Earlier this year, I was invited to work on a project for our healthcare system involving standards for point-of-use cleaning practices. The mission of our work group was to establish minimal expectations as a prevention effort, in order to further reduce the risk of infections, and improve overall quality for patients. During the project, I wrote a position statement to share my perspective on why, in my professional opinion, point-of-use cleaning is a critical area for healthcare facilities to focus improvement initiatives. Bellow you will find my rationale for taking this stance:
Healthcare systems pride themselves on being a leader in best practice. Organizations influence one another on a national level and should operate in a way that promotes others to view them as an entity that exudes expertise, quality, and safety.
The evidence for the value of point-of-use cleaning, as a prevention effort, is high and well documented. According to AORN Guidelines for Perioperative Practice Edition 2018: Guideline for Cleaning and Care of Surgical Instruments Recommendation III – Instruments should be cleaned and decontaminated as soon as possible after use, “Instruments should be kept free of gross soil during the procedure. [2: High Evidence] Periodically during the procedure, the scrub person should use sterile water to irrigate instruments with lumens. [1: Strong Evidence]”.
Point-of -use cleaning is not a new concept and has been recommended as a best practice standard of care for many years. Surgical technological schools implement this training into their programs by following AST Guidelines for Decontamination of Surgical Instruments, Standards of Practice for the Decontamination of Surgical Instruments Effective April 16, 2009, which states that, “The cleaning of instruments should begin during the surgical procedure to prevent drying of blood, soil and debris on the surfaces and within lumens”.
In addition AST’s publication entitled Guidelines for Best Practices for Breaking Down the Sterile Field, approved October 20, 2008 and revised June 1, 2018 provides further support for consistent point-of-use cleaning practices but also discusses rationale for continuing education and overall responsibilities of the scrub. Guideline II Section C states, “The principles of “point-of-use (POU) decontamination” of instruments should be applied by the CST; POU decontamination is the beginning of the cleaning process of instruments. POU decontamination is important because it assists in lengthening the life of instruments by preventing blood and saline from corroding the finish on instruments. Additionally, blood and body fluids that are allowed to dry on instruments are difficult to remove versus when they are kept moist. The CST should try to handle the contaminated instruments as little as possible while breaking down the sterile field.”
Should we only elevate our expectations when accreditation surveyors are looking to score against a particular area? Absolutely not! Having the backing and support of any accreditation survey organization is helpful in holding facilities accountable to best practice, however, it is not necessary. Who is to say we as healthcare systems should not go above and beyond to ensure that we are following the evidence outlined in the standards and guidelines that are recommended by AORN, AST, AAMI, etc…
There is a lack of consistency among manufacturer’s instructions for use (IFU’s). While some OR staff may monitor IFU’s, most do not and it is difficult to expect clinical staff to remember which devices state POU cleaning and which ones do not, without much more sophisticated systems in place for data delivery. The idea of limiting point of use cleaning only to manufacturers who have specifically mentioned to do so, is setting ourselves up for undue risk. As manufacturers catch up and revise their IFU’s, we will find that more and more outline this expectation. Similarly to Universal Precautions, implementing a standard precaution into work instructions for POU cleaning can allow facilities to remain ahead of the curve. (See bellow for IFU examples.)
We can be certain that there is a movement going toward POU cleaning as an expectation in the future, as more awareness is generated from the public through incidents that make media attention. We must prevent our facilities from being exposed to this vulnerability by creating interventions in our practice that promote the safest outcomes for our patients.
The main obstacle to feasibility in POU cleaning is the current culture in the OR for case turnovers and scheduling. Transitioning to more efficient means of turnovers and scheduling caseloads would have an additional impact on the surgical services value stream related to instrument availability, instrument processing time, and the reduction of IUSS, which drives ultimately the SSI rates. The argument of time as a limitation can be overcome with the adoption of creative solutions such as surgical turnover kits, which can significantly reduce the time it takes for turnovers. In addition, if surgical scrubs are proficient in wiping while they go, the practice is built in and hardwired into their day to day practice.
We understand that it is a collaborative effort and commitment between all stakeholders to ensure that our system is delivering on our promise to our communities. We must do everything within our power to create an environment that fosters healing by ensuring that we maintain conditions that are conducive to reducing the risk of infection. HAI’s are preventable, and POU cleaning is one piece of the whole picture that contributes to a prevention effort that reduces the opportunity for harm.
Developing guardrails that are approved by a multidisciplinary risk assessment team, Perioperative Administrative Council, and Sterile Processing Leadership Committee for healthcare settings can ensure that appropriate measures are taken. The standard that we set forth is to prevent Immediate Jeopardy and establish a benchmark of excellence. Organizations can take a stand with the support of executive leadership and shape the future of infection prevention from a collaborative and comprehensive approach.
By Lisa Wakeman MBA, CRCST, CIS, CHL, MBTI
Circle of Care National Director of Education
- AORN; (2018). Guidelines for perioperative practice Edition 2018: aorn guideline for cleaning and care of surgical instruments. Published by AORN. Denver, CO.
- AST; (2019). Guidelines for best practices for breaking down the sterile field.Retrieved January 4, 2018. http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Guidelines%20Breaking%20Down%20Sterile%20Field.pdf
- AST; (2019). Standards of practice for the decontamination of surgical instruments. Retrieved January 4, 2018. http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard_Decontamination_%20Surgical_Instruments_.pdf
- Smith & Nephew:
“Preparations at the point of use prior to processing
Keep instruments moist after use to prevent soil from drying on them. Follow Universal Precautions for handling and transporting contaminated instruments to the designated cleaning area. Contaminated instruments should be transported to the area for cleaning in a way that avoids contamination of personnel and hospital.
Prior to cleaning, gross soil should be removed from the surfaces, crevices, mating surfaces, cannulas, joints and all other hard-to-clean design features. Dried on soil is difficult and sometimes impossible to remove with automatic washing.
Instruments should be cleaned as soon as possible after use to prevent blood from drying on the devices. (A four-hour dry time is used for cleaning validations of Smith & Nephew Orthopaedics reusable devices.)” p.4
After use (within a maximum of 2 hours post-operatively) remove gross soil using absorbent paper wipes. Intensive rinsing of the reusable device with fluent water or transfer of the medical devices into a bath with an aldehyde-free disinfectant solution is highly recommended..” p.6
“• At point of use, soiled instruments must be removed from metal or polymer trays and moistened to prevent debris from drying before transportation to the reprocessing area for manual and/or automated cleaning procedures. Do not clean soiled instruments while in polymer or metal trays. Single-use devices must be cleaned separately from soiled instruments.” p.7
“D. Point-of-Use Preparation for Reprocessing
• Remove excess body fluids and tissue from instruments with a disposable, non-shedding wipe. Place instruments in a basin of distilled water or in a tray covered with damp towels. Do not allow saline, blood, body fluids, tissue, bone fragments or other organic debris to dry on instruments prior to cleaning.
Note: Soaking in proteolytic enzyme solutions or other precleaning solutions facilitates cleaning, especially in instruments with complex features and hard-to-reach areas (e.g. cannulated and tubular designs, etc.). These enzymatic solutions as well as enzymatic foam sprays break down protein matter and prevent blood and protein based materials from drying on instruments. Manufacturer’s instructions for preparation and use of these solutions should be explicitly followed.
• For optimal results, instruments should be cleaned within 30 minutes of use or after removal from solution to minimize the potential for drying prior to cleaning.” p. 8