Question: We do a great deal of manual washing of surgical instruments and other medical devices in our central service department. I know that it is important to use cleaning agents properly and that dilution rates are important. I worry that staff may not always be as conscientious as they should be when it comes to using cleaning agents. Do you have any suggestions on how I might be able to ensure the proper use of detergents by all employees?

Answer: The effectiveness and quality outcome of all manual procedures are contingent upon the human element. It therefore is critical that all staff are well educated in regard to all manual cleaning procedures including the appropriate use of cleaning agents, detergents, and other chemicals. Each employee’s competency in this regard should be verified and documented. The precise concentration and use, in accordance with the manufacturers’ instructions, is essential to ensure the safe and efficient use of their products. The problem with the use of manual cleaning agents is that users often are unsure of just how much detergent to use. For chemicals and cleaning agents to be effective the proper ratio of chemical to water is imperative. Manufacturers’ instructions will specify the dilution rate ratio; this is usually specified by ounces of product per gallon of water. The specified dilution ratio must be precise; there is no room for guesswork. Many individuals feel that if a little is good then more must be better - however nothing could be further from the truth when it comes to the use of detergents. Too low of a dilution rate will not effectively clean items while too high of a dilution rate may leave a residual film on devices which could be deposited into a patient during use affecting their welfare and safety. This residual film may also impede the sterilization process, and be damaging to medical devices. To minimize the risk of inappropriate mixture ratios you can place graduated markings on the inside wall of sinks to identify fill points for desired gallons of water. Measuring cups or pumps must be used to dispense the appropriate amount of chemical into the sink of water. The efficacy of this process relies on the employee’s conscientiousness and integrity. Some detergent manufacturers can provide an accurate precise dispensing method utilizing a proportion control device, which is attached to the sink faucet and detergent vessel. (see Figure 1) Once the water is turned on and the dispensing device is activated the precise ratio of chemical / detergent will mix with the water. Utilizing this system the precise dilution is assured regardless of how much water you utilize.

Figure 1:
Automated detergent faucet dilution proportioner

Question: Our corporate procurement department recently signed a contract for a new line of detergents. The new products are clear in color and do not foam or produce suds. The detergents we previously used were blue in color and foamy which allowed us to visibly see them in use. The problem with this new stuff is that we can’t see it and aren’t sure if we are using enough. Staff also have the tendency to use more of it just to be safe. We have had no complaints about the cleanliness of our instruments since using the new detergent but I just don’t feel confident about using it. What are your thoughts and suggestions on this?

Answer: It is very unfortunate that your corporate purchasing department would make a change in cleaning products without the input and approval of the users. Cleaning agents and chemicals are designed for specific uses and cleaning methods – there is no one size fits all. For that reason clinical and technical expertise is critical in the selection process of these products. CPD representation should be part of the product standardization committee at your hospital or corporate system. If this is not the case at your organization I would suggest that you as well as your colleagues from the other hospitals within the system make this request to the appropriate administrative source. You may want to document your reasoning sighting the critical impact CPD operations has on other departments and quality patient care. You should also outline and emphasize the technical and clinical complexities and expertises required to effectively and safely manage this specialized discipline including product selection.

The answer to the previous question addresses the importance of the proper utilization of detergents in relation to precise concentration and dilution ratios. It is very important that you take immediate action to ensure that you and your staff use your new products in accordance with the manufacturers’ instructions. The coloring of a detergent serves no real advantage to the cleaning process. Adding color to detergents is most often accomplished by adding a dye to the chemical. This dye can actually transfer onto instruments causing a discoloration to the finish. This is often the result of using excessive concentrations. Blue or greenish staining on instruments, basins, containers and other metallic utensils has often been traced back to the dye in cleaning agents. Clear colored non sudsing detergents also offer the added advantage of allowing visibility to what is below the water surface, which satisfies OSHA regulations in regards to safe work protocols. Foaming agents and suds do not facilitate thorough cleansing, as a matter of fact they can adversely affect the cleaning outcome in that they are not free rinsing and can leave a film on devices causing spots and stains. As mentioned previously, residual films can also impede the efficacy of the subsequent sterilization process as well as the potential for being deposited in the patient during use. We have been conditioned to think suds are important in cleaning through the use of household cleaning products. The sudsing in household dish washing products is a marketing ploy – psychologically, when we don’t see suds we add more detergent, which in turn utilizes more product and increases sales. HPN