Brushes on the Clean Side

Q: “We recently conducted a mock survey, and the consultant told us that it was acceptable to use brushes in the prep/pack area for inspection. When I argued, they said there are no standards saying you can’t use them. Can you use brushes to inspect instruments on the clean side of sterile processing? Are there any standards that speak to this?”

A: There are many “experts” in sterile processing. I see a lot of them on social media pages—not everything found on Facebook or a Reddit thread is good quality information—but it’s surprising to hear this coming from a consultant who is supposed to be guiding your facility in the right direction. The answer is “NO,” you shouldn’t use brushes in the inspection areas, but let’s dive deeper into why.

Standards

There are standards that support not using brushes on the clean side. The big one that sterile processing departments use is ANSI/AAMI ST79:2017 Comprehensive guide to steam sterilization and sterility assurance in health care facilities (also colloquially known within the industry as the “sterile processing bible”). Blasphemy aside, let’s see what it has to say on the subject:

ANSI/AAMI ST79:2017 - 7.6.1 General considerations¹

h) Brushing is a cleaning function and should only be done in the decontamination area and not in the clean (preparation and assembly) area.

That’s clear instruction from AAMI ST79:2017, and it’s not up for debate. If your facility follows AAMI standards, or especially if they are referenced in your policies, then you should follow that statement.

So why the confusion?

As with most debates in the sterile processing (SP) space, the confusion comes from a good place. We know we should make sure lumened instruments are inspected for cleanliness before being sterilized and sent to surgery, where contaminated instruments can potentially cause an infection.

In the old days (I sound like an old man SP technician now . . . when did that happen?!), brushes and/or sterile water flushes were the only tools at our disposal to “verify” (more on this word later) cleanliness. It’s likely that the consultant that came to your department also came from that era of “verification” of cleanliness by use of brushing.

This is further confused by manufacturers that sell brushes as “single-use inspection brushes,” and market them for “clean-side” inspection.

What is brushing?

This is not an existential or philosophical question. What it boils down to is the action: Brushing = Cleaning. You are brushing an instrument to see if you can remove soil from the device, and if the brush comes out either clean or soiled, you can “verify” if that device is clean or contaminated. Brushing is a cleaning action, and not a proper form of inspection.

Surveyors, like those from The Joint Commission (TJC), the Accreditation Association for Ambulatory Health Care (AAAHC), or DNV (which, fun fact, stands for Det Norske Veritas or “the Norwegian Truth”) also see brushing as a cleaning action, which is why surveyors have started giving findings to hospitals when they see brushes on the clean side. You might explain to them, “Well, these are inspection brushes. We only use them on the clean side,” but a surveyor doesn’t know the difference between using brushes in different settings. They see a brush, and a brush is used for cleaning.

If you are still using brushes on the clean side, the other factor that you should consider is, “What happens when we find soil on an instrument after brushing?” That instrument (and the entire set it came from) should be sent back to the decontamination area.

What about cross contamination?

That brush is certainly contaminated, and possibly the workstation; maybe even the technician who was holding the brush? Brushes clean by way of friction against surfaces, so is there a possibility that the brush aerosolized contamination? All things to consider with this issue.

What should we use if we shouldn’t use brushes on the clean side?

This is really the crux of our issue today. If Brushing = Cleaning, what are some ways that we can inspect these devices? Let’s get back to that terminology from earlier.

Verify: to establish the truth, accuracy, or reality of. (Merriam-Webster Dictionary online.)²

In this case, we are establishing our claim that our particular instrument or device is clean. There are a few ways to do this in modern times. (Another phrase that makes me sound ancient!)

Visual inspection: One of my favorite all-time keynote speeches at Healthcare Sterile Processing Association (HSPA) was when the legendary Sharon Greene-Golden gave her “View from My Window” talk. She talked about how in the old days (you know, since we’ve clearly established my old age now), “We used to clean suctions in decontamination, send them over to the clean side, say the magic words, ‘Hakuna Matata,’ and hope for the best!”^3,4 But now we have microscopes and borescopes and can visualize all the things we couldn’t previously see. Want to know if your lumen is clean? Put a borescope down the lumen and see if it was cleaned properly.

Swabs: Another form of inspection that should be considered. Swabs are used in various industries for sample collection purposes. (Note: Surveyors are seeing them in the medical field.)

Cleaning verification tests: Objective methods of testing that are run to show cleanliness of a device. If swabs and visual inspection are still considered subjective methods (meaning up for interpretation), then cleaning verification testing would be an objective method (meaning unbiased and based on factual data or measurable phenomena). Isn’t that what we’re really looking for—something measurable that can show if a device is contaminated?

There are several cleaning verification tests sold by many manufacturers in the sterile processing space. They can be:

Protein-based: testing for residual protein.

Hemoglobin-based: testing for presence of hemoglobin.

Adenosine triphosphate (ATP): testing for the primary energy carrying molecule found in all living cells.

Some cleaning verifications that combine multiple methods of testing:

References:

1. AAMI (2017). ANSI/AAMI ST79:2017 Comprehensive guide to steam sterilization and sterility assurance in health care facilities, 7.6.1 General considerations. Arlington, VA: Association for the Advancement of Medical Instrumentation.

2. Merriam-Webster Online. (n.d.). VERIFY Definition & Meaning. Merriam-Webster Dictionary. https://www.merriam-webster.com/dictionary/verify

3. Allers, R., Minkoff, R. (Directors); Mecchi, I., Roberts, J., Woolverton, L. (Writers). (1994). The Lion King [Film]. “Hakuna Matata.” Walt Disney Animation Studios. Burbank, CA.

4. Greene-Golden, S. (Sunday, May 7th, 2023). “View From my Window” [eShow Management conference]. Healthcare Sterile Processing Association (HSPA), Gaylord Opryland Resort & Convention Center (Delta A). Nashville, TN. https://s6.goeshow.com/hspa/annual/2023/conference_programs_sessions.cfm?session_key=6FDE4DC9-DF5E-071C-A5FA-B5644239C698&session_date=Sunday,%20May%2007,%202023

5. Healthmark. (Dec 2024). ProCheck-II™. Healthmark, A Getinge company. https://www.hmark.com/product/expose-contaminants-on-surfaces-with-prochek-ii

6. Healthmark. (Dec 2024). Getinge Assured SafeStep - ATP Monitor. Healthmark, A Getinge company. https://www.hmark.com/product/getinge-assured-safestep-atp-monitor/

7. Getinge. (2019). Getinge Assured SafeStep - ATP Monitor [White paper/Sales Flyer]. Getinge AB. https://www.getinge.com/dam/hospital/documents/english/mcv00095087-safestep-flyer-us-en-us.pdf