Q Our hospital has made a commitment to go green and each department head is required to identify significant ideas that could be included in the hospital’s master plan for a sustainability program. As the director of Surgical Support Services, (which includes the Central Processing department) I was wondering if it would be advisable or wise to include the reprocessing of "single-use" devices (SUDs) as part of my ideas?

A Many hospitals have engaged the services of third party reprocessing service companies that are FDA cleared and registered to reprocess single use devices. These reprocessing companies must go through a rigid process to receive clearance to reprocess each SUD for which they offer a reprocessing option. (See the August 2010 CS Solutions column for more detail) Hospitals have reported huge financial savings in supply expenses through reprocessing SUDs and further savings have been realized through a significant reduction in waste and trash handling. Less waste going to land fills is a positive outcome and environmentally friendly. Reprocessing of SUDs is also endorsed by environmental groups like Health Care Without Harm, Practice GreenHealth, the Global Health and Safety Initiative, and is listed as an environmentally friendly, recommended practice by the Association of peri-Operative Registered Nurses (AORN). It would make perfect sense for you to consider and evaluate the benefits and impact of incorporating the reprocessing of SUDs into your sustainability program.

Many group purchasing organizations such as, Premier, HealthTrust, MedAssets, VHA and others are now including FDA-regulated reprocessing of SUDs as part of their sustainability programs, and are recommending the practice to their members.

Q We are renovating our central processing area and are having a debate as to where the ultrasonic washer should be located. We have always had the ultrasonic washer in our instrument assembly room, which allowed us to re-clean any instruments found soiled after going through the automatic washer. Our infection control coordinator feels the ultrasonic washer should be placed in the decontamination area. What would you advise?

A Best practices and techniques state that soiled and clean materials should be segregated. Generally, sterile processing involves the decontamination (cleaning), assembly, inspection, packaging and sterilization of medical devices. Each functional work area, e.g., decontamination, preparation and sterilization, and sterile storage should be physically separated by walls and restricted to designated work activities and specific personnel.

Environmental control considerations include special air handling and circulation, a one-way flow of work through each work area, specific dress codes such as requiring personal protective equipment, and traffic control patterns to guard against and minimize the potential for cross-contamination. An ultrasonic cleaner is an automated washer used to clean instrumentation. Cleaning activity should be restricted to the decontamination area. The ultrasonic cleaner should be located in your decontamination work area. During inspection any instruments rejected due to inadequate cleaning should be returned to the decontamination area through a pass-through window and not cleaned in the preparation / assembly area.

Q I am an OR nurse and recently accepted the position as a clinical resource and QA coordinator for the OR and CSS. We have been having significant problems with residual soil and organic matter being discovered in our cannulated instruments at the sterile field. We have instituted strict visual inspections of lumens including running a white pipe cleaner through the channel to detect soil. We have also started to run all cannulated devices through our ultrasonic where most are connected to a manifold. Nonetheless we still have far too many incidents of soil being found during use. Is there anything more you could suggest we can do for better QA of this cleaning process?

A While visual inspections are a critical part of QA, many soils – especially those found in channels – cannot be seen. Further many soils, films, etc., cannot be detected by the naked eye. Cleaning efficacy must include the removal of all soils visible and invisible. Cannulated and channeled devices pose a real challenge to the cleaning process. For best results the reprocessing of soiled instruments should begin as soon as possible. Soiled instruments should be kept moist to prevent blood and other organic matter from drying. Enzymatic soaks and foams can help in this regard while also breaking down soil for more effective cleaning. All lumens should be flushed manually and the decontamination sinks should be equipped with a spray gun to facilitate this function. If you have one it is a good practice to connect your cannulated instruments to the flushing manifold in your washer or ultrasonic. To confirm the cleaning efficacy of the flushing manifold you can conduct QA monitoring utilizing a lumen testing device (see figure 1). This device replicates the cleaning challenge presented by cannulated instruments. A stainless steel plate containing organic testing soil is placed inside of the lumen testing tool. At the completion of the washing cycle the stainless steel plate is removed and the cleaning efficacy of the washer is verified. Cleaned lumens can also be tested for soil residual such as, blood, proteins and carbohydrates by flushing the cleaned channels with water and dipping a testing strip into the captured water which will identify residual soils. (See figure 2).

Figure 1	Figure 2