CHAPTER FOUR

INSTRUMENT
PROCESSING
 Objectives
At the end of this lesson learners should be
able to:
List steps of instrument processing
Define each steps of instrument
processing
Demonstrate solution preparation for
decontamination
List methods of disinfection
List methods of sterilization
Perform instrument processing
 Introduction
Surgical instruments are expensive and
represent a major investment.
Abuse, misuse, inadequate cleaning or
processing, or rough handling can damage and
reduce the life expectancy of instruments.
Guidelines which help increase the lifespan of
instruments and ensure their proper function
includes:
During surgery:
 Handle instruments gently
 Don’t throw them into basins
 Keep the sharp surfaces of cutting instruments
away from other metal surfaces that could dull them.
 Cont…
 Use the correct instrument for the job at hand, e.g.,
 Heavy needles will damage delicate needle
holders
 Wire sutures must be cut with wire cutters, not
suture scissors
 Use towel clips and not hemostats for securing
drapes.
After surgery:
Decontaminate/clean instruments as soon as
possible.
Don't allow blood to dry on them.
Separate sharp or delicate instruments from others
when processing.
Process all instruments from a surgical case,
whether or not they have been used.
 Cont…
Instrument set assembly:
After careful inspection, assemble instruments into sets
according to institutional procedures and the following
guidelines:
 Load heavier instruments first, cover with a towel, and
then place lighter instruments on top.
 Point clamps with curved jaws in the same direction to
protect their tips.
 Wrap smaller instruments and sharp cutting instruments in
towels.
 Use towels to segregate instruments in the tray or
container.
 Place sharps so that their points do not touch, and protect
their delicate tips with perforated tip protectors.
 Use dividers, pin mats, and clamps when needed to secure
instruments in place to avoid damage during sterilization
and transport.
 Cont…
 Recommended Practices specify that the total weight
of an instrument set should not exceed 25 pounds.
 Avoid overloading or crowding the containers or trays,
for this will prevent the sterilizing agent from reaching
all surfaces of the instruments.
 Cont…
Packaging/wrapping:
Most items to be sterilized will be packaged or wrapped
to prevent subsequent contamination by dust, dirt, and
microorganisms.
Choice of sterilization packaging material is based on
the following general standards of performance:
Ability to conform to the medical device.
Freedom from toxic ingredients and dyes.
 Strength, durability, and seal integrity during transport and
sterilization.
 Effectiveness of sterilant penetration.
 Ability to maintain sterility of contents until the package is
intentionally opened.
 Ease of aseptic delivery of the contents without
contamination.
 Cost-effectiveness.
 Cont…
Packaging materials:
 Packaging materials should be chosen based on the
type of instrument or instrument sets being packaged.
 Includes:

1) Sterilization Wrap
 Sterilization wraps come in many sizes, grades, and
materials.
 They are used for trays, mesh containers, as well as
single items.
 Cont…
2) Woven fabrics:
Woven textiles are made of natural cotton or
linen.
Woven fabric wraps provide the least effective
sterile barrier.
They require laundering, because they are
reusable.
 Cont…
3) Non-woven fabrics:
Nonwoven wrappers are single-use fabric
wrappers
 Cont…
4) Rigid containers:
 Rigid container systems are specially designed heat-
resistant metal, or anodized aluminum receptacles
used to package items, usually surgical instruments,
for sterilization.
 They generally consist of a bottom or base with
carrying handles,
 Includes mesh tray (baskets), tray and sterilizing
drums.
Advantages are:
 ease of handling,
 avoidance of wrapping material problems, and
 maximum protection for instruments
 Cont…
5) Peel pouches:
 Peel pouches are flexible packaging materials that
combine a paper or synthetic barrier material and a
transparent plastic or rubber film.
 Peel pouches are used primarily when visibility of the
instrument is critical for its effective use.
 They were designed for individual, lightweight devices
and as a means to separate dissimilar metals and
delicate instruments
Integrity of Packaging Material and Handling
The following are considerations regarding the integrity of
packaging materials:
Item is no longer considered sterile after an accidental
puncture, tear, or rupture of the package.
Squeezing or crushing a package may force air out and
draw unsterile air in, thus contaminating the contents.
The accidental wetting of a package contaminates the
contents.
It is necessary to avoid the following:
Handling the package with moist or wet hands
 Handling the package with soiled gloves
Placing the package on a wet surface
 Commercially packaged, sterilized items are usually
considered sterile until the package is opened or damaged
or the stability of the product becomes outdated
 Instrument processing
Every item, whether a soiled metal instruments or other
items, requires special handling and processing in order to:
Minimize the risk of accidental injury or blood or body fluid
exposure to cleaning and housekeeping staff; and
Provide a high quality end product (i.e., sterile or high-level
disinfected instruments and other items).
 Minimize the spread of blood borne pathogens
Steps of instrument processing:
 Decontamination (with chlorine solution immediately after
use)
 Cleaning (with soap and plain water)
 Drying and wrapping (based on instrument type and next
procedure)
 HLD or Sterilization
 Cool and Use immediatly/ store properly
 Cont…
1) Decontamination:
Process that makes inanimate objects safer to be
handled by staff before cleaning (i.e. inactivates
HBV, HBC and HIV and reduces, but does not
eliminate the number of contaminating
microorganisms).
It is done by soaking the equipments in 0.5%
chlorine solution for 10 minutes.
 Principles: decontamination:-
Inactivates HBV and HIV
Makes items safer to handle
Must be done before cleaning
How we prepare 0.5% chlorine solution from 5%
chlorine?
Formula for Making a Dilute Solution from Concentrated
Solutions
Determine the concentration (% concentration) of
the chlorine solution
Determine the desired concentration (% dilution)
Operating Room Technique
the following
Decontamination tips:
Use a plastic container for decontamination to
help prevent:
dulling of sharps (e.g., scissors) due to contact
with metal containers; and
rusting of instruments due to a chemical reaction
(electrolysis) that can occur between two different
metals (i.e., the instrument and container) when
placed in water.
Place instruments in 0.5% chlorine solution after
use; soak for 10 minutes and rinse immediately
with cool water to remove visible organic material
before being thoroughly cleaned.
Wipe surfaces (exam tables) with chlorine solution
Completely
submerge
instruments

labeling of the
containers is one of
the important
aspects of
decontamination.
 Cont…
2) Cleaning:
Process that physically removes all visible dust, soil,
blood or other body fluids from inanimate objects as well
as removing sufficient numbers of microorganisms to
reduce risks for those who touch the skin or handle the
object.
Consists of thoroughly washing with soap or detergent
and water, rinsing with clean water and drying.
Cleaning Tips
 Use PPE during cleaning
 Disassembled instruments only after decontamination
 Wash with detergent, water and a soft brush
 Scrub instruments under the water surface until visibly
clean
 Thoroughly rinse with clean water
 Allow items to air dry/dry with a clean towel
Fig. decontamination and cleaning/three dish
washing
 Cont…
3) Disinfection:
Eliminates pathogenic microorganisms on inanimate
objects, with the exception of bacterial spores.
Methods and procedures for disinfection vary according to
the intended use of the disinfected item.
Disinfection is generally achieved in health care settings
by the use of liquid chemicals or boiling.
Disinfection is used to make semi-critical and non-
critical items free from pathogenic MOs except from
endospores.
Disinfectants vary in their ability to kill
microorganisms.
Levels of disinfection :
 Low,
 Intermediate, and
 High.
 Cont…
i. High level disinfection: Is effective against;
 All vegetative bacteria,
 Viruses,
 Fungi, and
 Tuberculosis/TB
Most high level disinfectants have a
demonstrated level of activity against bacterial
spores.
High-level disinfectants are used primarily for
semi-critical items such as:
 Laryngoscopes
 Respiratory therapy and anesthesia equipment
etc.
 Cont…
ii. Intermediate-level disinfection: is less powerful and kill
less resistant microorganisms than high-level disinfection,
but more powerful than low-level disinfection.
Effective against vegetative bacteria, fungi, and lipid-
involved viruses, Mycobacterium tuberculosis and non-lipid
viruses.
Not effective against resistant bacterial spores.
Chlorine, iodophors, phenolics, and alcohol belong to this
group.
iii. Low-level disinfection: kills most vegetative bacteria,
fungi, and lipid-enveloped viruses, but do not kill spores or
non-lipid viruses.
Less active against the Mycobacterium tuberculosis and
some gram-negative rods, such as pseudomonas.
Low-level disinfectants are typically used to wipe down non-
critical items that will contact only intact skin or for
environmental surface disinfection.
Factors that influence effectiveness of
disinfectants:
A. Nature of the item.
 The crevices, joints, and hinges, the more difficult it is to disinfect.

B. Number and type of microorganisms present on the

object:
 The higher the level of the item’s contamination, the difficult it is
to disinfect.
 Some microbes are more difficult to kill than others.

C. Amount of soil or organic matter present:

 Soil protects microbes and may inactivate the disinfectant
solution.
D. Contact time:
 Disinfection requires direct contact with the agent for a specific
time.
E. Concentration of solution:
 The more concentrated the solution has, the greater is its killing
capacity. The solution must be used at the concentration specified
by the manufacturer to be most effective. Therefore, the
 Methods of Disinfection

Many products and methods are used to disinfect

instruments. A few are described below.
A. Chemical Disinfectants: kill microorganisms
by the oxidation of Enzymes,
coagulation/denaturation of Protein or inactivates
MOs.
Formaldehyde(8%)
Hydrogen Peroxide
Alcohol(70% to 95)
Chlorine Compounds
Glutaraldehyde(2%)
Iodophore
 Cont…
B. Physical Disinfectants
 Boiling / pasteurization - is a method of thermal
disinfection that involves immersion of pre-cleaned items
into water heated to approximately 75- 100ºC for 30 min.
 Boiling method:
 Cannot be depended on to kill spores
 Is a nontoxic, high-level disinfection process
Guidelines for Boiling
1. Never put focally contaminated instruments in the boiler.
2. Instruments to be boiled should totally be submerged
3. Timing should be counted when the water comes to its
full boil
4. Change the water in the boiler every day or every two
days since as the water boils it leaves a scum of impurities
which will stain the inside of the boiler and spoil the
instrument.
 Cont…
5. Boil instruments separately
6. Inspect the boiler from time to time and keep it in
good condition.
7. Do necessary repairs before anything goes really
wrong.
Guidelines for the Use of Instrument Disinfectants:
 Use the disinfectant in a well-ventilated room.
 Make sure that items have been thoroughly cleaned
before attempting disinfection.
 Disassemble all removable parts of the item.
 Thoroughly dry the item before placing it in the
disinfectant.
 Mix the disinfectant as recommended on the label.
 Completely immerse all parts of the item in the
solution.
 Cont…
 Do not leave the item in the disinfection solution
for an undetermined time. The solution may
damage the item and may also become a source
of contamination.
 Close the container to prevent evaporation of the
solution.
 Thoroughly rinse the item in at least two fresh
rinse solutions to insure adequate removal of the
disinfectant (use sterile water and then alcohol)
 Thoroughly dry the disinfected item with a sterile
towel, and place it in a dry, covered container
until ready for use.
 Cont…
4. Sterilization:
Sterilization is the process by which all
pathogenic and nonpathogenic
microorganisms, including spores, are killed.
It is the only process that ensures that an item
is free from all microbes.
Sterilization can be achieved with physical or
chemical methods.
Physical methods generally rely on moist or dry
heat.
Chemical methods on the other hand, use
gaseous or liquid chemicals.
 Methods of Sterilization

A. Chemical Methods
 Chemical sterilization is an alternative for items that would
be damaged if subjected to steam or dry heat sterilization.
 Ethylene oxide (EO or ETO) gas: is used to sterilize items
that are sensitive to heat or moisture.
 EO must have direct contact with microorganisms on or in
the items to be sterilized.
 EO is highly flammable and explosive in air and therefore
must be used in an explosion-proof sterilizing chamber in a
controlled environment.
 Its effectiveness depends on four parameters which include:
 Concentration of EO gas,
 Temperature,
 Humidity, and
 Time (duration of gas exposure)
 Cont…
 Glutaraldehyde (2%) and formaldehyde(8%): When
handling these products:
 Wear gloves to avoid skin contact.
 Wear protective eyewear to protect from splashes.
 Limit exposure time.
 Be in a well-ventilated area.
Sterilization tips in chemical:
Decontaminate, clean, and dry all instruments and other
items to be sterilized.
Completely submerge the items in a clean container filled
with the chemical solution and place the lid on the
container.
Allow items to soak (10 hours in glutaradehyde or 24 hours
in formaldehyde).
Remove objects from the solution with sterile forceps, rinse
all surfaces three times with sterile water, and air-dry.
Store objects in a sterile container with a tight-fitting lid.
 Cont…

B. Physical methods:
Heat is a dependable physical agent for the destruction
of all forms of microbial life, including spores.
It may be used moist or dry.
 The most reliable and commonly used method of
sterilization is steam under pressure/Autoclave.
Autoclave:
This method is the least expensive, most efficient, and
least time-consuming method and is the method of first
choice, whenever possible.
 For the steam process to achieve sterility, the time,
temperature, pressure, and moisture must be present in
correct proportions.
An imbalance in these components can result in failure of
the process.
 Cont…
The minimum time for the entire cycle in the autoclave
sterilizer is 25 to 30 minutes at 121 to 132 degrees
Celsius and 106 kPa pressure.
 However, it is possible, but not recommended to speed
up the process in the autoclave sterilizer by:
 • Increasing the temperature,
 • Decreasing the time, and
 • Processing the item unwrapped.
 This method is called flash/high-speed pressure
sterilization.
Because the delicate balance among processing time,
temperature, pressure, and moisture are changed, the
probability that sterility will be achieved is reduced.
For this reason, flash sterilization should be used only in
an emergency (e.g., a surgical instrument has been
dropped, no alternative exists, and the instrument is
needed immediately).
 Cont…
Sterilization tips in autoclave:
Decontaminate, clean, and dry all instruments and other
items to be sterilized.
All jointed instruments should be in an open or unlocked
position; when possible, instruments should be
disassembled.
Instruments should not be held tightly together by rubber
bands.
Wrap instruments
 Allow instrument packs to dry completely before
removal. Wet packs act like a wick, drawing in bacteria,
viruses, and fungi from the environment.
Wrapped instrument packs are considered unacceptable if
there are water droplets or visible moisture on the
package exterior when removed from the autoclave.
 Cont…
Advantages of Steam Sterilization

 It is the easiest, safest, and surest method of on-site

sterilization
 Steam is the fastest method; its total time cycle is the
shortest
 Steam is the least expensive and most easily supplied
agent.
 Most sterilizers have automatic controls and recording
devices that eliminate the human factor from the
sterilization process
 Steam leaves no harmful residue. Many items such as
stainless steel instruments withstand repeated
processing without damage.
 Cont…
Disadvantages of Steam Sterilization
 Precautions must be used in preparing and
packaging items, loading and operating the sterilizer,
and drying the load.
 Items need to be clean, free of grease and oil, and
not sensitive to heat
 Steam must have direct contact with all areas of an
item. It must be able to penetrate packaging
material, but the material must be able to maintain
sterility
 The timing of the cycle is adjusted for differences in
materials and sizes of loads; these variables are
subject to human error.
 Cont …

Dry Heat/ Oven

The following temperature/time ratios are
recommended:
 170°C (340°F)--------------60 minutes
 160°C (320°F)--------------120 minutes
 150°C (300°F)--------------150 minutes
 140°C (285°F)--------------180 minutes
 121°C (250°F)--------------overnight
By this method, the items to be sterilized are subjected
to heated air in an enclosed oven or container.
This method is usually reserved for sterilizing powders,
oils, sharps, sponges, and bandages.
The major disadvantages of dry heat are that it
penetrates materials slowly and unevenly.
 Cont…
Principles:
 Dry heat sterilization is accomplished by thermal (heat)
conduction.
 Initially, heat is absorbed by the exterior surface of an
item and then passed to the next layer.
 Microorganisms die as their proteins are slowly destroyed.
 Dry heat sterilization takes longer than steam sterilization
because the steam speeds up the penetration of the heat.
Sterilization tips in oven:
Decontaminate, clean, and dry all instruments and other
items to be sterilized.
Items can be wrapped in aluminum foil or placed in a
metal container with a tight-fitting lid. Wrapping helps
prevent recontamination prior to use.
Items should be removed and stored after cooling.
 Sterility Indicators and Control Monitors

It is necessary to have a reliable, inexpensive method for

checking the effectiveness of a sterilizing process.
 Packages wrapped for sterilization are sealed with
indicator tape.
 Tape used on packs to be steam sterilized has
temperature sensitive areas that change color when
exposed to high temperatures.
 Tape used on packs to be gas sterilized has areas that
change color upon exposure to the used (EO).
Other indicators, in the form of paper strips or gas vials,
are also available for insertion within the package. These
indicators are called process monitors.
It is important to note that these indicators reveal only
that the pack has undergone a sterilization process. It
does not indicate that the item is sterile.
The most efficient method of testing sterility is
with biological controls.
 A highly resistant, nonpathogenic, spore-forming
bacteria, contained in a glass vial or impregnated
onto a strip of paper, is placed in the load to be
sterilized.
 For steam sterilization, the dry spores of the
bacteria Bacillus stearothermophilus are used; gas
sterilization uses Bacillus subtilis.
 The vial or strip is recovered at the end of the
sterilization process and cultured.
This process is time-consuming and the results
may not be known for several days, but it is a very
reliable method of testing the efficacy of a
sterilization process.
 Shelf Life

The length of time an item can be considered sterile is referred

to as the shelf life.
Sterility is event related; it is not time related unless the package
contains unstable components such as drugs or chemicals.
Storage conditions are established to maintain the integrity of
the package.
An item is considered sterile on the basis of the following events:
 Handling of the package during transport and storage (i.e., the
prevention of contamination and physical damage.)
 Integrity, type, and configuration of packaging material.
 Condition of storage.
Most commercially sterilized products are considered sterile
indefinitely or as long as the integrity of the package is
maintained.
An expiration date put on the label by the manufacturer
indicates the maximum time the manufacturer can guarantee
product stability.
 Shelf life is affected by the:
 Permeability and density of the packaging material,
 Type of closure used, and
 Method by which the package is handled
 The following are considerations regarding the integrity
of packaging materials:
 An item is no longer considered sterile after an accidental
puncture, tear, or rupture of the package
 Squeezing or crushing a package may force air out and
draw unsterile air in, thus contaminating the contents.
 The accidental wetting of a package contaminates the
contents. It is necessary to avoid the following:
Handling the package with moist or wet hands
Handling the package with soiled gloves
Placing the package on a wet surface
 commercially packaged, sterilized items are usually
considered sterile until the package is opened or damaged
or the stability of the product becomes outdated.
 Storage Conditions

 The following guidelines are helpful in maintaining the sterility

of a package during storage:
 Storage areas are clean and free of dust, lint, dirt, and
vermin. Routine cleaning procedures are followed for all
areas in the perioperative environment.
 All sterile items should be stored under conditions that
protect them from the extremes of temperature and
humidity.
 Packages should be allowed to cool to room temperature
before being put into storage to avoid condensation inside
the package.
 Peel pouches should be stored on their sides to minimize
the pressure from items stacked on top of them.
 For open shelving, the highest shelf should be at least 18
inches (46 cm) below the ceiling and 8 to 10 inches (20 to
25 cm) above the floor. Closed cupboard are preferred.
 Sterile storage areas should have controlled traffic patterns.
END!!!
 QUIZ
1. List at least 5 components of OR attire.
2. List at least 4 factors that affect
effectiveness of disinfectants.
3. write the steps of instrument
processing
4. List each levels of disinfection and
write the major difference between
them
5. List and define each methods of
sterilization