Cost conscious chemical use; processing carbide insert instruments in the ultrasonic

by Ray Taurasi

Q Like so many others, our hospital is facing some serious financial woes and each department is facing significant budget cuts. My budget is already very tight, the work areas are run down and much of the equipment is obsolete. We are a small rural hospital. We only have one very old automated instrument washer, no ultrasonic and one steam sterilizer. When things get busy or equipment breaks down we have to do a lot of manual cleaning. I am really at a loss as to how I can possibly reduce my operational expenses. I know I am going to have to cut back on my chemical and detergent usage. I don’t see how I can get by with less detergent usage, but I am thinking perhaps I could eliminate the use of enzymes, as I doubt that would have much of an impact on the end results. Do you think it’s that important to use enzymes? Are there any regulations requiring the use of them?

A There is no "regulation" that mandates the use of enzymes. However the use of enzymes in the cleaning process is very important and their use has become the standard of practice. Blood and other organic matter is very difficult to remove from medical devices. Because of the design complexity of many surgical instruments and devices the cleaning process has become even more challenging. Many medical devices have moveable parts, crevices, serrations, small channels and the like where organic matter can adhere. Enzymes should be used during the prewash phase of the cleaning cycle. They basically attack and break down large organic molecules which facilitates more effective removal during the washing process. In today’s environment the use of enzymes is a critical component in the cleaning process.

You might want to assess your current practices ensuring that your chemicals and detergents are being used appropriately and at the correct levels and concentrations. Proper equipment functioning, water conditions, and temperatures can maximize the performance of detergents and enzymes. When these conditions are right concentration and usage can often be reduced, decreasing costs. Your chemical manufacturer can assist you in that regard and very likely may be able to provide guidance in your utilization that could reduce your expenditures.

You also have many options in detergents and enzymes; you’ll want to choose wisely. Different enzymes work on different soils so select enzymes that are effective for the soils we see in sterile processing. The most essential enzymes are those that are effective on Protease, Lipase and Amylase:

• Protease – Breaks down blood, mucous, feces, and albumin.

• Lipase – Breaks down fatty deposits such as bone marrow and adipose tissue.

• Amylase – Catalyzes (changes) starch.

If you are using a product that is costing more because it has more enzymes than are necessary for your application than perhaps you could find a more economical option.

The cleaning process is a critical function which if not done effectively can adversely affect the outcome of the sterilization process posing a real risk to patient safety. There can be no short cuts in this precise process and eliminating essential products to the efficacy of the process is non-negotiable as a budget reduction.

Q I recently attended a seminar on cleaning surgical instruments and the presenter reviewed the various cleaning tools that should be used such as brushes, spray guns, magnifiers, etc. They also reviewed the use of washer disinfectors, cart washers, AERs and ultrasonics. I was surprised and puzzled when she said that instruments with carbide inserts could not be processed in an ultrasonic washer. We always run our needle holders with inserts through the ultrasonic and have had no known problems. Should we not do this?

A I have never heard this before so I consulted with several instrument manufacturers and repair companies. They all stated that the carbide insert needle holders can be washed in the ultrasonic assuming the hospital is using a validated process and cleaning products.

It is very important that you use a reputable and qualified instrument repair company. The inserts after normal wear and tear do need to be replaced. As is the case with all surgical instrumentation it is wise to have a preventative maintenance program in place where all instruments receive routine professional inspection and appropriate servicing. When the inserts are replaced they are secured with a silver-copper-tin-zinc alloy that forms a strong bond between the insert and instrument jaw. In extreme cases, if corrosive cleaning agents such as strong oxidizers and those with a high acid base are utilized, over time they will cause pitting that can affect silver solder, and any aggressive cleaning and mechanical action including ultrasonic could loosen the insert. Following manufacturers’ IFUs and utilizing the appropriate chemical cleaning agents, there should be no problem processing carbide insert instruments in the ultrasonic.