The University of Michigan Risk Management Department recently took a close look at medical device reprocessing, inspired by the U.S. Food and Drug Administration's interest in this area. This study aimed to discover if the current cleaning methods were effective, identify contaminants left behind, and identify ways of making medical device processing more efficient and affordable.Testing began at the University of Michigan Health System in the Central Sterile Processing Department (CSPD) at a workstation specifically designed and assembled for this task. The workstation was equipped with sinks, brushes and enzymatic cleaners appropriate for safe handling of medical devices. Unique additions included a new automated reprocessor featuring cycles of mechanical and ultrasonic cleaning, a borescope, and a digital camera system for inspecting and recording lumen interiors, as well as extra workspace and supplies for the collection and chemical analysis of residues extracted from the medical devices.From internal review, many devices were known to be hard to clean, such as septorhinoplasty sets, due to the cannulae, and coronary suctions, due to cannula shape. A variety of these were tested early on to obtain a working data set to establish the scope of the problem (Table 1). The focus soon turned to suctions (Figure 1), which were ideal for study due to the many variations of design, soils they come into contact with, and the very large number of individual suctions available in CSPD at any given time.It is axiomatic in the industry that medical devices that cannot be cleaned cannot be considered sterile. So one cannot assume that all fully reprocessed devices are sterile. Practical considerations create acceptance of the standards: Reusable surgical instruments are a requirement, as are a steady supply and quick turn-around time to supply clinical needs. An additional challenge is the wide variety of devices used, with broad variations in size, shape, composition, and use. A device designed to pinch, pull, or hold during surgery will also do so in reprocessing. The challenge lies in finding a way to ensure the debris held by devices is removed.The unique characteristics of a specific surgical device can provide a great challenge to cleaning and the verification of effective cleaning. Because many of the critical surfaces of a device are difficult or impossible to visually inspect, other cleaning verification methods are needed. In addition, there are critical limitations to cleaning verification in an CSPD, including lack of laboratory equipment, lack of staff trained as laboratory technicians, and limited time for testing. The need then, is for tests that provide very rapid results (within minutes), are simple to use, and simple to interpret (for example, with pass-fail results).Such tests are already commercially available, and address these issues to varying degrees. Typically these tests involve either swabbing an instrument, or flushing water through the channel(s) of the instrument, to extract any residual soil that may remain for testing. Tests for cleanliness use markers likely to be found in any bodily secretion, such as protein or adenosine triphosphate (ATP); or markers that are secretion-specific, such as hemoglobin in blood. Two questions arise, however: What is the soil(s) that is being tested for, and is the method used to extract the soil effective? In our experience with suction tips, the greater challenge has been the efficacy of the extraction method, which makes identifying the soil more difficult.Most organic soils in the body are water soluble. However, when exposed over time to heat and chemicals, these organic soils can be rendered insoluble. This is particularly true when exposed to the high temperatures of steam sterilization. In these conditions, organic soils, including proteins, denature and can become fixed on the device surface. After repeated sterilizations, these soils can become almost “fused” with the device substrate, including stainless steel. The result, as we have observed, is obvious staining of the device with soil that is not readily or reliably extracted using nondestructive means such as swabbing or flushing. Solidified organic debris can flake off during use, posing an immediate risk to the patient. It can also harbor microbial contamination, another possible risk to the patient.The issue of “what is clean” is a well-discussed but not well-defined topic. In theory, clean means the complete absence of all contaminants, both organic and inorganic. In the real world, however, it is not possible to completely remove all contamination. Even if it were, it is not possible to confirm 100% removal. To compromise, one has to select tests and test methods that can access the most difficult-to-clean areas of a device and detect clinically relevant soil(s) that would be expected to be present. Soils that could be expected include:Once the composition of the soil present is known, it is easier to select an appropriate test method. Most suction tips we focused on primarily came into contact with blood. It would be logical to expect that the reddish soil or apparent staining observed on the internal channel of these medical devices is dried blood. There are readily available kits for blood testing (such as a peroxide reaction with hemoglobin), which are highly sensitive (detect 0.1μg), rapid (result in 30 seconds), and easy to interpret (produce dramatic color change).These tests also lend themselves to either a swab or flush extraction method. Unfortunately, as we have seen, soil observed inside these devices can be highly insoluble, and often cannot be harvested by either swabbing or flushing. Theoretically, more aggressive means could be employed to extract these soils, but could mean damage to the device (from scraping), or use of unsafe chemical solvents.Direct inspection of suction devices and other instruments with a flexible fiber optic bore-scope revealed widespread staining and debris in a variety of used devices that had been terminally processed (ready for use), including a suction tip (Figure 2) and an arthroscopic shaver (Figures 3-4). Stains range in color from red to black. Intuitively, the red might be blood. The black could also be blood, other proteins, build-up of detergents, or oxidation of the steel.To determine the composition of the stains, we conducted a variety of tests. The objective was to identify a test or panel of tests that could reliably detect the staining without destruction of the device, and without the use of a bore-scope. Of course, the composition of the stain would also indicate the source of contamination, and the potential risk to patients.The nondestructive tests we selected were hemoglobin (peroxidase reaction), protein (pyromol and bromophenol blue reactions), as well as ATP and bacterial detection, utilizing an enzyme reaction. Testing was conducted several times, over a period of several months, and each test panel included hemoglobin, protein, and ATP testing. A fourth test, bacterial detection by enzyme reagent, was added in later panels as a method for detecting possible biofilm formation. Extraction methods included flushing and swabbing over the series of tests. Visual inspection of the lumened devices was also conducted utilizing a borescope.Overall, while each method tested demonstrated positive results—with hemoglobin the most effective of the methods used—frequently, none of the tests proved to be positive for residuals, even when borescope inspection of the device revealed staining. It is likely that the reason for this is that the flushing and/or swabbing did not extract sufficient material. It is also possible that the staining was not due to organic soils, but some other source, such as oxidation of the steel.Given the difficulty of extracting soils for testing, destructive testing was considered. Use of surface analysis techniques offered an attractive option to identify soil composition. As an initial test, an instrument that had obvious staining, a Yankauer suction, was chosen for destruction (similar to the instrument in Figure 1). The first round of testing via scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDX), showed that the red stains in the device were comprised of organic compounds. (See the sidebar on page 52 for more on these techniques.)On this individual device, further testing via Fourier transform infrared spectroscopy (FTIR) showed that the staining was a combination of iron oxide, hydrocarbons, and esters, which could be indicative of a biological source such as blood and fatty acids, or a non-biological source such as steel oxidation and lubricating oils. Further analysis via X-ray photoelectron spectroscopy (XPS) was positive for organic compounds consistent with bodily secretions, but other sources are also possible. As this was one test on one device, the results cannot be generalized. A much larger study is required to obtain a good data set of stain composition.As the nondestructive testing discussed earlier revealed, the source of staining may often be bodily fluids. A study, which involves dozens or perhaps hundreds of clinically used devices subjected to destructive testing, is required to develop an evidentiary-based conclusion as to which soils are the sources of stains in these devices. Such an undertaking could be expensive and time consuming, but well worth the effort for an industry seeking to improve the reprocessing of devices used for patient care.The discovery of a problem is only the first step, but a step in the right direction. The testing procedures described here can be repeated in any CSPD or surgical center, using any of the medical devices and tools described. The questions raised are: Are the industry standards for device reprocessing adequate? Do instruments that cannot be cleaned pose a risk to patients? How can the cleaning process be improved?The next step proposed is continued and focused testing. Having identified the necessary steps, continued data collection is paramount, as this information will impact medical device reprocessing specifications and requirements.
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