As winter’s weather fades away and the flowers start blooming, the time for spring cleaning arrives. There is nothing better than opening the windows for the first time in months and letting in the sweet scents of spring into our homes. But as we clean out the clutter of a long and weary winter, there is also no better time to evaluate how we manage a cleaning of a different kind. Mechanical washers and ultrasonic cleaners help us ensure that the instruments that we process are safe and clean, so we can provide our patients with the best care possible. But beyond just cleaning, we must ensure that we are compliant with standards and best practices. Knowing that our processes are complete with no gaps in our records can be as refreshing as that first spring breeze through our open windows.
When we think about sterilization, one factor is paramount: documentation. The importance of ensuring that our sterilization records are complete and without error is hard to overstate. We meticulously record every item that we sterilize, every biological and chemical test, and every cycle parameter is logged. But just as important is ensuring that our cleaning steps are documented as well. AAMI ST79(2017) states that verification of the cleaning process should be documented and that the wash cycle should be reviewed and initialed by the operator to ensure the correct cycle was used.
Just as we review our sterilization records to confirm that the necessary parameters were met, so too must we check to make sure that our instruments are processed on the correct cycle, and that all parameters have been met. Did our ring-handled instruments undergo a lubrication cycle? Did our orthopedic instruments reach thermal disinfection temperatures? Was this cataract set to run in the correct ultrasonic? No one wants to get caught without an answer to those questions when inspectors come to visit.
Let’s consider a “typical” day in SPD, if there ever is such a thing. The first cases of the day are just beginning in the OR. Decontam stands strangely quiet; the instrument washers are still, the ultrasonics are silent, and sinks are clean and ready for action. The strange lull in the action won’t last long, once the first couple of cases come through the door or the lift, and then the “Decontam Symphony” will begin to swell and reach to a clamor of hisses and clanking.
This break in the organized chaos of instrument cleaning is the perfect time to perform the required inspections and checks on the tools that keep the SPD machine running. Often overlooked and unnoticed, a critical inspection point is the spray arms of the washer racks. While each manufacturer has their own design, nearly all washer racks come equipped with rotating sprayer arms. When in operation, these arms spin due to the force of the water coming out of the small holes running down their length, as well as the tips of the arms. To ensure that these racks provide the necessary impingement and cover as much area as possible, they must rotate freely. Giving them a spin is a quick and easy way to test. But since they rotate due to the force of water spraying from the tips, it’s critical to inspect these tips for clogs or other obstructions.
The tips of plastic container locks, fibers from a forgotten and now disintegrated container load card, the ever-present blue fuzz shed from nonwoven wraps can all find their way through the intricate plumbing of an instrument washer and wind up lodged in the sprayer tips. Clogged with debris, these tips cannot provide adequate pressure to spin the arms, and we can’t be sure that our instruments are being effectively cleaned. In addition, some tips can be rotated, the angle of the jet providing the force to spin the arms. Ensuring that the tips are correctly positioned should always be part of the inspection process. It’s important to remember that the sprayer arms are not only found on the racks but there is usually one in the washer itself. These sprayers do not get swapped through like the racks, and so are more susceptible to clogs and obstructions, and should not be overlooked.
Most instrument washers in fact recycle most of the water and solutions that they use. To help prevent larger debris from entering the system, most washers come equipped with a mesh screen in the washer chamber to block loose materials. To allow for effective recirculation and draining, it’s important to check this screen regularly and discard any trapped debris. Often overlooked, many washers also have an integrated filter to trap much smaller material, such as fibers. This filter is usually a part of the plumbing system and is not serviceable by SPD staff, but instead by the team that services the devices. Periodic cleaning of this internal filter should be conducted to ensure that the washers operate at peak performance and should be part of a regular preventative maintenance program.
Cart washers are an often-overlooked area when it comes to regular maintenance. While some cart washers are capable of adequately washing instruments with dedicated loading racks, more often they are only utilized for cleaning case carts or rigid containers. Despite their more common use, these devices should be held to the same rigorous standards as the instrument washers. Sprayer tips should be inspected for obstructions. Filters should be checked and cleaned as necessary. While not usually part of the sterile field, the items processed through the cart washer are in close contact with our sterile instruments and should always be as clean as possible. That starts with a thorough inspection.
Considering the importance of the work that goes on in all areas of the hospital, the old saying “if it wasn’t documented, it didn’t happen” is as relevant for SPD as anywhere else. Conducting the inspections of our cleaning devices is critical to patient and staff safety, but we must be sure that these important steps are recorded. CensiTrac provides an electronic method of documenting not only the cleaning, inspection, assembly, and sterilization of instruments, but also a means of recording any of the dozens of other tasks we must perform in our daily job duties. The Efficiency Task List module in CensiTrac provides a method of recording the completion of these responsibilities. Department leadership enters the tasks into the list, as well as a standard time to complete the task. A barcode sheet, specific to the area or group of tasks can be printed and made available to the staff. Upon beginning the task, the barcode for that task is scanned, documenting the task was performed, as well as providing a means of tracking department and staff productivity. Ensuring compliance with AAMI standards, inspections, accreditation surveys or governing agencies means complete compliance with documenting the important steps we take to ensure patient safety. Electronic documentation of these steps can replace paper logs which can easily be lost, damaged or contaminated. For department leadership, the Efficiency Tasks List module provides reportable metrics and confirmation that the required duties are performed. Using our exception reports feature, regularly scheduled reports can be automatically generated and delivered via email whenever you chose. Reports can also be exported to spreadsheet programs for integration into whatever your data reporting needs require, ensuring that you remain compliant.
Sterile processing has many hurdles, and to rise to those challenges, we must be sure that the technology we rely on to perform our duties is working correctly. Simply ensuring that debris isn’t lodged in a sprayer nozzle is not enough to ensure we are effectively cleaning. Just as we use process challenge devices (PCDs) in our sterilizers to confirm the biocidal effectiveness, we also challenge our instrument cleaners and washers.
To the initiated, ultrasonic cleaners appear nothing more than a noisy metal tank of cleaning solution. But the truth of their purpose cannot be seen with the naked eye. During operation, the ultrasonic produces a “static” noise, but that alone is not enough to demonstrate that it is working effectively. The strength of the sonic energy produced is directly linked to how effective its cleaning ability is. To ensure that this invaluable device is working properly, we have several choices for testing. Test strips provide a means of demonstrating the microscopic impingement process that takes place by how much of the test residue remains at the end of a cycle. Test vials respond to sonication by displaying a color indicator change. If the sonic energy is insufficient to produce this change, it may not be providing adequate cleaning. Performing and documenting this important efficacy test is critical to ensuring the instruments are as clean and safe as we can make them.
To test the effectiveness of our mechanical washers, there are many different products available, but most work essentially in the same fashion. Test strips are included in a dedicated wash cycle and exposed to the sprayer and enzymatic solutions. These test strips are coated in a bioburden analog, a material that simulates blood or other soils commonly encountered following surgical procedures. To test the effectiveness of the wash cycle, several of these strips are included, usually at least one per level of the washer rack. The pattern of residue remaining on the strips at the end of the cycle can help diagnose issues with the cleaning process. Certain patterns can indicate a failure to adequately impinge material, while others demonstrate an incorrect concentration of enzymatic or cleaning solutions. By including multiple test strips in the cycle, we can determine if our racks and washers as a whole are performing at peak performance. If residue remains on the test strips, it’s a good indicator that bioburden may linger on our instruments. Mechanical washers that fail this important step should be called in for service.
In addition to challenging our instrument washers, we mustn’t overlook the effectiveness of our cart washers. Residue tests like those performed in instrument washers can demonstrate that adequate sprayer pressure is available, as well as revealing issues with cleaning solution concentrations and spray patterns. Case carts and rigid containers are more than furniture and boxes. They are our shields against contamination, our guardians of sterility. Ensuring that they themselves are clean helps ensure that their precious cargo is secure from contamination.
Demonstrating that our equipment is functioning properly is indeed critical to our success. But of course, we must document this information. CensiTrac provides a means for this. As case carts and containers enter Decontam, they are scanned to the Decontam module. This one scan point provides a host of benefits. Case carts are emptied, providing a “clean slate” for future assembly. Containers are recorded as entering Decontam and CensiTrac can display special instructions specific to those containers, alerting staff to proper procedures for handling, disassembling, and cleaning. Recall alerts due to a failed sterilization process are removed. From the SPD perspective, the “perioperative loop” begins in Decontam. Recording what and when those items begin their SPD journey is a critical and necessary step.
It’s nearly unthinkable to sterilize an item without documentation. So why should the cleaning process be any different? Scanning items to our washers and cleaners should be just as routine as scanning assembled items to the sterilizer. CensiTrac records washer and cleaner cycles in the same way it does for sterilization cycles. The washer or cleaner is scanned, creating a new load, instruments are scanned to it, and the cycle is begun. Upon completion of the cycle, the results and cycle parameters are then recorded. By scanning items to the ultrasonics and mechanical washers and documenting the results of those cycles, we can be sure that our documentation is accurate, complete, and consistent. Recording efficacy tests and maintenance cycles such as a regularly scheduled descaling can all be recorded electronically. Retrieval of this information is as simple as running a report or verifying the results in the Load List module. When inspectors come knocking, you can feel confident that your documentation is at hand.
As warmer weather brings the delights of a new spring, it signifies a time of growth and renewal. We take stock of the possibilities before us as we look towards a brighter future. Even in the carefully climate-controlled environment of SPD, spring offers an opportunity to grow and cultivate new and better ways to care for the patients who rely on us. As April showers give way to May flowers, we must tend to our garden and ensure that we grow a culture of accountability, compliance, and best practices when it comes to documenting all the important steps we take to care for our patients.