Instrument Processing

Learning objectives
At the end of this topic, students will be able to:
 Describe the steps of instruments and other
items processing
 List commonly used disinfectants
 Explain how disinfectant solutions are
prepared
 Demonstrate the steps of decontamination
process, cleaning process, sterilization and
HLD
 Explain how to store sterilized and high level
disinfected instrument and other items

2
 Introduction
 Every item requires special handling and
processing in order to:
 Minimize the risk of accidental injury

 Minimize blood or body fluid exposure to cleaning

and housekeeping staff
 Provide a high quality end product (i.e., sterile or
high-level disinfected instruments and other
items).
 Key steps in instrument Processing
Decontaminate

 HLD
Clean  Boil
Sterilize  Steam
Chemical  Chemical
High-pressure steam
Dry heat

4 Dry/Cool and Store

Introduction to Chemical
Disinfectants
 Chemical Disinfectant

Chemicals that destroy or inactivate

MOS on inanimate objects
They are not meant to be used on the
skin or mucus membranes
 Chlorine and chlorine releasing compounds
Sodium Hypochlorite (bleach)
Advantages
  Usually is the least expensive and most readily
available disinfectant.
 Easy to prepare and use.
 Quickly inactivates all viruses including HBV,
HCV and HIV, as well as killing tubercle bacillus.
 Very useful for decontaminating soiled surgical
instruments, gloves and other items and large
surface areas
 Chlorine … cont’d
 Limitation

  Inactivated by organic matter.

 Loses potency on standing if left in open

container (replace at least daily).

 May corrode metal instruments with prolonged

exposure (>20 minutes) to concentrations

greater than 0.5%.

 Chlorine … cont’d

Calcium hypochlorite or chlorinated

lime
Available in powder form.
 70% chlorine.

 35% chlorine.
Advantages
 Both decompose more slowly than sodium
hypochlorite
 But they still should be protected by
storing away from heat and light.
 Limitation
 Inactivated by organic matter.

May corrode metal with prolonged

exposure (>10 minutes) > 0.5%conc

More difficult to prepare dilute

solutions in alkaline water (pH >8)

 Formaldehyde
 Can be used as a chemical sterilant, as well
as a high-level disinfectant.
 However have the following limitations
 Causes skin irritation.
 Potential carcinogen
 Irritates the skin, eyes and respiratory tract,
even at low concentrations.
 Produces a dangerous gas (bischloromethyl-
ether) when mixed with chlorine.
Should not be used for HLD or
sterilization if others available.
 Glutaraldehydes
 An alkaline-stabilized 2% glutaraldehyde

 Available as Cidex® or Cidex 7®

Advantages
Not readily inactivated by organic
materials.
Generally can be used for up to 14–28 days.

Noncorrosive and can safely be used on

surgical endoscopes (laparoscopes)

 Limitation
 Can cause skin irritation or dermatitis
with chronic exposure.
Vapors are irritating to mucous
membranes (eye, nose and mouth) and
respiratory tract.
Work best at room temperature (20–25oC
or 68–77oF).
Expensive.
 Preventing Contamination Disinfectants

 Pour solutions into smaller for use during

service delivery.

 Label reusable containers with the date

 Always use clean (for decontamination)

and/or boiled/sterile (for HLD/Sterilization)

water to dilute disinfectants.

 Preventing Contamination Disinfectants
 Prepare and use disinfectant in a clean, less
trafficked and duty area.
 Pour the amount of disinfectant needed for a
given procedure
 Discard any remaining solution at the end of the
procedure (if soiled) or maximum allowable time
for full strength of the solution is completed.
 Store disinfectants in a cool, dark area.

 Avoid storing them in direct light or excessive

heat, as this may reduce their strength.
 Household Bleach Safety

 Use mask, goggles, rubber gloves,

waterproof apron and cape
 Mix in well-ventilated area

 Do not use or mix with other

detergents
 Use cold or room temperature water
to mix

17
Decontamination
19
 What is decontamination?
The process of making inanimate
objects safer to handle by staff before
cleaning.
 Inactivates HBV and HIV
 Must be done before cleaning
It is done by soaking the equipments in
0.5% chlorine solution

20
Instructions for Preparing Dilute Chlorine
Solutions

 % Concentrat e  -1
Total parts (TP) (H2O) =  % Dilute 
 

 5% Concentrat e  = 9 Total parts (TP) (H2O)

Total parts (TP) (H2O)=  -1
 .5% Dilute 

To make a 0.5% chlorine solution from 5%

bleach, mix 1 part bleach to 9 parts water.

21
 Examples Using 5% Bleach for
0.5% Concentration

One part bleach to 9 parts water (use the

same container to measure the bleach and
water)
22
Instructions for Preparing a Chlorine Solution
from a Powder

 % Dilute 
Gram/Liter X 1000
 %= 
 Concentrat e 

 .5% Dilute 
Gram/Liter = X 1000 = 14.2 Gram/Liter
 35% Concentrat e 
 

To make a 0.5% chlorine solution from

a 35% chlorine powder,
mix 14.2 grams of powder to 1 liter of water.

23
 Decontamination practices

 Place instruments and

reusable gloves in 0.5%
chlorine solution after use
 Soak for 10 minutes and
rinse immediately.
 Wipe surfaces (exam
tables) with chlorine
solution
 Flush syringe and needles
with 0.5% chlorine solution
24
 Use two buckets, one filled with 0.5% chlorine
solution and one with water, so instruments can be
placed in the water after 10 minutes to help prevent
corrosion.

25
Completely submerge
instruments

26
Labeling of the containers is one of the important
aspects of decontamination .

27
 Cleaning

 Physically removing infectious agents and other

organic matters
 Method of mechanically reducing the number of
microorganisms, especially endospores
 Doesn’t necessarily destroying infectious
agents

28
 Cleaning cont--d

 Is an essential pre- requisite to ensure

effective disinfection or sterilization
 Use of soap is important for effective
cleaning
 However, the use of hand (bare) or
powdered soap is discouraged.
 Use liquid soap.
 Cleaning
Cleaning practices
 Use PPE during cleaning
 Disassemble instruments
 Wash with detergent,
water, and a soft brush.
 Scrub instruments under
the water surface until
visibly clean.
 Thoroughly rinse with
clean water.

30
Sterilization and Storage
 Sterilization

Destroys all MOS , including

endospores
Used for instruments and other items
that come in direct contact with the
blood stream or tissue under the skin

32
Common Methods of Sterilization
High-Pressure Steam Chemical
(autoclave)

Dry-heat
(oven)

33
High-Pressure Steam Sterilization
(Autoclave)
 Principles:
 Steam, especially under pressure, carries thermal
energy.
 The protective outer layer of the microorganisms
can be softened by the steam, allowing
coagulation.
 Certain contaminants, such as grease or oil
materials, can protect microorganisms against the
effects of steam.
 Requirements:
 Adequate contact
 Sufficiently high temperature
 Correct time
 Sufficient moisture
34
 Autoclave … Cont’d
The temperature, pressure and time combination
for steam sterilization is:

 121°C (250ºF); 106 kPa (15 lbs/in2) pressure:

 20 minutes for unwrapped items

 30 minutes for wrapped items

1320C (2700F), pressure of 30lbs/in2 for 15

minutes for wrapped items.

 Allow all items to dry before removing.

35
 Autoclave…cont’d
 Sterilization depends on correctly
following certain practices and
processes including:
 Routine maintenance
 Preparing items to be sterilized
 Packing and wrapping
 Operating
 Unloading the sterilizer
36
 Loading an Autoclave

37
 Autoclave…cont’d
Instructions for operating steam sterilizer
Decontaminate, clean, and dry all instruments and
other items to be sterilized.
 All jointed instruments should be in an open or
unlocked position; when possible, instruments
should be disassembled.
Instruments should not be held tightly together by
rubber bands.
Allow free circulation and penetration of steam to
all surfaces.
 Wrap instruments in double thickness of muslin
or
38
newspaper.
 Autoclave
Instructions for operating steam sterilizer
Allow instrument packs to dry completely before
removal.
Wet packs act like a wick, drawing in bacteria,
viruses, and fungi from the environment.
Wrapped instrument packs are considered
unacceptable if there are water droplets or visible
moisture on the package exterior when removed
from the autoclave.
Place sterile trays and packs on a surface padded
with paper or fabric, away from windows or fans.
Wrapped items remain sterile as long as the pack
remains clean, dry (including no water stain), and
intact.
39
 Dry Heat Sterilization (Oven)
 Principles:
 Dry heat sterilization is accomplished by thermal
(heat) conduction.
 Initially, heat is absorbed by the exterior surface of
an item and then passed to the next layer.
 Microorganisms die as their proteins are slowly
destroyed.
 Dry heat sterilization takes longer than steam
sterilization because the steam speeds up the
penetration of the heat.

 Requirements:
 Adequate temperature
 Correct time
40
 Oven…cont’d
Recommended temperature/time ratios
170°C (340°F) 60 minutes
160°C (320°F) 120 minutes
150°C (300°F) 150 minutes
140°C (285°F) 180 minutes
121°C (250°F) overnight
Remember:
Depending on the temperature selected, the total
cycle time (preheating, sterilization time, and cool
down) will range from about 2.5 hours at 170°C to
more than 8 hours at 121°C.
41
 Oven
Instructions for dry heat oven
 Decontaminate, clean, and dry all instruments
and other items to be sterilized.
 Items can be wrapped in aluminum foil or placed
in a metal container with a tight-fitting lid.
Wrapping helps prevent recontamination prior to
use.
Place loose (unwrapped) instruments in metal
containers or on trays in the oven and heat to
desired temperature.
 Begin timing after the desired temperature is
reached
 Items should be removed and stored after
cooling.
42
 Chemical Sterilization
 Chemical sterilization is an alternative for items that
would be damaged if subjected to steam or dry heat
sterilization.
 Glutaraldehyde and formaldehyde are sterilants if
used for the appropriate time.
 Glutaraldehyde and formaldehyde are not readily
inactivated by organic materials.
 When handling these products:
 Wear gloves to avoid skin contact.
 Wear protective eyewear to protect from splashes.
 Limit exposure time.
 Be in a well-ventilated area.
43
Chemical Sterilization…cont’d
 Sterilization takes place by soaking
 For 10 hours in 2–4% glutaraldehyde solution
OR
For 24 hours in 8% formaldehyde.
 Rinse with sterile water.

44
 Chemical Sterilization
Instructions for chemical sterilization

Decontaminate, clean, and dry all instruments

and other items to be sterilized.

 Completely submerge the items in a clean

container filled with the chemical solution and
place the lid on the container.

.

45
Allow items to soak (10 hours in
glutaradehyde or 24 hours in formaldehyde).

Remove objects from the solution with

sterile forceps

 Rinse all surfaces three times with sterile

water, and air-dry.
 Store objects in a sterile container with a
tight-fitting lid
 Monitoring Sterilization Procedures

Sterilization procedures can be

monitored routinely using:
Biological indicators:

Mechanical indicators:

Chemical indicators:

47
49
Storage of a Sterile Package
All sterile items should be stored in an
area and manner whereby the packs
or containers will be protected from
dust, dirt, moisture, animals, and
insects.
The storage area is best located next
to or connected to the place where
sterilization occurs, in a separated
enclosed area with limited access
that is used only to store sterile and
patient care supplies.
50
51
Storage area
 The Shelf-Life System
 The shelf-life of a item (how long items can be
considered sterile) after sterilization is event-
related.
 The item remains sterile until something
causes the package or container to become
contaminated.
 An event can be:
 A tear or worn area in the wrapping
 The package’s becoming wet
 Anything that will enable microorganisms
to enter the package or container
 These events can occur at any time.
53
 The Shelf-Life of a sterilized
Object
Shelf-life depends on the following
factors:
 Quality of the wrapper or container
 Number of times a package is handled
before use
 Number of people who handled the package
 Whether the package is stored on open or
closed shelves
 Condition of the storage area (humidity,
cleanliness)
 Use of plastic dust covers and method of
54
sealing
High Level Disinfection
 High-Level Disinfection
Principles:
Destroys all microorganisms including
HBV, HCV, and HIV
 does not reliably kill all bacterial
endospores
Only acceptable alternative when
sterilization equipment is not available

56
 Common Methods of HLD
Boiling Steaming

Chemical

57
 HLD…Cont’d
Practices of HLD by
Boiling
 Boil instruments for 20
minutes.
 Always boil instruments in
a pot with a lid.
 Start timing when the
water begins to boil.
 Do not add anything to the
pot after timing begins.
 Air-dry before use or
storage.
58
 HLD… cont’d
Practices of HLD by Steaming
 Steam for 20 minutes.

 Be sure there is enough water in the bottom pan

for the entire steam cycle.
 Bring water to a rolling boil.

 Start timing when the steam begins to come out

from under the lid,
 Do not add anything to the pan after timing starts.

 Air-dry and store instruments in covered steamer

pans.
59
Steamer Used for High-Level Disinfection

60
 HLD…cont’d
Practices for Chemical High-
Level Disinfection
For HLD, a 0.1% chlorine solution
shall be prepared from boiled
water
Decontaminate, clean, rinse and
dry instruments,
Cover all items completely with
disinfectant,
Soak for 20 minutes,
Rinse thoroughly with boiled
water three times,
Air-dry before use and storage,
Remove items using HLD or
sterile forceps/gloves
61
 HLD… cont’d
 Chemicals for HLD

 Chlorine solution 0.1%

 Safe for stainless and plated instruments

 Concentrated solutions >0.5% can corrode metals

 Formaldehyde 8%

 Vapors are irritating (staff should wear

appropriate PPE)
 A potential carcinogen

 Do not mix with chlorine (can produce dangerous

gas)
62
 HLD… cont’d
 Glutaraldehyde 2-4%
Less irritating but still needs to in well
ventilated area
 Hydrogen peroxide 6%
Highly corrosive and should not be used
to disinfect copper, aluminum and zinc
Loses potency rapidly when exposed to
heat and light,
Note
 Chemical disinfectants should be stored in a cool,
dark area,
 Never store chemicals in direct sunlight or in
excessive heat
63
 Guidelines for which Process to Use
Procedure Sterilization HLD
Cesarean Section Preferred Acceptable
Abdominal Laparotomy Preferred Acceptable
Vaginal Childbirth Preferred Acceptable
Contraceptive Implants Preferred Acceptable
Laparoscopy Preferred Acceptable
(chemical only)
MVA Cannulaea Acceptable Acceptable
IUD (insert/remove) Acceptable Acceptable
Pelvic Examination Acceptable Acceptable
a
MVA: manual vacuum aspiration (for treatment of incomplete
abortion)
Adapted from: Tietjen, Cronin and McIntosh 1992.
 Table 10-3: Effectiveness of Methods for Processing Instruments
Method Effectiveness End Point
(kill or remove
microorganisms)
Decontamination Kills HBV and HIV 10-minute soak
and most
microorganisms
Cleaning (water only) Up to 50% Until visibly clean

Cleaning (water and Up to 80% Until visibly clean

soap)
Sterilization 100% High-pressure steam, dry
heat, or chemical

High-Level 95% (does not Boiling, steaming, or

Disinfection inactivate some chemical for 20 minutes
endospores) 65