(To earn 2 CEs for HSPA & CBSPD, read the article below, watch this panel discussion, then take the CE quiz here!)
If you’ve been around Sterile Processing or the OR at all for the last 5-10 years, I’m sure you’ve already heard about the importance of Precleaning. Every accreditation survey group expects precleaning to be performed, every Infection Preventionist is pushing for more pre-cleaning of surgical instruments, and every Sterile Processing and OR professional has heard at least one plea to get instrument precleaning done right, either from their manager or some consultant. You might say, “With all this industry focus on Pre-cleaning circling around, surely we can leave this topic to rest now, right?” Not a chance (…and don’t call me Shirley). Proper pre-cleaning is more than an idea, a product, or a compliance checkbox to be reviewed once and left alone. Pre-cleaning is the foundation of the reprocessing cycle: it requires a commitment to a process, an understanding of what’s at stake, and the time to get it right every time. In this article, we are going to review more than just the need for pre-cleaning. We’ll look at some of the policies, products, and processes that will hardwire excellence in your organization’s pre-cleaning program.
I say Tomato… Pre-Cleaning or Point-Of-Use Cleaning?
One thing I’d like to get out of the way at the start of our deep dive into Pre-Cleaning is the difference between Pre-Cleaning and Point-of-Use Cleaning. These two terms can refer to the same process, and as far as I’m concerned, can be used interchangeably. Some prefer the term Point-of-Use Cleaning because it highlights and emphasizes when and where the cleaning should take place. Regardless of which term you and your facility choose to use, Pre-Cleaning involves the initial cleaning step of the reprocessing cycle, which takes place during and after the use of the instrument or equipment. Pre-cleaning removes gross soil from the instrument and keeps the instruments moist to prevent the hardening of soils.
Show Us How It’s Done
One of the biggest assumptions (or call it a myth) with pre-cleaning is that it is a simple, cheap, one-step process that takes place after the surgical procedure is over. “We just spray this stuff on those instruments, then we send ‘em down to Sterile Processing.” While this sentiment is honestly better than doing nothing, it falls short of best practice and standards. Surgeries happen over a span of time, and surgical instruments that are used can go untouched on the back table for hours before the surgery is over. The AAMI ST79 document states:
“throughout the surgical or invasive procedure, instruments should be wiped, as needed, with sterile moistened surgical sponges to remove gross soil; and cannulated instruments or instruments with lumens should be irrigated with sterile water, as needed, without creating aerosols.” (6.3.1)
In addition:
“Gross soil should be removed as soon as possible to reduce the number of microorganisms on the item, reduce the nutrient material that supports microbial growth, prevent it from drying on…” (6.3.2)
The removal of soil from the instruments during the procedure, particularly gross soil from heavily soiled instruments is the often-overlooked step of pre-cleaning. There are usually two objections to this standard:
1. I don’t have the time! This is a legitimate concern and an alarming objection. Surgical techs are pressured to move so quickly during a procedure, that they cannot find the time to “clean as they go.” This problem has to be addressed at the leadership level. Does the organization value patient safety enough to supply the technicians with the appropriate time to clean their instruments according to best practice. This is also going to require the partnership of physicians who may be impatient with the additional time it takes to do a procedure.
2. That’s Sterile Processing’s job! This complaint shows a fundamental lack of understanding about the risks associated with dried soils and biofilm. Regardless of whose “job” the cleaning process is assigned to, every team member who touches that instrument is responsible for its proper care and handling, including preventing dried soils and biofilm. Failure to remove gross soil at the point of use can lead to instrument damage, cross contamination, sterilization failure, and ultimately patient infections. In addressing this concern, it can also be helpful to show the instrument IFU (which will detail the steps of pre-cleaning at the point-of-use), and the AORN and AST guidelines which also confirm that point-of-use cleaning is to take place during the procedure.
The Right Stuff
There are a ton of choices out there for pre-treatment products that are applied after the procedure is over. I’m not here to recommend any one product in particular, but there are a few factors you need to consider when picking one. The primary consideration for transport is that you keep the instruments moist and do not allow soils to dry. Whether you use sprays, foams, gels, or a moist towel, make sure your pre-treatment can keep the instruments moist. If your instruments are going to be sitting for a long time before being cleaned in decontamination, it may be best to choose a pre-treatment product with enzymes and anti-corrosives. Enzymatic pre-treatment sprays begin the process of breaking down the soils, and anti-corrosives will help protect the instruments from damage.
Let’s Get It Done
Implementing a successful pre-cleaning program at your facility is all about consistency. Considering you will likely have dozens of people that will need to be trained to follow the same standard procedure for pre-cleaning, a simple one-time in-service isn’t going to get you good results. Here are some key steps to making your pre-cleaning program consistent and successful:
1. Give the employees the time. Do not make your staff members choose between doing what is right (pre-cleaning) and doing what “needs to be done” (getting the case turned over faster).
2. Design a simple process. Make pre-cleaning the natural and easy thing to do. Do you want the OR to spray a product on instruments after the case? Put the product in a spot where it is available and easy to access.
3. Add it to competencies. Pre-cleaning should be a part of every person’s competency who handles used surgical instruments. If they bear responsibility for performing the task, they should be able to demonstrate at least annually that they know the process.
4. Audit for results. Any new change is going to take some getting used to. Have Sterile Processing audit trays for pre-treatment spray and for gross soil removal and collect the data. Instrument tracking systems are a huge help here as you can easily capture un-treated trays using a unique scan point. Post the data and collaborate with department leaders to set and achieve goals. What isn’t measured isn’t improved.