Answers to Case Studies
The operating theater is considered a "clean" area, and washing used instruments and other items is considered a "dirty" procedure. In this situation, it would be very easy to contaminate the instruments, other items, and sterile field by cleaning items from the prior surgery during the next surgery.
Dirty procedures should not be performed in clean areas; Nurse Ekachai should clean the instruments and other items in another room. In addition, a new client should not be brought into the operating theater until all instruments and other items used in a prior case have been removed and any potentially contaminated surfaces have been cleaned.
Any handling of instruments and other items used during a procedure increases the staff member's risk of infections.
It is natural for the solution to become contaminated during use. The decontamination solution can be used throughout the day, but if there are many cases, or if the instruments and other items are very bloody, the solution will need to be replaced more frequently.
Mr. Silverman is most at risk in this situation. All instruments and other items should be placed in a decontamination solution immediately after the procedure to reduce the risk of infection for the staff who clean them.
No. Nurse Scherbina should carefully and thoroughly clean all reusable instruments and other items, since proper cleaning removes organic debris, which may protect microorganisms or interfere with the sterilization or high-level disinfection process. In addition, cleaning significantly reduces the number of microorganisms, including bacterial endospores.
Rubbing an item with your fingers under running water is not sufficient. Instruments and other items should be disassembled, and hinged instruments or instruments with ports and valves should be opened before cleaning in a detergent and water solution using a soft brush or toothbrush. Instruments and other items must then be rinsed thoroughly under running water and, if they will be wrapped or processed using chemicals, dried.
No. Hand soap is not a good substitute for detergent when cleaning reusable instruments and other items. Soap has fatty acids in it that will react with the minerals in water, leaving a residue on the instruments and other items that is difficult to remove.
No. Detergent can reduce the effectiveness of the chemicals used for sterilization and high-level disinfection. Instruments and other items should always be rinsed well and dried before they soak in a chemical solution during processing.
Microorganisms on used instruments and other items may be protected by blood and other body fluids and survive the sterilization process.
Dr. Santiago should make sure that items are thoroughly cleaned to ensure that sterilization or HLD is effective. Items that contain spots of dried blood or bits of dried tissue should not be used--they should be reprocessed after thorough cleaning.
No. The purpose of decontaminating instruments is to protect health care workers from bloodborne viruses. Items used during procedures should be placed in the chlorine solution immediately after use. A bucket containing a 0.5% chlorine solution should be kept in every operating theater and procedure room. The bucket may then be transported to the processing room. After 10 minutes, the instruments should be removed and rinsed. They should not be left soaking in the solution for extended periods of time, because chlorine can damage the instruments.
No. Different brands of bleach powder and liquid bleach may have different percentages of "active" (available) chlorine. The amount of water and bleach powder or liquid needed to make a 0.5% solution varies depending on the percentage of active chlorine. Whenever a new bleach product is used, the label must be checked to determine the active percentage of chlorine, and the amounts of water and bleach product needed must be corrected, if necessary. If information about the percentage of active chlorine is missing from the label, contact the manufacturer.
No. Chlorine loses its effectiveness over time. Mr. Lester should make a new solution at the beginning of each day--or whenever the solution looks as though it needs to be changed, such as when it becomes heavily contaminated with blood or other body fluids or becomes cloudy. (Note that when bleach powder is used, the solution is likely to look cloudy at the start.)
No. Instruments should be wrapped in a double layer of paper, newsprint, or cotton or muslin fabric. They should not be wrapped in gauze because the material is woven too loosely and does not provide an adequate barrier against contamination after the sterilized instruments are removed from the autoclave. In addition, wrapped instruments must be placed loosely in a drum or tray to allow for adequate passage of steam, and must be processed for 30 minutes (not 20 minutes) once the temperature and pressure requirements are met.
No. Even though stringing instruments is an acceptable practice (it keeps the set intact and helps in setting up the sterile field quickly and efficiently), it is not acceptable to steam sterilize instruments that are closed or locked. Instruments must always be unlocked and opened for steam sterilization, so that steam can contact all surfaces, which is necessary for sterilization to be achieved.
No. A 0.5% chlorine solution should not be used to sterilize instruments, because chlorine does not reliably kill all bacterial endospores. In addition, long-term exposure to chlorine is caustic to metal and can damage the instruments. Also, items soaked in a chemical for sterilization must be thoroughly rinsed with sterile water, not boiled water.
Nurse Hsu should have used the glutaraldehyde solution she found in the storeroom to sterilize the instruments.
No. Wrapped items are damp after steam sterilization. If they are handled and left to air-dry, microorganisms can move through the damp, porous material and contaminate the items. Items should remain in the autoclave until dry.
No. The instruments and other items will become contaminated:
- By being placed on the gauze, which is too thin and thus allows the passage of microorganisms from the instrument tray to the sterile items
- By airborne microorganisms that may pass through the gauze covering the items during the night
If items are sterilized unwrapped, they should be stored dry in a sterile, covered container until they are used. The proper handling and storage of items after sterilization is as important as the sterilization process itself.
No. Once instruments and other items have been placed in boiling water and the timing begins, no other instruments or items or additional water should be added. It does not matter if the instruments can be differentiated: adding anything to the boiling water will contaminate it and its contents. If Mr. Ramirez adds anything to the water, he must begin timing for the IUD equipment all over again. In addition, he should not rely on memory for timing the boiling. He should either write down the time or use a timer.
No. Nurse Jimines should not roll the gloves into balls for either steam sterilization or HLD by steaming. In order for steam to work in these processes, it must have contact with all surfaces. Gloves that are to be steamed should be placed in pairs with the cuffs folded back and loosely layered in a criss-cross design. After processing, trays should not be placed directly on a surface such as the counter, because the holes in the tray can allow microorganisms to contaminate the gloves. If at all possible, gloves should be allowed to dry for 4-6 hours before use.
No. The instruments should first be decontaminated in a 0.5% chlorine solution (except for the laparoscope and cable, which may be damaged by the chlorine). All items should then be cleaned with soap and water, rinsed, and dried before soaking in the glutaraldehyde solution for 20 minutes. All ports and valves should be opened and items should be completely submerged in the solution. After soaking, they should be thoroughly rinsed with boiled water.
No, instruments and other items are not sterile after boiling. Boiling is a method of HLD, not sterilization. With HLD, all microorganisms, except some bacterial endospores, are killed.
Yes, HLD is suitable for processing specula to be used during vaginal examinations because the specula will come in contact only with intact mucous membranes. In addition, HLD by boiling may be more cost-effective than sterilization.