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sELf-sTudy sERiE
sELf-sTudy sERiEs
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OSHA Regulatory Requirements:
February 2015
The self-study lesson on this central service topic
was developed by 3M Health Care. The lessons are
administered by KSR Publishing Inc.
Earn CEUs
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Certification
The CBSPD (Certification Board for
Sterile Processing and Distribution)
has pre-approved this in-service for
one (1) contact hour for a period of
five (5) years from the date of original
publication. Successful completion of the lesson and
post test must be documented by facility management
and those records maintained by the individual until
re-certification is required. DO NOT SEND LESSON OR
TEST TO CBSPD. For additional information regarding
certification contact CBSPD - 148 Main Street, Suite
C-1, Lebanon, NJ 08833 • www.sterileprocessing.org.
IAHCSMM (International Association of Healthcare
Central Service Materiel Management) has pre-approved this in-service
for 1.0 Continuing
Education Credits
for a period of three years, until January 6, 2018. The
approval number for this lesson is hPN 150601.
For more information, direct any questions to
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ext. 202.
Learning Objectives
1. Discuss the importance of proper
care and handling of contaminated
instruments.
2. Describe scrub personnel’s
responsibilities relating to the care
and handling of instruments at the
point of use.
3. Explain post-procedure steps
required prior to transportation
of contaminated items to the
decontamination area.
Instrument decontamination
begins at the point of use
by Rose E. Seavey MBA, BS, RN, CNOR, CRCST, CSPDT
d
espite increased emphasis in infection
prevention efforts (e.g., enhanced
sterilization methods, sterile barriers,
and antimicrobial prophylaxis), surgical site
infections (SSIs) remain a considerable basis
of morbidity and mortality among patients.1
One consideration for prevention of SSIs is
post-procedure handling of contaminated
instruments.
There are many procedures involved
in the care and handling of contaminated
instruments, however there are none more
important than those at the point of use,
where decontamination should begin. This
article will focus on the perioperative responsibilities for surgical instruments at the
point of use.
Understanding and following current standards and guidelines helps to ensure patient
safety and facilitates compliance with the Occupational Safety and Health Administration
(OSHA) regulations in limiting occupational
exposure to bloodborne pathogens and minimizing the risk of infection.
Protect patients and employees
A primary focus of the perioperative team,
which of course includes Sterile Processing,
is to protect patients as well as healthcare
practitioners from transmissible infections.1
One of the risks for all health personnel
is occupational exposure to bloodborne
pathogens. The perioperative team has a potential for increased risk of this work-related
hazard due to the nature of the procedures
performed, the potential for blood exposure,
and use of sharp devices.2, 3
One of the most frequent recommendations I make as a consultant is the need to
improve the care and handling of contaminated surgical instruments at the point of
use. More often than not, I see instruments
coming to decontam covered in blood and
tissue, delicate and sharp instruments unprotected and solutions in open containers.
Healthcare facilities should develop policies
and procedures built on current standards
and guidelines that lead to best practices in
helping to ensure safe practices for patients
and employees. Following best practices can
also lead to prolonged life of some of the
facility’s most expensive resources, surgical
instruments and equipment.
Current standards and guidelines
The Association of periOperative Registered Nurses (AORN) recently updated the
guidelines (formerly called recommended
practices) for Cleaning and Care of Surgical
Instruments. These current evidence based
guidelines are very comprehensive and
intended to help healthcare facilities reduce
the incidence of SSIs and protect healthcare
workers as they care for and handle surgical tools.
The Associations for the Advancement of
Medical Instrumentation (AAMI) Comprehensive guide to steam sterilization and sterility
assurance in health care facilities ST79:2010 &
A1:2010 & A2:2011 & A3:2012 & A4:2013 also
discusses procedures and rationales for care and handling
of instruments at the point of
use in sections six and seven.
During the procedure
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Instruments transported in biohazard solution and not contained
in closed leak-proof container marked as biohazard.
36 February 2015 • HEALTHCARE PuRCHAsing nEWs • www.hpnonline.com
Decontamination of instruments begins at the procedure site. Both AORN and
AAMI recommend moistening and keeping instruments
wiped down at the point of
use. Throughout the surgical
procedure, the scrub person-
Self-study series
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Instruments not wiped down at point of use
and not kept moist for transportation
nel should keep instruments and equipment
free of gross soil. If allowed to dry on surgical
instruments, blood, organic material, debris,
and saline can result in corrosion, rusting,
and pitting. 2,3 Keeping instruments free of
gross soil can be accomplished by wiping
the surfaces with a sterile surgical sponge
moistened with sterile water. Large items
(e.g., orthopedic broaches) or instruments
that tend to hold a lot of bioburden (e.g.,
acetabular reamers) may require a basin in a
ring stand filled with sterile water in order to
wipe away the gross soil. Saline is corrosive
and should not be used to clean instruments.
Discourage biofilm formation
When blood or other bioburden dries it
can cause the formation of biofilm. Biofilm
is a buildup of bacterial and extracellular
material that can quickly start to form on
instruments if they are not kept free of gross
bioburden. If left to dry, blood and other
bioburden can make cleaning more difficult
and can affect the efficacy of disinfection and
sterilization.2,3
Biofilms protect microorganisms and make
them harder to be removed with regular
cleaning processes used in the sterile processing area. “Once biofilm forms, direct friction
and/or oxidizing chemicals are needed to
remove it.”2 Therefore, it is extremely important the perioperative team take measures
to remove gross soil as soon as possible in
order to reduce or eliminate the population
of biofilm-forming microorganisms and thus
prevent the formation of biofilm.2
Keep lumens clear
The formation of biofilm can happen on
many surfaces, however if it forms inside a
lumen it is particularly challenging because it
is very difficult to see and remove. Throughout the procedure scrub personnel should
frequently irrigate lumens with sterile water
Instruments transported without being in a
closed container marked as biohazard
(not saline). This can be accomplished by having a basin or pitcher with sterile water and
periodically suctioning the water through
the lumen or using a syringe to irrigate it.
The smaller the lumen the more important
it is to keep it clear.
Expedite turnaround time
Organic material and debris are more difficult to remove from surgical instruments if
allowed to dry. The efficacy and effectiveness
of cleaning and decontamination is improved
when scrub personnel remove gross bioburden at the point of use both on surfaces and
inside lumens. In addition to discouraging
the formation of biofilm, removing gross bioburden at the point of use can help expedite
the turnaround time for instrument sets. This
is extremely important when the instrument
sets are needed for subsequent procedures in
the same day.
Protect sharps
OSHA’s bloodborne pathogens standard
requires the safe disposal of contaminated
sharps in order to decrease the risk of bloodborne pathogen transmission.4 All members
of the perioperative team should contribute
to sharps injury prevention. Scrub personnel
are responsible for confining sharps (e.g.,
needles, scalpel blades) on the sterile field
until the patient is out of the room. During the
procedure, sharps/needle counter devices
should be used to contain and isolate sharps
on the sterile back table.5 Contaminated
disposable sharps must be removed and
disposed of in a closeable, puncture-resistant
container that is leak-proof and is labeled or
color-coded as biohazard.2,3
Post procedure
Part of the scrub personnel’s responsibility
after the procedure is to prepare the instruments for transportation to the decontamina-
tion area. This includes separation of waste,
linen and reusable items; segregating and
protecting sharp instruments; disassembling
multipart instruments; protecting delicate
items; arranging instruments in an orderly
fashion, and maintaining instrument sets
together.
Separate waste, linen and reusable items
At the point of use, reusable instruments and
equipment should be separated from waste
(e.g., wrappers, drapes, disposable instruments, etc.) and reusable linen. Separation at
the point of use minimizes handling by other
staff and therefore decreases the potential for
injury or exposure to hazardous material.
Contaminated disposable items should be
placed in an appropriate container according to OSHA regulations. Disposable items
contaminated with blood, body fluids or tissue must be placed in a leak-proof container
marked as biohazard before transport from
the point of use.2,3,4
Segregate sharp instruments
According to OSHA regulations, reusable
instruments that are sharp (e.g., skin hooks,
trocars, osteotomes, etc.) must be segregated
from other instruments and confined in a
puncture-resistant container at the point of
use. OSHA forbids procedures that require
personnel to reach their hands into containers
that have sharp instruments in them due to
the risk of percutaneous exposure to bloodborne pathogens.4
Protect delicate items
Easily damaged and delicate instruments
(e.g., fiberoptic cords, endoscopes, and
microsurgical instruments) should be protected from damage. Delicate items should
be placed above heavier instruments and
equipment or placed into separate containers
See self-study series on page 38
Self-Study Test Answers: 1. A, 2. B, 3. A, 4. B, 5. A, 6. B, 7. A, 8. B, 9. B , 10. A
www.hpnonline.com • HEALTHCARE Purchasing NEWS • February 2015 37
Self-study series
because instrumentation may shift during
transport. 2,3
Disassemble multipart instruments
Instruments and other items composed of
more than one part (e.g., laparoscopic instruments, trumpet valves, dental handpieces,
etc.) should be disassembled at the point
of use, according to the manufacturer’s
written instructions for use (IFU).3 Disassembling instruments helps to discourage
the retention of organic material and debris
on surfaces that otherwise may not be contacted by cleaning solutions, disinfection or
sterilization processes.
Arrange instruments
Instrument preparation and logically arranging instruments at the point of use can
help reduce damage to instruments. Instrument sets should be kept together and not
mixed with other sets/trays. Disassembled
instrument components (stopcocks, trocars,
depth gauge, etc.) should be kept together
in order to help ensure correct reassembly.
Items should be kept organized for safety
reasons and to discourage instrument loss
or misplacement.
All instruments on the sterile field should
be considered contaminated whether or not
they have been used. Instrument contamination on the field may occur without the
incidence being noticed. Unused instruments may have been touched by scrubbed
personnel without them being aware of it.
Instruments may also come in contact with
airborne microorganisms.3
Items needing repair or sharpening should
be identified or tagged at the point of use for
easy identification. This will allow SPD staff
to segregate them during decontamination,
reducing the risk that they’ll be returned for
use without the necessary repair being done.2
Keep instruments moist
Instruments should be kept moist until
they are cleaned in order to help prevent
bioburden from drying and adhering to the
instruments making cleaning more difficult
and increasing the potential of biofilm formation. The scrub personnel should keep
instruments moist until they are cleaned.
This can be accomplished by placing a towel
moistened with water (not saline) over the
instruments, using an instrument treatment
such as an enzymatic or disinfectant spray,
foam or gel, or placing the instruments inside
a container designed to maintain humid
conditions.2,3
Contain during transportation
OSHA regulations require soiled instruments to be contained during transport to
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the decontamination area. Contaminated
instruments must be transported in a closed
container or enclosed cart that is leak proof,
puncture resistant, large enough to contain all of the contents, and labeled with a
biohazard label. 3,4 Care should be taken to
avoid contamination of the outside of the
instrument containment device. If the transport containment device is contaminated, it
needs to be cleaned at the point of use or
placed within another clean containment
device which is labeled as biohazard.3
A red bag or red container may be used
instead of a label to indicate contaminated
waste if it is suitable to the configuration of
the contents.3,4
Osha fines hospital
Last year a hospital in the Northeast faced a
$28,000 fine for violations of the bloodborne
pathogen standard after they received a
complaint about unsafe practices relating
to contaminated instruments.6
The OSHA report cited several serious
concerns including:
•Potential for staff exposure to biohazards
and sharps injuries due to:
oSurgical instruments not wiped down
after use,
o Surgical instruments not disassembled,
oDisposable blades not removed from
reusable surgical instruments prior to
transportation,
o Contaminated instruments transported
in open or loosely covered basins,
oTransportation carts leaked contaminated fluids during transportation.
Conclusion
Procedures for handling contaminated
instruments must be created to protect
personnel, patients, and the environment
from contamination and to comply with
OSHA regulations limiting occupational
exposure to bloodborne pathogens. Current standards and guidelines should be
used to develop policies and procedures
that define authority and responsibility for
instruments at the point of use. Conducting
periodic process audits on how instruments
are delivered to the decontamination area
may help ensure correct procedures are
being followed. Developing and following
a checklist for contaminated instrument
transportation (see Example 1) may help
with compliance. As a scrub tech, I was
taught that we have as much responsibility
for instrument safety as we do for patient
safety. hpn
References:
1. Recommended Practices for Prevention of Transmissible Infections
in the Perioperative Practice Setting. In: Perioperative Standards and
38 February 2015 • HEALTHCARE Purchasing NEWS • www.hpnonline.com
Contaminated Instrument
Transportation Checklist
•Instrument wiped of gross bioburden and
lumens irrigated
•Sharps separated and placed in a puncture
resistant container
•Multipart instruments disassembled and kept
together
•Delicate instruments and sharps protected
•Instrument sets kept together
•Linen, waste and disposable instruments
separated from reusable instruments
•Solutions disposed of prior to transportation
•Contaminated items placed in closed containers
•Containers marked as biohazard
Example 1
Recommended Practices. Denver, CO: AORN, Inc. 2014, p385-417.
2. Association for the Advancement of Medical Instrumentation.
Comprehensive guide to steam sterilization and sterility assurance in health care facilities, ANSI/AAMI ST79:2010 & A1:2010
& A2:2011 & A3:2012 & A4:2013 (Consolidated Text).
3. Recommended Practices for Cleaning and Care of Surgical Instruments. In: Perioperative Standards and Recommended Practices.
Denver, CO: AORN 2014, e106-e140.
4. 29 CFR 1910.1030. Occupational exposure. Bloodborne pathogens. 2009. http://www.gpo.gov/fdsys/ pkg/CFR-2011-title29vol6/pdf/CFR-2011-title29-vol6- sec1910-1030.pdf. Accessed
November 1, 2014.
5. Recommended Practices for Sharps Safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc. 2014,
p351-374.
6.United States Department of Labor. Occupational Health
and Safety Administration. Inspection 974812.015 - Hallmark
Health - Melrose Wakefield Hospital. https://www.osha.gov/pls/
imis/establishment.inspection_detail?id=974812.015. Accessed
December 13, 2014.
Ms. Seavey is an Educational Consultant
to 3M Healthcare, Infection Prevention
Division.
Rose Seavey is President/CEO of Seavey
Healthcare Consulting. Seavey served on the
AORN Board in 2008-2010 and was President
of ASHCSP in 2003. She received numerous
awards such as AORN’s
award for Mentorship in
2012 and Outstanding
Achievement in Nurse
Education in 2001. In
addition, she received the
national 2013 IAHCSMM award of Honor,
the Industry Leadership
Award from the Massachusetts chapter and
the educator of the year award from the Golden
West chapter. Seavey was one of the Who’s Who
in Infection Prevention in 2006 by Infection
Control Today. Ms. Seavey is widely published in
professional journals and is the author of the book
titled Sterile Processing in Healthcare Facilities:
Preparing for Accreditations Surveys, published
by AAMI and she serves on several AAMI committees writing standards. Ms Seavey is also a
valued member the the HPN advisotry board.
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Continuing education test • February 2015
OSHA Regulatory Requirements:
Instrument decontamination begins at the point of use
Circle the one correct answer:
1. Exposure to bloodborne pathogens is an occupational risk for all healthcare
workers.
a.True
b.False
2. Instrument decontamination begins when they arrive in the decontamination
area.
a.True
b.False
6. Saline should be used to clean instrument surfaces.
a.True
b.False
7. During the procedure, sharps/needle counter devices should be used to
contain and isolate sharps on the sterile back table.
a.True
b.False
8.Reusable instruments and equipment should be separated from waste (e.g.,
wrappers, drapes, disposable instruments, etc.) after transportation to the
decontamination area.
a.True
b.False
3. Instruments should be kept free of gross soil during the procedure.
a.True
b.False
4. The formation of biofilm makes instruments easier to clean.
a.True
b.False
5. The efficacy and effectiveness of cleaning and decontamination is improved
when the scrub person removes gross bioburden at the point of use both on
surfaces and inside lumens.
a. True
b. False
9. Instruments placed on the sterile field but not used do not need to be decontaminated.
a.True
b.False
10.Items needing repair or sharpening should be identified or tagged before
being transported to the decontamination area.
a.True
b.False
Continuing education test • February 2015
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