Operating Room (OR) and Sterile Processing (SP) have a shared responsibility for the care of surgical instruments. The preparation for decontamination begins at the point of use (POU). Nevertheless, many organizations do not follow the guidelines of the current standards. The Joint Commission surveyors have been citing facilities for not following POU care and handling of contaminated instruments and therefore are putting their patients at risk for cross-contamination. OSHA has fined organizations for violating the Blood Borne Pathogen Standard relating to POU care that puts their employees at risk.1
Here are some specific quotes from the most current guidelines/standards from the Association of periOperative Registered Nurses (AORN), the Association for the Advancement of Medical Instrumentation (AAMI) and the Association of Surgical Technologists (AST).
|Begins at POU
|III.a. Preparation for decontamination of instruments should begin at the point of use (POU).
-help prevent organic material and debris from drying on instruments
– can improve the efficacy and effectiveness of cleaning
|6.3 Gross soil should be removed at the POU
– reduce the number of microorganisms, nutrient material that supports growth
|I. The cleaning of instruments should begin during the surgical procedure to prevent drying of blood, soil and debris on the surface and within lumens.
|III.b.1…scrub person should remove gross soil by wiping the surfaces with a sterile sponge moistened with sterile water
III.b.2. Periodically during the procedure, the scrub person should use sterile water to irrigate instruments with lumens
|6.3.1 Throughout the procedure…
– wipe instruments as needed with a sterile sponge moistened with water.
– irrigate cannulated lumens
|I. The CST in the first scrub role should keep the instruments free of debris and blood during the surgical procedure.
– use a sterile water-moistened sponge
– lumens flushed with a sterile, water-filled syringe
– Instruments not being used for the remainder of the procedure, eg, acetabular reamers should be placed in a basin of sterile water to soak.
|Post procedure||III.d. In preparation for transport, sharp instruments must be:
– segregated from other instruments
– confined in a puncture-resistant container
– minimizes risk of injury to personnel handling instruments during cleaning and decontamination
|6.2 Reusable items should be separated from waste at the POU
– separation is best done at the POU by persons aware of the potential for injury from sharps, and the potential infection hazards of the contaminated items
|II. The cleaning of instruments should continue at the point of use post-procedure, including:
– sorting and disassembly of instruments,
– containment, and
– transportation to the decontamination room
|Disassembly of Instruments||III.e. When composed of more than one piece, instruments should be:
ü opened and disassembled according to the manufacturer’s written IFU, and
ü arranged in a manner that will permit contact of cleaning solutions with all surfaces of the instruments.
|6.3.4 When composed of more than one piece, instruments should be opened, disassembled according to the written IFU, and arranged in an orderly fashion.
Disassembling and opening of instruments followed by their placement into the original set configuration minimizes the risk of instrument displacement and efficiency of reprocessing.
|Separation is best done in the OR by the CST
Wipe gross soil from the instruments.
Ringed instruments should be placed in a carrier arranged in single layers or placed on stringers.
ü Box locks should be opened.
ü Assembled instruments should be taken apart.
|Separation of Sharps||III.d. In preparation for transport, sharp instruments must be:
ü segregated from other instruments
ü confined in a puncture-resistant container. [Regulatory Requirement]
Segregation of sharps from other instruments minimizes the risk of injury to personnel handling instruments during cleaning and decontamination.
|6.2 Separation of waste and reusable items at POU
At the point of use, items should be separated into:
ü reusable items,
ü single-use disposable and
ü waste categories
Sharps must be placed in puncture-resistant sharps containers that are OSHA compliant.
|(4) Reusable sharp instruments with points or edges should be placed in a separate puncture-resistant, closable container.
|Instruments open but not used||
III.c. All instruments opened should be cleaned and decontaminated
ü Scrubbed persons may touch them without being aware.
ü Used instruments may come in contact with unused items.
ü Airborne microorganisms may come in contact.
ü Contamination of unused instruments can occur without the occurrence being noticed.2
|6.3.3 All instruments opened in the OR should be considered contaminated whether or not they have been used.
Rationale: Scrubbed persons might touch instruments without being aware of it. Used instruments also might come in contact with other instruments.3
|All instruments that were on the sterile field, used or not used, are considered contaminated and a possible source of microorganisms that could cause an infection in HCWs and patients.4|
POU care and transportation of surgical instruments help to decrease risks to patients, employees, the instruments and the facility. Healthcare facilities should ensure their policies and procedures includes these current published guidelines and standards and that they are routinely followed in both the OR and SP.
- United States Department of Labor. Occupational Health and Safety Administration. Inspection 974812.015 – Hallmark Health – Melrose Wakefield Hospital. https://www.osha.gov/pls/imis/establishment.inspection_detail?id=974812.015.
- Guideline for cleaning and care of surgical instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2019.
- ANSI/AAMI ST79:2017 Comprehensive guide to steam sterilization and sterility assurance in health care facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2017.
- Standards of Practice for the Decontamination of Surgical Instruments Standard of Practice I – The cleaning of instruments should begin during the surgical procedure to prevent drying of blood, soil and debris on the surface and within lumens. Available at: http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard_Decontamination_%20Surgical_Instruments_.pdf