Address particular requirements of a range of general surgical instruments
Soak instruments as required and rinse off gross debris in line with manufacturer’s instructions for effective and safe use of enzymatic detergents
Brush instruments with textured surfaces in the direction against the design to remove the debris effectively and in line with safety requirements
Address requirements of instruments with tightly coiled structures such as flexible reamers
Safely process fine, delicate items, brushing gently with a suitable brush to remove adherent soil
Follow guidelines for safe and correct processing of instruments with specific processing requirements
Some endoscopes are inserted into sterile body cavities and some into non- sterile body cavities such as gastroscope and colonoscopes.
Using your standard precautions, flexible endoscopes should be inspected, tested and processed according to their design and function with consideration given to the manufacture’s instructions. Extreme care should be taken to prevent damage to lenses, fibre-optics and the delicate components and accessories.
There should be:
The processing facility and associated equipment needs to comply with the requirements set out by occupational health and safety legislation and guidelines. Any chemical disinfectants, sterilants and processing equipment needs be regulated by the Therapeutic Goods Administration.
Flexible and rigid endoscopes and their accessory items are extremely fragile, and because of their complex construction they are also very difficult to clean. Staff need to be involved in adequate training and assessment to ensure they understand how the equipment works, how to correctly clean the equipment and the processing and sterilisation/disinfection procedures.
Staff also need to be educated on the safe use of chemical disinfectants and sterilants. It is a good idea for staff assessment to be checked off along side a competency tool and that tool used on a regular basis to monitor the staff’s performance. Each item type requires specialised care and handling instructions, therefore there is no generic method for reprocessing these items for reuse. It is important to consider the manufacturers instructions.
Proteinaecious matter is extremely difficult, if not impossible to clean once it is allowed to dry and this will cause failure to the sterilisation/disinfection cycle.
It cannot be over emphasised that as soon as the endoscope and their accessory items are removed from the patient that the process needs to begin starting with insertion tube being wiped using enzymatic cleaning solution.
Then aspirate the enzymatic solution through the suction channel, and air and water through the air/ water channels (where applicable).
All endoscopes need to be leak tested prior to immersion.
It is important to remember that perforated channels of endoscopes are an infection control risk. This is why it is vital for the leak test to be the first step undertaken in processing flexible endoscopes as this allows for any major or minor leaks to be recognised instantly. Angulations of the distal end of the endoscope will often reveal small holes in the angulations rubber other wise this may go undetected.
It is necessary to contact the manufacturer or supplier when resulting in testing fails to ascertain what procedure to follow in the disinfection/sterilisation process.
The following are classified as, but are not limited to, rigid endoscopes:
Rigid endoscopes are used in sterile body cavities and therefore needs to be sterile for use. The lenses or fibre-optical endoscopes are fragile items that are easily damaged. This damage can be difficult to detect when not in use or connected to a light source or camera with a monitor screen.
The cameras with couplers and attachment devices all have delicate surfaces that interface together which are required to be meticulously clean to ensure no blurring of the image distortion or occlusion of the view.
The light leads or cables can be damaged by coiling too tightly, bending or crushing, and the light will be diffracted into the lead, and not out the distal end damage can be detected when not in use however, the minor damage may be detected when the scope is in use.
Rigid fibre-optic endoscopes should not be subjected to ultrasonic cleaning as this process loosens lenses and cement.
The drying process takes place after the flush rinsing, rigid endoscopes and accessories which do not have fibre-optic light carriers or cables can be placed into a drying cabinet. Accessory items that are not suitable for this drying method can have medical grade air blown over them via a regulator at a low pressure example no greater than 165 kpa until dry.
There are several different methods of sterilisation for this type of equipment such as:
In all circumstances the instrument manufacturer’s instructions should be considered before selecting a sterilisation process.
Any rigid endoscopes that may require repairs, needs to be cleaned and sterilised before being sent to the manufacturer for repairs. If this is not possible because of the damage to the endoscope then it should be returned in a soiled state packaged in a sealed container and labelled hazard warning. The health care facility will need to comply with the legislative and regulatory bodies and other authorities regarding the transport of hazardous materials.
Any flexible or rigid scopes on loan need to undergo a complete routine cleaning and sterilisation process before use in the health care facility and before being returned to the loaner. All cleaning accessories should also come with the scope with instructions for use, example if you receive a 4 channel scope it should have a 4 channel cleaning adaptor. This is a really essential part of the cleaning and sterilisation process.
The instruments used for minimal access surgery are similar to those used in open surgery the difference is they are longer, narrower and insulated. The surgeon uses these instruments guided through a port to deliver an electrical current that is directed as a focus beam at a targeted area. This provides non-contact coagulation. The surgeon is able to operate the tip of the instrument from the handle. Other insulated instruments are coated with insulation to prevent the patient from burns during a procedure.
These instruments are used for minimal invasive surgery. They usually consist of three parts - handle, shaft and outer sheath.
Reusable laparoscopic instruments that are not or cannot be properly cleaned and sterilised can cause major deep organ surgical site infections. To care for this type of instrument the process needs to begin whilst the instrument is still in the theatres. It is important that the instrument is kept free of gross soil during the surgical procedure. Limit the time it takes to receive the instruments from the theatres. Ensure the reprocessing staff has had adequate training and follow the manufacturer’s recommendations, and know and follow the correct process. You need to have the correct cleaning equipment and chemicals in place. These instruments can be time consuming to disassemble.
Are very fine and delicate instruments. They can be used for various types of surgical procedures such as ears, eyes, micro laryngoscope etc. These instruments require extreme care when cleaning. Only some can be ultrasonically cleaned. Some are spring type or jointed. Once again you need to follow manufacturer’s recommendations for reprocessing. To ensure these instruments will not be damaged during the reprocessing there are special perforated trays with clip inserts for mechanical cleaning. Instruments should not be placed on top of one another during sorting, cleaning or any part of packing or sterilisation process.
Perforated trays with lids should be used for sterilising and storage of these delicate instruments.
The instrument needs to be tested and inspected before packaging and sterilisation. Testing may produce aerosols so a cabinet or exhaust hood maybe required to reduce exposure. The manufacturer’s instructions should be considered. Triggers and handles need to be in the safety position when changing attachments. If an attachment is not attached correctly it can disassociate from instruments when activated and cause injury. Regulated medical air or compressed dry nitrogen should be used as recommended by the manufacturer to operate air powered instruments. However the medical grade gas will ensure the best performance in use, safety and instrument life. The power tool should be operated at the correct pressure according to the manufacturer’s written instructions and the rate needs to be set when the instrument is running. If excessive gas pressure is used it will cause damage to the power instrument and place undue stress on the hose.
Damaged power tools and hoses need to be repaired by a qualified instrument technician or the manufacturer. Before being sent for repair the instrument will need to be cleaned and sterilised.
Power hoses and tools must not be immersed in water or placed in an ultrasonic cleaner or washer/ disinfector. Power hoses must be attached during the cleaning process unless otherwise recommended by the manufacturer. This is to prevent cleaning fluids entering the hose or handpiece.
Also check the hose for damage and wear. A damaged hose should never be used. A drying cabinet or a second non-linting cloth should be used to dry the power tool and hose.
The power tool needs to be disassembled for sterilisation. The hose should be coiled loosely and the accessories also need to be packaged for sterilisation, delicate and sharp parts need to also be protected. Remember the sterilant needs to contact the surfaces of the instruments.
Handpieces used in ear nose oral maxillo-facial surgery, dental and oral surgery and podiatry should be cleaned and sterilised after each use. This is because the internal surfaces from low and high speed handpieces maybe soiled with debris during use and the debris maybe dispersed into or onto other patients.
Waterlines supplying water to a handpiece need to limit retraction at the point of delivery so fluid retracted will not be drawn from the handpiece. At the end of each procedure the handpiece needs to be operated to discharge water and air for a minimum of 30 seconds or the manufacturer’s instructions. This is to ensure that gross debris that may have entered the turbine and air or water lines will be dispersed.
Thorough cleaning of internal surfaces with recommended cleaner lubricant and external surfaces wiped clean with a detergent impregnated damp cloth. Where it is practicable, the handpieces shall be disassembled for cleaning. The handpiece needs to be processed using an automatic flush through and lubricant system. The handpiece needs to be packaged and sealed before sterilisation. Wiping or soaking handpieces in a chemical disinfectant is not an acceptable method of reprocessing. Certain instruments that do not come into contact with patients have motors that cannot be submersed or sterilised. The health care facility should have instructions documented for the cleaning of these instruments.
Aspiration systems for dental procedures become soiled with use. Water needs to be run through lines in-between each patient. The lines need to be cleaned daily by flushing low foaming detergent and water. You also need to consider manufacturer’s instructions. With triplex syringe for dental procedures, you need to remove the tip after each use to clean and sterilise it. The triplex line needs to be cleared by flushing thoroughly with water into a high speed suction system. If sterilising is not possible use single-use only tips.
After removing the tip, the scaler shall be flushed with running water for 30 seconds into the high speed suction system. The tip needs to be cleaned and sterilised and the handle cleaned. Again the manufacturer’s instructions need to be considered.
Fibre-optic equipment are instruments that require considerable care as they are items such as cameras, light leads, telescopes, flexible endoscopes.
This equipment is heat sensitive and manufacturer’s instructions need to be considered. Most of this equipment is manually cleaned using a lint-free soft cloth and suitable cleaning chemicals. Manual cleaning is usually carried out using a neutral or mild alkali detergent diluted in water. Use gentle rinsing to free this equipment of any chemicals or residue. Manufacturer’s instructions for the chemicals used for reprocessing also need to be considered.
Telescopes and cameras have lenses that need to be treated with care so the reprocessing does not cause damage or cause fogging to the lens. Some manufacturers recommend the lenses need to be polished with specialised lens polish only. Polish the lenses with what the manufacturer recommends. Always check the telescope lens is clear by looking through the eyepiece towards the light. If damaged or foggy it will need to be sterilised and sent for repair. Telescopes can be damaged if they come into contact with other metals. When packing telescopes always use a perforated telescope container with lock in clips to keep the telescope from rolling around. Fibre-optic light leads should never be stretch or squeezed as this could cause the fine glass rods to break. You can check for damage by holding your thumb over the end and then removing it. It will go from dark to light and if it remains dark then there is damage and you will need to ask theatres to check that there will be enough light source for the equipment to work.
Enzymatic detergents are particularly effective against proteinaceous substances (blood and body fluids) as enzymes are known to breakdown proteins. These detergents are usually used for soaking difficult to clean items, particularly items with lumens that may have a build up of biofilm internally, that would otherwise be hard to remove.
Some instruments require soaking to remove stubborn stains or debris. Some need to be soaked in an enzyme solution. If this is the case, always refer to the manufacturer’s recommendation for the dilution and water temperature. In some cases the water temperature activates the enzymes to remove fats and tissue etc, so it is really important you follow the manufacturer’s instructions.
Instruments should only be soaked for a minimum of time or the manufacturer’s recommendations. There is no need to soak instruments for extended periods of time — in some cases when the water temperature drops the enzymes are no longer effective. This is why, once again it is important to follow the manufacturer’s instructions. Before you soak in the enzyme solutions disassemble, flush brush if possible. If it is not possible to flush brush just soak and when soaking is complete, clean as usual.
Some instruments have textured surfaces and some have cannualtions built into the instrument design. Heavy soiling such as, dried on blood or body fluids, adhesives, dyes, gels and lotions can occur with this type of instrument. It is important these are removed prior to sterilisation so the sterilant can contact all parts of the instrument surface for sterility to be effective. To remove the debris you will need to brush with a suitable cleaning brush in the direction against the design to ensure the debris is removed. If brushed in the some direction as the design, chances are the debris can become wedged into the crevices of the textured design. If this occurs, not only is sterility compromised but the sterilising process may loosen the debris and it can end up in the patients wound causing infection for the patient. Some examples of this type of instruments are:
Always ensure you are wearing PPE and brush theses instruments under the water surface.
Instruments that have tightly coiled structure can be difficult to clean. There are several steps to be considered when cleaning this type of instrument:
These instruments are extremely difficult to clean so the process may need to be repeated several times until the instruments are clean.
Flush instruments with tightly coiled structures with high pressured water and brush the cannulations, attaching to the ultrasonic’s flushing mechanism ensuring that flexion opens the coil as much as possible.
Check for retained debris by safely flushing with high pressure water and high pressure air.
It is always advisable to ask for an in-service training session from the manufacturers as well as the written instructions for cleaning and sterilising delicate instruments. Sterilising technicians need to be aware that they can damage these instruments by incorrect cleaning methods and the damage may go noticed until being used under a microscope. The manufacturer’s instructions are important. Some may need to wiped using a specific instrument wipe to remove debris in the operating suite before being transported to SSD.
The manufacturer may recommend you use a certain type of nylon soft bristle brush that will not cause damage to the instrument. Never use scotch brite, stainless brushes or hard brushes on this type of instrument. The teeth are so fine you will cause damage to the delicate instruments.
Cleaning precautions should also include documented procedures to minimize the risk of damage to instruments which can occur through inappropriate cleaning methods and materials. Some manufacturer’s instructions may include guidelines such as: