Case Studies
Nurse Ekachai assists the surgical team of a large hospital and is responsible for cleaning the instruments and other items used during surgery. To make sure that she is always available to assist the team, Nurse Ekachai cleans the instruments and other items used during the prior surgery in the operating theater while the next surgery is going on. The new head nurse asks her to discontinue this practice.
Why would the new head nurse ask Nurse Ekachai to discontinue this practice? What should be done instead?
After surgery, Mr. Silverman takes the bloody instruments and other items to the sink and rinses off most of the blood before putting them in the bucket of decontamination solution. He is concerned that if he does not rinse the instruments and other items first, the decontamination solution will become bloody after just a few procedures and he will have to replace it.
Should he be concerned about having to replace the decontamination solution? Who is most at risk of infection? What should be done differently?
Nurse Scherbina works in a busy family planning clinic. Unfortunately, there is a shortage of instruments and she is constantly trying to keep up with the demand. After each clinical procedure, she soaks the used instruments in a 0.5% chlorine solution for 10 minutes and then quickly rinses them under running water. She always wears gloves, and sometimes she rubs her fingers over the item to remove some visible debris. Because the instruments have been decontaminated and are going to be either sterilized or high-level disinfected, she does not think she has to spend a lot of time cleaning them.
Is this an appropriate practice? Why or why not?
Mr. Kamau, a cleaner in the operating theater, generally washes used instruments and gloves in a solution of detergent and water. Yesterday, he discovered that the supply of detergent was low. Since he saw many bars of hand soap in the supply area, he decided that instead of ordering more detergent, he would just use soap to wash the instruments and other items from then on.
Is this an appropriate practice? Why or why not?
Mrs. Scanlon is responsible for washing instruments and other items at a rural health clinic where water is scarce. To save water, she does not rinse the items after cleaning them with a detergent solution, since they are going to be soaked in chemicals and then rinsed.
Is this an appropriate practice? Why or why not?
Dr. Santiago is a surgeon at a small, rural hospital. Frequently, he notices that the instruments he uses during surgery have some spots of dried blood or bits of dried tissue on them. Because these instruments are always put through the autoclave each morning before surgery, he is not concerned about the dried matter.
What is the problem in this situation? What should be done to correct it?
Midwife Juarez gathers the instruments and gloves used during a recent delivery. She takes them out of the delivery room and carries them down the hall to the instrument processing room, where she places them in a bucket of 0.5% chlorine solution and lets them soak for several hours before cleaning them.
Is this an appropriate practice? Why or why not?
For the past year and a half, all of the departments in a 150-bed hospital had been decontaminating items with a 0.5% chlorine solution. One morning, Mrs. Cook, who works as a cleaner in the operating theater, prepares the chlorine solution using the bleach powder and the premeasured and marked plastic cup and bucket. As she is mixing the powder and water together, she notices that the label on the container of bleach powder is a different color than it used to be. She guesses that either the hospital supply agent changed brands, or the company changed the look of the label. Whatever the reason, she thinks, it does not matter because it is still bleach powder and the measurements will remain the same.
Is Mrs. Cook's reasoning correct? Why or why not?
Each morning, Mr. Lester, a technician in the operating theater of a district hospital prepares the 0.5% chlorine solution for each of the three operating theaters. This morning, however, he decides to prepare only enough solution for two of the rooms, because yesterday no surgeries were performed in the third room, and the bucket of chlorine solution he prepared for the third room remained unused. He figures that this bucket of solution can be used today.
Is he correct? Why or why not?
A large maternity hospital has a central supply department that processes all instruments and other items used during procedures. Instruments are wrapped in one layer of gauze and packed tightly in autoclave drums. The holes in the drums are opened, and the drums are placed in the autoclave and processed for 20 minutes at 121°C and 106 kPa.
Is this an appropriate practice?
At a local city hospital, after all the instruments are washed and dried, they are closed or locked and assembled by sets. Before placing each set in an autoclave tray, a piece of heavy cotton thread is strung through the instruments and tied so that the set remains together during processing.
Is this an appropriate practice? Why or why not?
One afternoon, the autoclave at Nurse Hsu's small clinic broke, and she realized that she needed an alternate method of processing the instruments needed for the next day's cases. She decided to chemically sterilize them overnight. The bottle of glutaraldehyde solution in the storeroom had not been open, so she used a 0.5% chlorine solution instead. The next morning, she removed the instruments from the chlorine solution with sterile forceps, rinsed them in the water from the boiler, and left them to air-dry.
Is this an appropriate practice? Why or why not?
The day before several minilaparotomy procedures are scheduled, Ms. Harper, an attendant in the operating theater of a local clinic, processes wrapped instruments for the next day. She has several loads of instruments, gloves, and linen to sterilize. Rather than waiting for the autoclave to dry the items, she removes the packages from the autoclave after sterilization and air-dries them on the counter overnight.
Is this an appropriate practice? Why or why not?
Instruments and other items that will be needed for the next day's surgery are sterilized unwrapped the evening before scheduled cases. After the items are sterilized, they are laid out on a piece of sterile gauze on an instrument tray in the operating theater and covered with another piece of sterile gauze, ready for use in the morning. The doctors prefer this approach so that they do not need to worry about any delays in the morning.
Is this a good system? Why or why not?
Mr. Ramirez, who cleans instruments and items used in the operating theater, has just finished washing and rinsing a set of minilaparotomy instruments and adds them to the boiler. He looks at the clock and mentally takes note of the time. The boiler already contains a set of IUD instruments, which have to remain in the boiler for 5 more minutes before they can be removed. Mr. Ramirez is not concerned about noting the time that the IUD instruments need to be removed from the boiler, since he thinks he will be able to keep track of when each set of instruments needs to be removed.
Is his reasoning correct?
Because of the constant electricity outages at the clinic, Nurse Jimines does not rely on the autoclave to sterilize surgical gloves. She always HLDs gloves by steaming. Before HLD, she prepares the gloves as she would for the autoclave, by rolling them into balls, Ten pairs of gloves fit neatly but snuggly into each of two steamer trays, and she is able to process all 20 pairs at one time. After steaming, she places the two steamer trays on the counter to air-dry.
Is this practice appropriate?
Each Thursday afternoon, Dr. Gomez and her staff perform laparoscopic tubal occlusions on women from the local villages. In between clients, the laparoscope and instruments are washed, rinsed, and soaked in a glutaraldehyde solution for a few minutes before they are dipped in water and reused.
Is this practice appropriate?
At a community health clinic, the specula used for pelvic examinations are processed by boiling. Nurse Diop, who has just started working at the clinic, feels that the specula should be sterilized to reduce the risk of infection in clients. Nurse Mwari, who is responsible for processing the instruments and other procedure items, tells Nurse Diop that the specula are sterile, because the label on the front of the boiler says "Instrument Sterilizer."
Are instruments and other items sterile after boiling? Is HLD appropriate for processing specula?
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