SELF-STUDY SERIES


being used. For example, one manufac- turer recommends placing an indicator in a hinged holder in a wire basket. One half of the holder should be placed flat on the bottom of the basket and the other half positioned at 90 degrees vertically (Figure 3, previous page) for the best challenge to the cycle.


What to do with a failing result A washer indicator failure result is easily determined by the presence of soil remain- ing on the indicator at the end of a washing cycle. A failure indicates that something went wrong in the cleaning process and allows staff to investigate the process. The department’s protocols will help in determining the root cause of a failure and the next action steps. The benchmarking process will have provided the facility with predetermined cycle parameters to compare with the failed cycle (e.g., enzyme cycle; minimum of two minutes, water specific temperature range 100-140).


Failures may be related to impingement arm function, chemistry-related issues, or time and temperature factors. Impingement arm failures may be caused by a clogged spray arm, loss of pump pressure, over- loading of a rack or basket of instruments, or incorrect positioning of the indicator. Chemistry-related failures may be due to insufficient use of enzymes or insufficient chemistry available (an empty container). Temperature and cycle factors include an insufficient temperature reached or too short an enzyme cycle. As part of the documented protocol for washing, staff should develop and docu- ment a troubleshooting process. Some indi- cator manufacturers offer troubleshooting guides complete with comparison photos of indicators in various states of failure, which can assist in determining causes. If a facility is creating its own checklist, the document should include all the possible causes listed above. When troubleshooting, all the po- tential factors should be examined, since there may be occasions when more than one causal factor is involved in a washer failure. It’s important to note here that a failure


result on a washing indicator does not necessarily mean that the load is not clean. Visual inspection always remains the final step in the cleaning process. CSSD staff should carefully examine the instruments and determine if they should be re-washed. If the instruments are visually clean, the load may move on to the clean prep and pack side.


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Best washer indicator practices The role of washer indicators is to verify automated cleaning processes performed on surgical and medical devices in order to prepare them for sterilization. They are a major contributor to the washing process and should be included in any robust CSSD protocol. Professional standards organiza- tions and cleaning indicator manufacturers provide baseline recommendations as to their use, but how they are used, and how often, are ultimately determined by each facility.


When developing a protocol for indicators it’s important to balance the washing equa- tion. A typical washer/disinfector process equation includes four primary factors: time, temperature, impingement (mechanical action) and chemistries. These four factors must be balanced against each other to optimize the cleaning process and ensure optimal cleaning outcomes. Depending on the type of washer/disinfector being used, the essential parameters in a wash cycle may need to be adjusted in order to assure a passing a washer indicator. For example, a high impingement washer provides a more aggressive spray action. Therefore, a less aggressive chemistry (neutral pH) can be used to pass a washer indicator and ensure superior outcomes (Figure 4).


For this reason, it is essential to establish a benchmark that accounts for these wash- ing variables and test the resulting cycle with washing indicators until a passing result is achieved. Once this balance is veri- fied, it can become a best practice that is applied consistently for repeatable results. Washer indicators can also be used to drive competencies and enforce best practices in the CSSD. For example, one hospital system used washer indicators to help educate their CSSD staff on the dan- gers of overloading baskets. Following the manufacturer’s instructions for use, they placed the washer indicator in an empty load in the morning, and it passed. The CSSD manager then had the staff run the same type of washer indicator again in a cycle with a load of instruments. This time, the washer indicator failed. The only difference between the two cycles was the presence of instruments. The CSSD manager used this scenario to il- lustrate to the staff how overloaded the instrument basket was. After loading a new basket with an appropriate amount of instruments and running a full cycle, the washer indicator passed, which made the manager’s point with a concrete object lesson.


Consistent processes and verifications are among the hallmarks of CSSD best practices. Making the best possible use of washing indicators, in combination with careful visual inspection procedures, can significantly enhance the consistency of a department’s cleaning and disinfection processes, and ultimately benefit their entire sterile processing cycle. HPN


Figure 4


In contrast, a low impingement washer provides a less powerful stream of spray cov- erage, making it important to select a more aggressive chemistry (high alkaline pH) to thoroughly clean the instruments (Figure 5).


Ann Burke, R.N,. B.S. is a clinical education specialist for STERIS Corporation. Her areas of responsibility include education, clinical support and troubleshooting for issues related to sterilization, instrument reprocessing and infection control. She has worked as a clinical educator in healthcare for the last fourteen years and has provided clinical consultation to the operating room, central sterile service, ambulatory services and infection control de- partments. Her expertise includes the topics of surgical site infections, decontamination and sterilization practices, and mock JC surveys.


References


1. Association for the Advancement of Medical Instrumenta- tion, Comprehensive guide to steam sterilization and sterility assurance in health care facilities, ANSI/AAMI ST79: 2010 & Amendment 4:2013 (consolidated text), Annex D.


Figure 5 48 September 2015 • HEALTHCARE PURCHASING NEWS • www.hpnonline.com


2. Association of periOperative Registered Nurses, Guideline for Perioperative Practice, 2015 Edition, Recommendation XVII (a) and (a.1).


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