Washing instruments in the scrub sink; proper prion removal

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Q When working in the OR core I have often observed nurses coming out of a room and washing instruments in the scrub sink prior to immediate use steam sterilization (IUSS). When I question them they claim it is just a few items that need to be sterilized quickly and they have no time to bring them to the instrument room. Is this an acceptable practice?

A Instruments should not be washed in the scrub sink or any sink used for hand washing. The same principles for decontamination and cleaning apply regardless of where the process is conducted. The scrub sink area is not designed for decontamination of surgical instruments, and the necessary supplies, detergents, brushes, personal attire and the like are not readily available. Decontamination techniques and sterile processing policies and procedures must be adhered to including environmental control. Appropriate personal protective equipment (PPE) must be worn to protect personnel from exposure to blood borne pathogens. Washing contaminated instruments in a scrub sink is an unacceptable practice and can pose a risk to both patients and personnel through cross contamination of microorganisms and pathogens left behind after washing the instruments. Cleaning is the first and most critical step in the sterilization process, including IUSS. It should not be abbreviated for the sake of convenience or haste. Shortcuts can result in personnel hazards, and failed sterilization outcomes which places patients at risk. Cleaning is the most critical step in the sterilization process and it is imperative that every step in procedures and IFUs be strictly adhered to.

Q I work in the OR at a very small rural hospital. There are two ORs and we average about two surgical cases per day. Patients needing major, complicated or emergency procedures are usually scheduled at, or transferred to the regional hospital 75 miles away. Our nursing supervisor recently returned from a seminar and said we needed to look into the requirements for reprocessing instruments exposed to dangerous neuro diseases.Since we do not do neuro-surgery here, she felt it would be unlikely we’d ever encounter this situation; however the speaker at the conference said we should be prepared. I am not familiar with any special requirements to sterilization, we use the same instrument sterilization cycle for everything so wouldn’t that be acceptable?

A I believe the speaker was addressing Creutzfeldt–Jakob Disease, commonly referred to as CJD, a fatal neurological disease which often has a very long incubation period. The symptoms may be similar to other neurological disorders such as Alzheimer’s and therefore may be misdiagnosed until further progression of the disease. CJD is a prion disease. This disease can develop in two ways: 1. Spontaneously, meaning it is passed on genetically or 2. It is acquired via transmission through contact with contaminated tissue or surgical instruments. A prion is a small proteinaceous infectious disease-causing agent that is believed to be the smallest infectious particle, and often very difficult to detect. A prion is neither bacterial nor fungal nor viral and contains no genetic material. Prions are not destroyed by standard sterilization processes. To minimize the risk of cross contamination and disease transmission, here are some important processing protocols to consider and implement for processing instruments exposed to CJD:

• Use single-use disposable supplies and accessories.
• Only open and use necessary items.
• Employ and enforce the OSHA blood born regulations for the handling of potentially contaminated items (e.g., wear high-risk PPE).
• Use single-use instruments when possible on high risk tissue.*
• Be certain that reusable surgical instrumentation used on high-risk tissue during the procedure is compatible with extended steam sterilization cycle parameters.
• Restrict the number of essential instruments to be used during procedure.
• Treat instruments that contact high-risk tissue* in accordance with infection-prevention guidelines.
• Keep instruments moist and containerized until cleaning and decontamination begins.
• Decontaminate instruments in a mechanical washer/decontaminator.
• Use cleaning agents with prioncidal activity.
• Conventional reprocessing methods may be applied to semi critical surgical/medical devices which contacted low risk tissue.
• High-risk* instruments may be steam sterilized in a prevacuum cycle at 273° F for 18 minutes or gravity steam sterilization at 270°F for 60 minutes.
• Use an instrument tracking system.

*The World Health Organization identifies the following as high-risk tissue for CJD (e.g., brain, spinal cord). It is also possible for transmission to occur from exposure to lower risk tissue such as, blood transfusions and corneal transplants. Thus, if a patient with CJD or other prion disease undergoes surgery there is the risk of the surgical and medical devices used in the procedure to become contaminated with prions.