While the removal of blood, tissue and bioburden is, of course, critical, it isn’t the only matter CSSD professionals must consider and remove. Devices and processing equipment may also harbor dangerous residuals that can negatively impact decontamination and sterility, and, ultimately, patient safety. These residuals are essentially left-behind organic matter that can cling to devices even after they have undergone seemingly thorough cleaning and disinfection/sterilization. Residuals may originate from previous patients, tap water, chemical detergents and enzymatics, and biofilms that may have been present in washer-disinfectors or on instruments themselves.

The presence of residuals can have lead to negative outcomes, not the least of which might include hospital-acquired infections, severe inflammation and fever, explained microbiologist Michele Alfa, Ph.D., FCCP, professor for the department of medical microbiology at the University of Manitoba, Canada. Alfa spoke of these risks during her session, "Unraveling the Importance of Residuals," at the 2010 IAHCSMM Annual Meeting in May.

Although detergents and enzymatics can do a terrific job of removing bioburden, Alfa stressed that residuals can rear their ugly head when these solutions aren’t properly rinsed from instruments.

"The proteins in enzymatics can effectively break down bioburden and other organic matter on instruments, but those same proteins can also serve as a food source for bacteria and organic matter if instruments are soaked in enzymatics for an extended period," and then aren’t fully rinsed, she explained.

Another point to consider: even the most advanced, state-of-the-art washer-disinfectors can inadvertently expose instruments to residual matter. Alfa reasoned that CSSD professionals can run into problems if they assume the equipment is working properly just because the water is flowing and the power is on. She referred to studies that have shown how instruments can become contaminated with significantly higher levels of organic matter (carbohydrates and potentially dangerous endotoxins) after being subjected to cleaning in an automated washer.

"That’s because, in some cases, that organic matter has built up in the unit’s water chamber," she reasoned. "Automation is great, but the equipment is only as good as the driver."

To help ensure that equipment is cleaning properly, she said that CSSD professionals may want to consider using a cleaning monitor as part of a quality plan. According to Alfa, these tools, which are available from a number of vendors, can especially benefit CSSD professionals who are relying on old, outdated equipment and are looking for validation that the equipment is operating properly and as intended. The use of monitors may also benefit facilities with new (or newer) processing equipment, however, according to Alfa. "Just because equipment isn’t old and outdated doesn’t necessarily mean it’s working properly."

Whatever the situation, it would behoove CSSDs to factor organic residuals and biofilm into their processing protocols. They should also recognize that not all devices should be treated equally. The need for using only sterile treated water when reprocessing ophthalmic surgical instruments is a prime example, noted Alfa. Sterile treated water, she said, can help prevent the development of Toxic Anterior Segment Syndrome (TASS), which causes pain, inflammation and blurred vision, and typically develops in cataract patients within 12-24 hours post-surgery.

Of course, no practice can trump the importance of ongoing staff education and a willingness of each and every member in the CSSD team to stand up and do what’s right for the sake of quality patient care. If a problem arises, whether it pertains to equipment, devices, policies, or practices, the team must take notice and respond swiftly and appropriately.

"If we see something, we must stand up and say, ‘No, this is not acceptable.’ That’s the only way changes will get made."

When addressing the risks of residuals, it would also behoove CSSDs (and the facility, as a whole) to educate other departments on the importance of proper detergent and enzymatic use, and removal – including those in the OR and Labor and Delivery, where staff are often responsible for spraying enzymatic detergents on instruments prior to their being sent to the decontamination area. And, finally, Alfa stressed that CSSDs should not underestimate the value of consistent, diligent documentation of equipment monitoring results. It’s a wise practice that she said can help CSSDs make a stronger case for newer, better functioning equipment.