Precision Surgical Instruments Cleaning Journey
Precision surgical instruments are medical devices with fine, complex and fragile structure, which are used in special surgeries or have special methods and technical requirements for cleaning, disinfection and sterilization treatment. With the continuous improvement of the level of surgical treatment and the rapid development of minimally invasive surgery technology, a large number of precision surgical instruments have been used in surgery. According to the domestic survey, the utilization rate of precision surgical instruments in ENT, ophthalmology, neurosurgery, stomatology, orthopedics, and cardiothoracic surgery has reached more than 50%  .Precision instruments have complex structure, fine and valuable, easy to wear and tear, cleaning difficulty, once cleaning is not in place, it directly affects the quality of sterilization and service life, and even cause patient infection, therefore, standardized, scientific cleaning is to ensure the cleaning quality, prevention and control of medical infections is the key.At present, the domestic routine precision instrument cleaning, disinfection, sterilization monitoring methods follow the People’s Republic of China health industry standard WS310.3-2016 “hospital disinfection supply center management specification”. There are literature reports of problems in various aspects of cleaning of ophthalmic microsurgical instruments and sterilization and packaging in 170 hospitals across the country , which shows that there is a certain degree of difficulty in the cleaning of precision surgical instruments. Whether it is the management system, personnel requirements, technical requirements are very strict, must be implemented in the sterilization supply center (CSSD) centralized processing, training of full-time staff with job competence, strictly in accordance with the standard specifications.I. Related concepts:1. Sterilization and Supply Center (CSSD) centralized management: Repeatedly used diagnostic and therapeutic instruments, appliances and items are recycled to CSSD centralized cleaning, disinfection or sterilization management.
2. Tubular lumen instruments: instruments that contain a tubular lumen with a diameter of ≥2mm, and the distance from any point in the lumen to its opening to the outside world is ≤1500 times its internal diameter.3. Ultrasonic cleaning: is the use of ultrasonic cavitation in the liquid, acceleration and direct flow effect on the liquid and dirt direct and indirect action, so that the dirt layer is dispersed, emulsification, stripping and achieve the purpose of cleaning.4. Traceability: The key elements affecting the sterilization process and results are recorded and kept for inspection, so as to realize traceability.Second, precision surgical instruments processing difficulties:1. Complex and fine structure, various types and special materials.2. Various shapes, many attachments, sharp and fragile head end, easy to damage.
3. Expensive price, many manufacturers.4. Few spare bases, high frequency of use, quick turnover.5. Specialist specialization.Third, precision surgical instruments cleaning principles:1. Follow the instrument manufacturer’s instructions and structural characteristics of the choice of cleaning methods.
2. Choose manual wiping for moisture-intolerant instruments, choose manual cleaning plus ultrasonic cleaning and medical cleaning machine for moisture-resistant instruments, preferred hygrothermal disinfection, and 75% alcohol can be used for disinfection for moisture-intolerant and heat-resistant instruments.3. According to the structure, function and material of the instruments, disassemble to the smallest unit for cleaning, pay attention to the protection to prevent the loss of small parts.4. Pay attention to the cleaning and disinfection process, avoid pressure, extrusion, bending, falling and other damages, which may affect the function and use of instruments, and use protective pads for instrument boxes and cleaning pools when necessary to prevent damage to instruments.
(5) Precision luminal surgical instruments should be cleaned manually with special cleaning tools.6. The manual cleaning steps of precision surgical instruments include rinsing, washing, rinsing and final rinsing.Fourth, personnel requirements
1. The post should master the precision surgical instruments operating duties, familiar with the post system. Understand the classification, structure and basic use of precision instruments, learn and be familiar with the relevant instrument manuals, and master the operation process and operation steps of precision surgical instruments.2. Strengthen training, regularly conduct special training on the disposal of precision surgical instruments as well as professional training on the handling of newly purchased instruments and new technologies, and regularly evaluate the quality of work. Produce precision instrument mapping and upload it to the traceability system, and the data can be shared with the whole traceability management system through the network for learning and registration of infection, absence and damage.
3. Staff should have a strong sense of responsibility and prudence, and perform strictly according to the standard specifications, especially when working at night, and cannot privately simplify the process and shorten the processing time.
4. Preparation for protection: When cleaning precision surgical instruments, the staff should wear necessary protective equipment, including coveralls, water apron, mask, goggles, hats, gloves, waterproof boots, etc. In case of special treatment of infected instruments, they should wear isolation clothes and upgrade their masks.
V. Cleaning process: manual cleaning and mechanical cleaning
(A) manual cleaning
(1) Cleaning and disinfection equipment, items prepared: including cleaning tank, ultrasonic cleaner, pressure water gun, pressure air gun, size matching cleaning tools.
2. Tube lumen class precision surgical instruments cleaning process:
(1) Pre-treatment: Recovered tubular lumen type instruments are first rinsed with flowing water to wash the blood stains and stains visible to the naked eye on the surface of the instruments.
(2) Soaking: put into the prepared enzyme solution containing medical cleaning agent to soak, pay attention to the configuration of the concentration specification, according to the degree of instrument contamination to determine the soaking time.
(3) brushing: should choose and precision lumen instruments lumen matching cleaning brush brushing lumen, should be brushed under the surface of the water to prevent aerosols, manual cleaning water temperature of 15-30 ℃.
(4) Scrubbing: cleaning swabs should be used to wipe the blood and stains on the ports of the luminal instruments.
(5) Rinsing: pressure water gun should be used to rinse the inner wall of the lumen.
(6) Select the appropriate ultrasonic cleaner frequency according to the instrument manufacturer’s instructions, the cleaning time should not exceed 10min, and the water temperature should be <45℃.
(7) Rinsing and final rinsing: ① Repeatedly rinse the washed precision surgical instruments with flowing water; ② Use purified water to carry out the final treatment process of the rinsed precision surgical instruments.
(8) Disinfection: Mechanical moist heat disinfection is preferred, 75% ethanol, acidic oxidation potential water or other disinfectants can also be used for disinfection.
(9) Lubrication: the instruments will be immersed in medical lubricant solution, the immersion time follows the requirements of the lubricant instruction manual, if necessary, can be used to spray, wipe method of lubrication of the instrument shaft joints, screws, and other parts of the lubrication process should be prevented from re-contamination of the instruments.
(10) Drying: Drying cabinet, pressure air gun, 95% ethanol and disinfected low-fiber wiping cloth can be chosen for drying.
3. Power tools class precision surgical instruments cleaning process:
(1) according to the requirements of the manual to choose the appropriate cleaning method, power tools should be handled by a person responsible for the class.
(1) power handle should be handled in a timely manner after use, otherwise it will affect the performance and use of the handle.
② After surgery, the handle will be placed under flowing water rinsing, rinsing repeatedly close and open the switch to rinse the blood and bone residue left in the drill.
(3) Rinse and wipe:
Flowing water rinses the outer surface of the drill and the drill retainer, key, battery protector, and battery cover; the drill must not be completely immersed in any liquid during the cleaning process; the end of the battery where the batteries are placed must be kept dry at all times; hollow drills should be used to scrub the cavity with a long, thin, soft brush.
(4) Ultrasonic cleaning of removable parts: ① The key, battery protection sleeve, battery cover are contained in a mesh basket, placed in the ultrasonic cleaner basket, ultrasonic cleaning with enzyme-containing medical detergent, the cleaning time should not be more than 10min, the water temperature should be <45℃. ② Replacement of gloves, flowing underwater rinse keys, battery protection sleeve, battery cover, etc..
(5) non-removable parts of the cleaning method: ① gauze dipped in medical cleaning agent to scrub the outside surface of the handle. (② replace the gloves, flow underwater scrubbing handle external surface, high-pressure water gun rinse drill bit fixer. ③ difficult to clean the drill, available special cleaning tools, high-pressure water gun rinse.
(6) Rinsing: scrub the outer surface of the handle under flowing purified water, rinse the drill fixer, battery protector and battery cover under flowing water.
(7) Lubrication: Use special lubricant to spray into the head of the cutter, the suction tube section, and the flushing tube, and then stand the handle upright to fully lubricate all joints.
(8) Disinfection: 75% ethanol can be used to wipe disinfection.
(9) drying: pressure air gun, drying cabinet or 95% ethanol and disinfection of low-fiber floc wipes for drying.
(B) mechanical cleaning
(1) Manual pretreatment before carefully checking its integrity and the integrity of its accessories.
2. Initial manual cleaning, with flowing water to rinse the instruments on the blood and other dirt, lumen instruments using high-pressure water gun for rinsing, instruments can be removed part must be disassembled to the smallest unit, small accessories using a small with a lid closed cleaning basket properly placed to prevent loss.
3. Instrument cleaning rack loading operation
(1) The number of instruments should not be too many, the ends of tubular instruments should not be exposed to the liquid surface, sharp instruments should be fixed, and the instruments should not be placed beyond the height of the basket. The valves of the tubular instruments should be in the open state, and the tubular instruments should be connected to the model-matched perfusion device to ensure the thorough flushing of the tubular instruments.
(2) Removable instruments, including shears, should be placed in the basket and ensure that the shaft joints, pincer end fully open to ensure the quality of cleaning.
(3) Non-removable instruments and small instruments should be placed in a dense mesh basket with a lid to ensure that there are no drops and collisions during the cleaning process.
(4) Optical eyepieces suitable for mechanical cleaning need to be independently placed and fixed in a special basket for cleaning.
(5) For luminal instruments such as ultrasonic emulsification handle, before cleaning, tighten the power connector protective cap, and then coiled handle power cord placed in the cleaning basket (coiled diameter greater than 10 cm) , the flushing hose needs to be connected to the irrigation interface, to ensure that the lumen is thoroughly cleaned and dried.
(6) Select and start the cleaning and disinfection procedure, including pre-washing, washing (with enzyme-containing detergent/alkaline detergent), rinsing, final rinsing, disinfection, and drying. Final rinsing and disinfection should use purified water. The temperature of water in the pre-washing stage should be ≤45℃. The temperature of moist heat disinfection should be ≥ 90 ℃, time ≥ 1 minute, or AO value ≥ 600.
(C) Infectious medical device processing methods
(1) Prion-infected devices: soak in 1 mol/L sodium hydroxide solution for 60min before cleaning and disinfecting treatment according to specifications.
(2) Gas gangrene infected instruments: soak with chlorine disinfectant solution 1000mg/L-2000mg/L for 30min-45min when there is obvious contamination with 5000mg/L-10000mg/L chlorine disinfectant solution for at least 60mim before processing.
(3) New coronavirus infected instruments: chlorine disinfectant solution 1000mg / L-2000mg / L immersion 30min, or 75% alcohol wet wipe disinfection and then routine treatment.
Sixth, quality standards
1. The cleanliness of the inspection: the use of visual inspection or the use of magnifying glass with a light source on the drying of each piece of precision surgical instruments, appliances and articles for inspection. The surface of the instruments and their joints, teeth and teeth should be smooth and clean, free of blood stains, stains, limescale and other residual substances and rust spots; the lumen of the tubular instruments should be smooth, and the inner wall of the lumen should be free of blood stains and stains.
2 Functional check: the parts of the instruments should be complete without missing, each instrument should be structurally complete, the axial joints are flexible without loosening; the rivets and screws at the joints and fixed places of the instruments should be complete and normally tightened; the instruments should be closed completely when closing the clamp end; the cannulae and seals are complete without deformation, the tension of the springs is moderate, and the instruments such as scissors are sharp without curled edges and gaps; the lumens of all kinds of luminal instruments are fluent: the power line of the ultrasonic emulsification handles are free from any cracks, breaks and aging; the walls of the canal lumens are fluent. The power cord of ultrasonic emulsification handle is cracked, broken and aged.
The insulation of instruments with power supply is qualified, and the insulation layer is free of cracks and gaps.
1. Adopt centralized treatment, specialized personnel, cleaning personnel should have excellent technical operation ability and professional theoretical knowledge and sense of responsibility.
2. Configuration of medical cleaning agent and soak time to follow the manufacturer’s instructions, should not use abrasive cleaning materials and cleaning tools for instrument processing, should be used with the instrument material to match the scrubbing utensils and supplies.
3. The water temperature should be 15~30℃ for manual cleaning, and the ultrasonic cleaning time should not exceed 10min, and the water temperature should be <45℃.
4. The scrubbing operation should be carried out under the surface of the water to prevent the production of aerosols. Removable parts of the instrument must be disassembled to the smallest unit, small accessories using small with a lid of dense grain cleaning basket properly placed to prevent loss.
5. During mechanical cleaning, each precision surgical instrument should be properly placed to avoid falling or damage; the lumen should be correctly connected to the matching irrigation interface to ensure that the water flow fully contacts the lumen of the instrument.
6. The conductivity of purified water for final rinsing and disinfection should be ≤15μ S/cm (25℃).
7. Special contaminated precision surgical instruments should be disposed of in strict accordance with the requirements of WS / T 367.
8. After daily cleaning, the operating environment and cleaning materials should be cleaned and disinfected to make them in a standby state. Protective equipment using 1000mg / L of chlorine disinfectant or 75% ethanol disinfectant solution soaked in 30min disinfection, flowing water rinse clean, dry and spare; environmental surface using 500mg / L-1000mg / L chlorine disinfectant wipe or mopping the floor, and then wipe with water once.
9. Timely and accurate record and save the cleaning information, has realized the traceability.
Summarize the above.
To do a good job of cleaning and disinfection of precision surgical instruments, it is necessary to be professionally trained personnel, have a certain understanding of the structure and function of precision surgical instruments, use professional cleaning tools, and under the premise of centralized treatment in the disinfection and supply center, the staff has a high degree of responsibility, and strictly in accordance with the standard specifications for cleaning, in order to ensure the quality of cleaning and prolong the service life of the instruments, and to eliminate the incidents of nosocomial infection The occurrence of nosocomial infections can be prevented.