AATCC 127).

Level 4 Gowns: Are intended for the surgical field, although I would argue the fact that these should be used in decontamination too. Not only are they as resistant liquid penetration as Level 3 Gowns, but they are also resistant to penetration by blood borne pathogens (ASTM test F1671using synthetic blood and surrogate microbes to test for viral penetration under continual liquid contact).

So all that being said, make sure you are using Level 3 gowns in your decontamination area, because those yellow isolation gowns don’t provide enough protection!

Now that you’ve got me thinking about PPE, I feel the need to elaborate a little more here. Please make sure that ALL of your PPE is correct:

1. Exam length gloves that only cover your hand (up to your wrists) are not long enough! Rule of thumb: if water from the soak sink can easily get inside the gloves while you work, they are not long enough. Also make sure the gloves you are using don’t tear easily.
2. Masks should be as impervious to liquids as your gown is; and unless you don’t breath through your nose, it needs to be covered by your mask, too.
3. Your eye protection should be sufficient to protect your eyes in case of any large splashes of liquid; we have all dropped something in a sink full of water at home and know water happens. Your protective eyewear should cover your eyes so that NOTHING will splash over it and INTO your eyes. I would suggest a disposable full face shield with a foam pad that seals above the eyebrows.

I know that working in decontamination can be uncomfortable with all this gear on, especially if the temperature is above 65°F in the room (which it shouldn’t be). However, wearing proper PPE is “for your own good,” as my mother would say.

In the end, it is your employer’s responsibility to supply the proper PPE, and YOUR responsibility to wear it.

First, let me again clarify that I suggested the use of alcohol for disinfection, as opposed to a halogen (bleach) or a quaternary ammonium compound, because alcohol is not corrosive to stainless steel surfaces. Alcohols are effective at killing a wide range of micro-organisms (bacteria, fungi and mycobacteria) as well as inactivating viruses. They are not, however, effective against spores and some hydrophilic viruses.

Alcohols work by denaturing cellular proteins and dissolving some cellular lipids. Since proteins denature more quickly in the presence of water, and water is needed for alcohol to cross the cell wall, alcohols are most effective below 90% concentration. Above 90% concentration, alcohol will only dehydrate the cell wall without entering the cell and denaturing its proteins.

The two most common types of alcohol used in healthcare are ethyl and isopropyl. Since 70% isopropyl is less dehydrating to living tissue than 70% ethyl alcohol, 70% isopropyl is normally the choice for skin antiseptic and the most prevalently used. 70% isopropyl alcohol is also a common choice as both an antiseptic and disinfectant because of its relatively low cost (90% isopropyl cost more because of its higher alcohol content).

Always remember that in order for alcohol (or any other disinfectant) to be effective, the surface where it is being applied must be clean and dry (soil and moisture will inactivate disinfectants). Additionally, that surface should be saturated for the proper amount of time in order for disinfection to take place.

Finally, I also suggest that you download and print a copy of the CDC’s “Guideline for Disinfection and Sterilization in Healthcare Facilities 2008” (click this link). It is a great resource to have on hand and has a wealth of information on disinfectants and sterilants.

Yes, you should be disinfecting the chamber every evening using 70% isopropyl alcohol. After emptying and rinsing the chamber, dry it with a huck towel to remove excess moisture, then saturate the surface of the chamber with alcohol. If you have a small ultrasonic where you can control the emptying valve, keep the valve closed while you are doing this to keep the surface of the chamber moist with the alcohol. Let it sit saturated for at least 5-10 minutes before emptying the chamber and let it air dry. This will stop the odor problem you are having by killing the cause, which are the bacteria growing in your ultrasonic. Please only use alcohol to do this since other disinfectants, like bleach or quaternary ammonium compounds, will react with the stainless steel chamber of your ultrasonic and damage it.

Remember, you should be disinfecting all work surfaces (countertops) and re-usable cleaning brushes at the end of the day, too. 70% isopropyl alcohol is great for both surfaces and brushes: it is less expensive that other disinfectants, and will not react or leave residue on surfaces like other disinfectants can. Again, make sure these surfaces are saturated for at least 5-10 minutes. If you have a washer/disinfector, your brushes can be run in the wash cycle with a thermal rinse to clean and disinfect them too–just make sure that their manufacturer states that they can be disinfected this way before doing so.

My first suggestion is to refer you a previous blog question regarding cloudy enzymatic detergent solution (I have noticed our enzymatic detergent becomes cloudy in hot water.  Why does that happen?)

Low foaming detergents usually cloud in hot water for a reason: the “cloud-point surfactants” contained within are what makes these detergents low or non-foaming. My other suggestion is to ensure that you use the right amount of detergent (dosing per gallon) in your sink and ultrasonic cleaner. Overdosing the detergent, especially one with a cloud point surfactant, will increase the cloudiness of your solution once the detergent is brought to its “cloud point” temperature.

I also suggest that you have analysis performed on the water used in your sink and ultrasonic. The chemistry of your water may be reacting with the detergent you are using, causing excessive clouding. Once you get the results of your water testing, contact your cleaning chemistry manufacturer with the results to see if they have any special dosing ranges for your water type.