AORN JOURNAL

MARCH 1992, VOL 5 5 , NO 3

Recommended Practices CAREOF INSTRUMENTS, SCOPES, AND POWERED SURGICAL INSTRUMENTS

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he following recommended practices were developed by the AORN Recommended Practices Coordinating Committee and have been approved by the AORN Board of Directors. They were published as proposed recommended practices in the August 1991 AORN Journal for comment by members and others. These recommend practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the recommended practices can be fulfilled. AORN recognizes the numerous different settings in which perioperative nurses practice. The recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional operating rooms, ambulatory surgery units, physicians’ offices, cardiac catheterization laboratories, endoscopy rooms, radiology departments, and all other areas where surgery may be performed. Purpose: These recommended practices provide guidelines to assist the perioperative nurse in the decontamination, cleaning, maintenance, handling, storage, and/or sterilization of surgical instruments, endoscopes, and powered surgical instruments. The perioperative nurse needs to be cognizant of this information so a safe environment can be provided for the patient. The appropriate committees in the practice setting should review all practices 838

related to care and handling of instruments, endoscopy equipment, and powered surgical instruments.

Recommended Practice I An instrument should be used only for the specific purpose for which it was designed. Interpretive statement 1: Perioperative personnel should be responsible for the correct use of instruments during a surgical procedure. Rationale: Proper use of instruments will ensure their effectiveness. Instruments that function ineffectively can cause delay in the surgical procedure and increase the risk of infection and patient injury.’

Recommended Practice II Instruments should be kept free of gross soil during the surgical procedure. Interpretive statement 1 : Instruments should be kept free of gross soil by wiping instruments with a sponge moistened with sterile water. Rationale: Inadequate cleaning of dried blood and secretions on instruments may result in possible concealed organisms. Corrosion, rusting, and pitting occur when blood and debris are allowed to dry in or on surgical instruments.2 Interpretive statement 2: Instruments with lumens should be kept

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patent by irrigating with sterile water. Rationale: Instruments with lumens may become obstructed with organic material. Irrigating with sterile water removes residues and prevents tissue damage. Saline causes deterioration of instrument surface^.^

Recommended Practice 111 Decontamination of instruments should occur immediately after completion of the surgical procedure. Interpretive statement 1: Automated cleaning should be used for the initial decontamination of instruments following use. Rationale: Instruments are considered contaminated because the presence of pathogens may not be known at the time of surgery. Immediate decontamination of instruments is necessary for the protection of personnel and to prevent transmission of pathogens! Discussion: The decontamination process for surgical instruments involves four steps: prerinsing, washing, rinsing, and sterilizing. Soaking instruments and prerinsing in an enzymatic detergent solution for a minimum of two minutes effectively removes all visible debris except for ointment, thus proving to be an acceptable alternative to manual cleaning.’ Instruments should be arranged in an orderly fashion in mesh-bottom trays so all surfaces are exposed to the action of the automated cleaner. The following practices should be completed: open instrument box locks, disassemble instruments with removable parts, place scissors, lighter weight instruments, and microsurgical instruments on top, and place heavy retractors and/or other heavy instruments in a separate tray. Interpretive statement 2: When manual cleaning of instruments is recommended by the manufacturer, personnel should wear surgical attire as described in the 840

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“AORN recommended practices for surgical attire” and the instruments should be submerged in warm water with appropriate detergent and cleaned while submerged. Rationale: Delicate instruments usually are washed manually. Adherent particles of tissue, bone, and blood may resist cleaning in the automated cleaner and can cause instrument corrosion. An enzymatic soak solution may be useful for these and other hard-to-clean instruments.6 Discussion: Manual cleaning of instruments must be done in a manner that protects personnel handling the instruments from aerosolization and splashing of infectious material and from cuts, sticks, and other injuries from sharp objects. Prolonged soaking of instruments may be detrimental, and the solution may damage the instrument surfaces. Interpretive statement 3: Manufacturers’ written instructions should be followed for the detergent selection and the proper use, care, and maintenance of the instruments. Rationale: Abrasives will damage the protective surface of the instruments, contribute to corrosion, and impede sterilization.’

Recommended Practice IV Following initial decontamination by manual or automatic decontamination, instruments should be processed in an ultrasonic cleaner. Interpretive statement 1: Manufacturers’ written instructions should be followed for use of the ultrasonic cleaner. Rationale: Instruments are processed in an ultrasonic cleaner to remove small particles of debris from the crevices of instruments.x Interpretive statement 2: Instruments should be rinsed with water and drained after ultrasonic cleaning. Rationale: Instruments must be rinsed with water to

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remove surface suspended particles.' Interpretive statement 3: Manufacturers' written instructions should be followed when placing dissimilar metals in the ultrasonic cleaner. Discussion: Dissimilar instruments (eg, copper, brass, stainless steel) should not be combined in the ultrasonic cleaner. Ultrasonic cleaning of dissimilar metals causes ion transfer resulting in etching and pitting. Chrome-plated instruments may be damaged by mechanical vibrations that cause flaking. Interpretive statement 4: The manufacturers' written instructions should be followed for the detergent selection and proper use, care, and maintenance of the ultrasonic cleaner. Rationale: The use of recommended detergents is important to the overall performance of an ultrasonic system. Ultrasonic cleaning can prolong the life of instruments."

Recommended Practice V Instruments with movable parts should be lubricated after every cleaning according to manufacturers' written instructions. Interpretive statement I : After use of the ultrasonic cleaner, instruments should be lubricated with an antimicrobial, water-soluble lubricant and then drained. Rationale: The ultrasonic cleaner removes all lubricant from instruments." Interpretive statement 2: The lubricant should be prepared and used according to the manufacturers' written instructions. Rationale: The lubricating solution should not be rinsed or wiped off the instruments. The lubricating solution must be water soluble to allow steam penetration; oily solutions cannot be penetrated.'* Discussion: Instrument lubrication should protect against rusting, staining, and corrosion,

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improve instrument function, lessen the growth of bacteria, and allow penetration of steam.

Recommended Practice VI Instruments should be inspected and prepared for storage andlor sterilization following the cleaning process. Interpretive statement 1: Instruments should be inspected for cleanliness, proper function, and alignment, and freedom from defects, sharpness of cutting edges, looseness of pins, and chipping of plated surfaces. Rationale: Inspection provides evidence of thorough cleaning and proper functioning of all instruments. Instruments in poor working condition are hazardous to penoperative personnel and patient^.'^ Interpretive statement 2: Instruments should be dried, then stored. Rationale: Instruments must be thoroughly dried before storage to prevent rust formation. Proper storage provides protection from damage.14 Interpretive statement 3: Instruments with removable parts should be disassembled and placed in trays designed for sterilization. Ring-handled instruments should be secured in a manner that retains an open position. Rationale: The sterilizing agent must contact all surfaces to ensure sterilization. Instrument trays are designed for effective sterilization and provide space for orderly arrangement of instrument~.'~ Interpretive statement 4: Delicate and sharp instruments should be protected according to the manufacturers' written instructions. Rationale: Damage to delicate and sharp instruments can render them ineffective.

Recommended Practice VII Flexible and rigid endoscopes should be 841

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inspected, tested, and processed according to design and type and manufacturers’ written instructions. Interpretive statement 1: Endoscopic equipment should be handled so as to prevent damage to lenses and fiberoptic components. Rationale: Use of damaged instruments may increase the risk of tissue trauma, infection, and the length of the surgical procedure.I6 Interpretive statement 2: Endoscopes should be disassembled, thoroughly cleaned with an endoscopic processor or cleaned manually, and dried before sterilization or high-level disinfection. Rationale: The removal of dried secretions and organic material is imperative for cleaning, disinfection, or sterilization. Cleaning and drying of the endoscopes and accessories is essential to reduce gross soil and minimize dilution of the disinfectant Interpretive statement 3: Disinfected flexible or rigid endoscopes should be thoroughly rinsed with sterile water and dried before storage. Rationale: Tap water may contain a variety of microorganisms; rinsing should not recontaminate equipment. Moisture retained in channels will create a reservoir for microbial growth.” Interpretive statement 4: Accessories should be decontaminated, cleaned, and sterilized. Rationale: Medical devices with multiple pieces such as endoscopes, which have crevices, joints, and channels, are more difficult to disinfect than flat surfaces because problems may arise in the penetration of a chemical germicide to all parts of the equipment. Removing gross soil from narrow structures such as channels and lumens is diffic~1t.l~ Discussion: The spring-like structures of accessories such as biopsy forceps and cytology brushes are difficult to disinfect. Use of one-time-only dispos842

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able accessories may be safer, more efficient, and more Interpretive statement 5: Sterilization of all parts and accessories of endoscopes should be processed according to the manufacturers’ written instructions. Rationale: Sterilization of endoscopes and accessories ensures patient safety and minimizes the risk of infection.21 Interpretive statement 6: Immediately before use, the disinfected endoscope should be rinsed with sterile water. Rationale: Adequate rinsing with sterile water after disinfection removes residual disinfectant which could cause a toxic reaction in body tissue.”

Recommended Practice VIII Powered surgical instruments should be properly decontaminated, cleaned, and sterilized to maintain optimal performance. Interpretive statement 1: Powered surgical instruments should be decontaminated and cleaned after use. Methods of decontamination should be compatible with manufacturers’ written instructions. Rationale: Any organic debris left on powered surgical instruments hinders the sterilization process and may interfere with their proper fun~tion.’~ Interpretive statement 2: Powered surgical instruments and air hoses should not be immersed in water or placed in the automated or ultrasonic cleaner. Rationale: Permanent damage may result if water enters the internal mechanism of powered surgical instrument^.^^ Discussion: Additional information for processing powered surgical instruments should include the following. Hoses and cords should be inspected for damage or wear. 0 Air hoses of powered surgical instruments should remain attached to hand pieces during cleaning.

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instrument surface. Ultrasonic cleaning is particularly effective in removing soil deposits from hard-to-reach areas. Washerldecontaminator: A processing unit that cleans by a spray-force action known as impingement. This machine uses a vigorous agitation bath combined with jet stream air to create underwater turbulence. This unit cleans, decontaminates, and removes excessive amounts of dried debris from instruments. Washerldisinfector: An automated processing unit that prerinses, washes, lubricates, provides high-level disinfection, and dries a wide variety of surgical products. Washerlsterilizer: A processing unit that cleans by a spray-force action known a s impingement. This machine uses a vigorous agitation bath combined with jet stream air to create underwater turbulence. A sterilization cycle follows the washing cycle.

Notes 1. H Jamner, “Care and handling of surgical instruments ,” J o u r n a I of H o sp ita I Supply , Processing, and Distribution 2 (September/October 1984) 47; P Christensen, D Kropp, “Care and processing of surgical instruments,” Hospital Topics (September/October 1985) 32-35. 2. J J Perkins, Principles and Methods of Sterilization i n Health Sciences, second ed, (Springfield, Ill: Charles C. Thomas, 1982) 237; M H Meeker, J C Rothrock, Alexander’s Care of the Patient in Surgery, ninth ed (St Louis: The C V Mosby Co, 1990) 65. 3. Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 65; American Society for Hospital Central Service Personnel, “Surgical instmmentation,” in Training Manual for Central Service Technicians (Chicago: American Hospital Association, 1986) 90. 4. Perkins, Principles and Methods of Sterilization in Health Sciences, 244; Christensen, Kropp, “Care and processing of surgical instruments,’’ 33; Association for the Advancement of Medical Instrumentation, “Good hospital practice: Steam sterilization and sterility assurance,” AAMI Standards and Recommended Practices 2 (Arlington, Va: Association for the Advancement of Medical Instrumentation) 129. 5. J Kneedler, M Darling, “Using an enzymatic detergent to prerinse instruments,” AORN Journal 5 1 (May 1990) 1326, 1332. 6. Perkins, Principles and Methods of 846

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Sterilization in Health Sciences, 244; Association for the Advancement of Medical Instrumentation, “Good hospital practice: Steam sterilization and sterility assurance,” 130; American Society for Hospital Central Service Personnel, “Surgical instrumentation,’’90. 7. Jamner, “Care and handling of surgical instruments,” 47. 8. American Society for Hospital Central Service Personnel, “Surgical instrumentation,” 94. 9. Ibid Jamner, “Care and handling of surgical instruments,” 47; M S Detwiler, “Ultrasonic cleaning in the hospital,” Journal of Healthcare Materiel Management (April 1989) 48. 10. Detwiler, “Ultrasonic cleaning in the hospital,” 47. 11. Jamner, “Care and handling of surgical instruments,’’ 47; L Underwood, “The care and handling of instruments,” Hospital Topics 61 (January/ February 1983) 46. 12. Underwood, “The care and handling of instruments,” 46; American Society for Hospital Central Service Personnel, “Surgical instrumentation,” 95. 13. Perkins, Principles and Methods of Sterilization in Health Sciences, 266; Underwood, “The care and handling of instruments,” 46; American Society for Hospital Central Service Personnel, “Surgical instrumentation,” 92. 14. Jamner, “Care and handling of surgical instruments,” 47; American Society for Hospital Central Service Personnel, “Surgical instrumentation,” 96. 15. Perkins, Principles and Methods of Sterilization in Health Sciences, 266. 16. Meeker, Rothrock, Alexander’s Care of the Patient in Surgery, 137. 17. Ibid Christensen, Kropp, “Care and processing of surgical instruments,” 35. 18. “Guidelines for cleaning and disinfection of flexible fiberoptic endoscopes (FFE) used in GI endoscopy,” AORN Journal 28 (November 1978) 907; W A Rutala, “Disinfection, sterilization and waste disposal,” Prevention and Control of Nosocomial Infections, ed R P Wenzel (Baltimore: Williams & Wilkins, 1987) 261. 19. Rutala, “Disinfection, sterilization and waste disposal,” 261. 20. “Guidelines for cleaning and disinfection of flexible fiberoptic endoscopes (FFE) used in GI endoscopy,” 907; “Sterilization or disinfection of flexible fiberoptic endoscopes,” (Letters to the Editor) AORN Journal 30 (August 1979) 350, 352. 21. S Crow, “Disinfection or sterilization? Four views on arthroscopes,” AORN Journal 37 (April 1983) 855; J Garner, M Favero, “Guidelines for handwashing and hospital environmental control,

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1985,” Guidelines for the Prevention and Control of Nosocomial Infections (Atlanta: Centers for Disease Control, 1985)10, 12. 22. “Guidelines for cleaning and disinfection of flexible fiberoptic endoscopes (FFE) used in GI endoscopy,” 907; Garner, Favero, “Guidelines for handwashing and hospital environmental control, 1985,” 11. 23. R Young, P Walsh, “Sterilization of powered surgical instruments,” AORN Journal 37 (April 1983) 946. 24. American Society for Hospital Central Service Personnel, “Surgical instrumentation,” 103; J Kneedler, G Dodge, “Implementing perioperative patient care,” in Perioperative Patient Care: The Nursing Perspective, second ed (Boston: Blackwell Scientific Publications, Inc, 1987) 412-413. 25. Young, Walsh, “Sterilization of powered surgical instruments,” 946; American Society for Hospital Central Service Personnel, “Surgical instrumentation,” 103. 26. L J Atkinson, M Kohn, Berry and Kohn’s Introduction to Operating Room Nursing, sixth ed, (New York City: McGraw Hill, 1986) 464. 27. Ibid. 28. J Kneedler, G Dodge, “Instruments and equipment,” in Perioperative Patient Care: The Nursing Perspective, second ed (Boston: Blackwell Scientific Publications, Inc, 1987) 41 1; R M Hall, “The care and handling of air surgery instruments,” AORN Journal (May/June 1966) 83. 29. Hall, “The care and handling of air surgery instruments,” 86. 30. K Kereluk et al, “Sterilization of air-powered instruments by steam: Recommended exposure times,” Hospital Topics 51 (March 1973) 51-57. 31. Young, Walsh, “Sterilization of powered surgical instruments,” 948; Perkins, Principles and Methods of Sterilization in Health Sciences, 258. 32. Perkins, Principles and Methods of Sterilization in Health Sciences, 258; Kereluk et al, “Sterilization of air-powered instruments by steam: Recommended exposure times,” 5 1-57. 33. Kereluk et al, “Sterilization of air-powered instruments by steam: Recommended exposure times,” 51-57. 34. Ibid. 35. Association for the Advancement of Medical Instrumentation, “Good hospital practice: Steam sterilization and sterility assurance,” 5.

Suggested reading Crow, S . “Washer-decontaminator: An evaluation.” Infection Control Hospital Epidemiology 10 (1989) 220-221. Demback, C. “Dual enzymatic detergents: A safer way to decontaminate.” Today’s OR Nurse 11 848

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(September 1989) 220-221. Groah, L K. OR Nursing: The Perioperative Role. Norwalk, Conn: Appleton & Lange, 1990. Harrison, S K, et al. “Cleaning and decontaminating medical instruments.” Journal of Healthcare Materiel Management (January 1990) 36-42. MacDonald, E. “Rigid endoscopes-telescopes: Light cables, light sources.” AORN Journal 40 (July 1984) 56-63. Rothrock, J C. Perioperative Nursing Care Planning. St Louis: The C V Mosby Co, 1990. Ryan, P. “Concepts of cleaning technologies and processes.” Journal of Healthcare Materiel Management (NovembedDecember, 1987) 2027.

Research Committee Issues Call for Experts The Nursing Research Committee of AORN is in the process of identifying experts to participate in a four-round Delphi study to identify research priorities for the Association. If you are interested in being considered for participation in the study, you are invited to submit your resume/curriculum vitae to:

AOFW, Inc Nursing Research Committee Dorothy M. Fogg, staff consultant 10170 E Mississippi Ave Denver, CO 8023 1 The deadline for submission is April 1, 1992. If you are selected to participate in this study, you will be notified by mail. You also will receive the necessary instructions and materials to complete the first round of the study.

Recommended practices. Care of instruments, scopes, and powered surgical instruments.

AORN JOURNAL MARCH 1992, VOL 5 5 , NO 3 Recommended Practices CAREOF INSTRUMENTS, SCOPES, AND POWERED SURGICAL INSTRUMENTS T he following recommen...
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