During this live webinar, Lori Pacheco will discuss best practices in sterile processing. Topics include the decontamination phase, the various methods of sterilization with advantages and disadvantages of each, quality control, and storage/return to the sterile field.
Lecturer: Lori Pacheco, RN, CRNO, Orbis International
MS PACHECO: Hi, everyone. Welcome! My name is Lori. Thank you for joining me today. I do hope that you are safe. Thank you, Lawrence, and thank you, Cybersight. We’re gonna be talking today about decontamination and sterilization of ophthalmic instruments. Before we start, a little bit about me. My name is Lori, I’m a registered nurse, I’m certified in ophthalmology. I currently work for Orbis on the faculty relations team, and I spent a wonderful 27 years with Ophthalmic Consultants of Boston, working in ambulatory surgery. I’m a scrub nurse at heart, and I live in the United States, the state of Massachusetts, an area right down there not far from Cape Cod. I’m a true New Englander all the way, so I apologize if I start to speak a little fast. I’ll try to slow down a little bit. But I want to thank you for joining me. This talk is very near and dear to me. I think this is the start of infection control. This is where it begins. This is the heart and soul of infection control, before your patient even comes into the operating room. This already begins. So thank you for sending me all of your questions. They were awesome. They were fantastic. Great questions, and I did add quite a few of the answers into the slide, so hopefully I’m able to answer many of your questions. So with that said, let’s get started! So I do like to start off with conflict of interest. There are no slides that have any correlation, but I do consult with Mobius Therapeutics and I’m on the board of the American Society of Ophthalmic Nurses. So today we’re going to talk about three critical steps. These are the most important steps. Actually, there are four. I added one extra one. These are our objectives today. We’re going to start off with cleaning and de contamination, we’ll go into sterilization, I’ll discuss various methods of sterilization, we’ll go into quality control, and how to test these sterilizers, and then we’ll talk about storage and return to sterile field. So we’re gonna start off with a question from our first objective for decontamination. The decontamination process should begin when? As soon as the instruments reach the decontamination area? At the end of the surgical procedure? As soon as possible after use? Or when the surgery is near done? Let me know what you think. Very good! So it is as soon as possible after use. It starts right there, at that table. And I’ll go through that. All right. So first of all, why do we decontaminate? These instruments — I hear this quite often. Ophthalmic instruments, they’re not grossly contaminated, this isn’t orthopedics, this isn’t a GI case. Why can’t we just take them out of the sterilizer, wash them, take them to the operating room, wash them on our back table, and put them into the sterilizer? First of all, cleaning and rinsing are the first and most important steps in decontamination. It does start right there at your table. But lens matter, viscoelastic agents, all these things can permanently block lumens, get into those little cannulas, phaco handpieces, saline salt crystals, blood, body fluids, this can all cause pitting and deterioration of your instruments, and it can be very difficult to remove. You’ve got organic material, you have soil, and all this type of debris can block the sterilizing agent from making complete contact with the instrument. So if you’ve got dried blood on those instruments, if you’ve got salt crystals, your sterilization agent can’t get to that instrument. So if you ever get an instrument back that has blood on it — I’ve heard it before. Oh, it’s gone through sterilization. It’s okay. It’s not okay. It actually blocked the sterilizer from getting to your instrument. Now, when? Immediately. On your back table. Decontamination should begin immediately. During a surgical procedure. To prevent that drying of blood, prevent the soil and debris from sitting on the surface. Flushing out your lumens right there on the back table. How do you do that? Instructions for use. You’re gonna hear me say this over and over again throughout this talk. Follow the manufacturer’s guidelines for instructions for use. We call them IFUs. The manufacturers are telling you what you need to do to clean the instruments you purchased from them. They’re gonna tell you exactly what you need to do to clean them. And also for longevity. You spend a lot of money on these instruments. These instruments — you want them to last a long time. So you want to make sure you’re caring from them properly. You want to follow the manufacturer’s guidelines in how to do that. So very common question these days. Everyone is wondering: COVID-19. What are we doing in sterile processing during COVID-19? And I’m gonna tell you: Nothing different. Nothing different. Everything pretty much stays the same. PPE. Personal protective equipment. Universal precautions. Everything that you’re already doing is what you should be doing. Including during these pandemic times of COVID-19. Utility gloves. Liquid resistant gown. Liquid resistant shoe covers. Face mask. Fluid resistant face mask. Eye protection. You can be using goggles or even a face shield. These are all things that you’re already doing. These are all things that are gonna keep you protected from COVID-19. Same thing with aerosols. Some people ask with aerosols — you really shouldn’t be having any aerosol spray in a decontamination room. Everything is typically done under the waterline. So you should be washing your instruments — if you’re washing them in a sonic machine, you should have the top on it, or if you’re washing in the sink, you should be washing it under the waterline. So you really shouldn’t be getting any aerosol spray. Some people have asked about N95 masks. That’s gonna be up to your facilities policies and procedures. There is nothing written stating that you have to use an N95 mask in sterile processing. What you’re currently doing for personal protective equipment to protect your eyes, to protect your face, that should be fine. But if your facility talks about N95 masks, that’s up to your facility’s guidelines. But otherwise, it’s not necessary. So start off with manual cleaning. You have instrument wipe. So you can start cleaning your instruments with a moistened sponge, an instrument wipe. A soft toothbrush. You can’t use hard bristles to scrub instruments. You have delicate ophthalmic instruments. You need a soft toothbrush. Instruments with lumens should be flushed with distilled water. Treated water, sterile water — that’s all called critical water, that’s treated water. So you want to flush your lumens with distilled or treated water, followed by compressed air. Always followed by air. We’re gonna talk about mechanical cleaning. So you can have many different types of mechanical cleaning. You have ultrasounds, ultrasonic machines. You can see some here. Larger ones, smaller ones, and then you’ve got the big large ones that look like dishwashers. Either way, you use a mechanical cleaning, you want to talk about the characteristics of a cleaning agent. Whatever you’re using for detergent. It should be low sudsing, low foaming. You don’t want this bubbling up. Biodegradable. Easily rinsed off. Non-abrasive. It should be able to disperse organic soil and it should be nontoxic. And you’re gonna get this from the manufacturer’s IFU, instructions for use. When you’re purchasing your cleaning agent, you want to be looking for all of these characteristics, from that detergent, from that manufacturer, in the IFU. TASS. So I’m sure many of you know TASS. Detergents and TASS. Toxic anterior segment syndrome. This goes along with detergent. Okay? Acute, severe intraocular inflammation of the anterior segment after intraocular surgery. If you haven’t seen it, it’s… It is not fun. It’s not fun for a patient to have. It’s not fun for us to see. Because we know that it can be tied back to many of these things. Things that are happening in our operating room. Contaminated balanced salt solutions. Irrigating solutions with abnormal pH. You’ve got your viscoelastic solutions. Intraocular medicines. Intracameral antibiotics. The list goes down. When you get to the end, you see: Inadequate sterilization of surgical instruments and tubing. Inadequate flushing of instruments between cases, which can build up ophthalmic viscoelastic solution. So you’ve got stuff inside those cannulas. Think about it. If you’re not flushing them out, you’re not cleaning them well enough, you’re putting your instruments in a sonic machine with detergent, you’re not rinsing, you move on to the next patient, this is how TASS starts. So the cleaning solutions should be mixed with measured amounts of water. I’ve seen people use little medicine cups. Look at your IFUs, instructions for use. You want to see what it’s telling you that you need. How big is your sonic machine? How much water are you putting in there? How much detergent do you need? You don’t want to use any more than what you need. Don’t guess. You want measured amounts. Rinse, rinse, rinse. I can’t stress it more. Take the time you need to rinse. They must be thoroughly rinsed with copious amounts of water to be able to remove that detergent. I’ve asked people how much. I tell people… People ask me how much, and I typically try to tell them… 120 CCs is average of what is recommended. Again, that’s not really written anywhere. It just seems to be what everyone recommends when you ask them how much, how much, how much. About 120 CCs. Rinse, rinse, rinse. You get it through those cannulas. Tap water. If you’re using tap water, just make sure your tap water is compatible with instructions for use for that detergent, and for that equipment. Just make sure it says that you can use tap water. But either way, no matter what you’re using, the final rinse should be distilled, sterile, or treated water. Critical water. Okay? So the warm water — don’t go more than 60 degrees Celsius, 140 Fahrenheit. That will ruin your instruments. You don’t want hot, hot water. A lot of people will use hot water, thinking that’s what’s gonna clean it. You want warm water. Completely open and disassemble parts. So anything that you see that has jaws, scissors, that you have to open up, you want to open those up when you clean and when you sterilize. The sterilant has to get in there. Decontamination, your detergent, your water — everything has to get in there to clean it. It can’t get in there if it’s completely closed. Especially those jaws. When you’re cleaning, completely open them up and you’re gonna keep them open. I say disassemble. If it wasn’t manufactured that way, it doesn’t get sterilized that way. Okay? So many people, to save time, leave certain instruments together and don’t take it apart. I/A handpieces, phaco needles, if they’re not disposable and you can resterilize them, they keep them together. You can’t do that. You have to take it apart. Disassemble everything. If it didn’t come that way in a box from the manufacturer, it doesn’t get sterile that way. So make sure you’re disassembling all of your instruments if it requires disassembling. No lumens in detergent. I stress this because of TASS. This is very important. Some people do it, and that’s okay. If that’s their policy. Then you have to really concentrate on flushing, flushing, flushing, and rinsing, rinsing. But typically in ophthalmology, we try to stay away from putting anything with cannulas — Simcoes and sonic machines that have detergent in it. Because it can be very difficult to remove all that detergent. You want to make sure you’re flushing it. You still want to get it flushed out, but not with detergent. Okay. Lubricants. So you want to use lubricants for hinged instruments only. Scissors, needle holders, some forceps. It prevents those joints from getting stiff, and inhibits the development of corrosion. So lubricant is wonderful. It’s a great thing to do for your instruments. It will keep its longevity. They get dipped one by one into the lubricant. They don’t get soaked. Look at your IFUs, your manufacturers’ recommendations. Typically with lubricants, they just get dipped and they dry. But also make sure you do not put cannulas in lubricants. You don’t want to put anything like Simcoes or any kind of cannulas in lubricants. Those are meant for scissors and needle holders and things like that. But it can definitely extend the life of your instruments. And then dry. Instruments must be dried thoroughly before being stored, or else they’re gonna look like that. If they get put away wet or damp, they’re gonna rust out. So you have to take time to make sure that they’re dried. Now, one of the questions — actually quite a few questions that I received was about stains. And some of you were asking: They’re not quite sure what some of the stains that they see — what they are. So we’re gonna talk about stains a little bit. So there’s a difference between stains, rust, pitting, so stain is a discoloration of the instrument surface. Rust is kind of a red or orange coloration on the surface of the instrument and that’s resulting from oxidation. And pitting, erosion, corrosion of an instrument’s outer surface. It can render it beyond repair. These are tiny visible dots that can lead to deep holes. Once you start with pitting, typically it’s beyond repair. You have to buy a new one. Identifying them. So those orange stains, they can be rust. When instruments lose their finish, like chrome or nickel, they become susceptible to rust. You’ve got phosphate residue. That can result from high alkaline detergent. You want a detergent with a neutral pH, which should be around 6 to 8. Again, look at your IFUs for the detergent that you’re using. Water quality. That last rinse should be with critical water. Saline can also cause brown-orange stains. You have the dark brown black stains, it can be dried blood or it could be a high acidic detergent. Again, you want something with a neutral pH. Blue-gray, cold sterilization solution, like a glutaraldehyde. Check your manufacturer’s recommendations. You could be exposing it to the glutaraldehyde too long. And light and dark spots can be water spots from inadequate drying, and that can lead to rust. So hopefully that cleared it up for you. Removing the stains. You can use a non-abrasive cleaner, commercial stain removers, honestly, you can use an eraser. Many manufacturers’ recommendations say that. A simple pencil eraser can be sufficient to remove the stain. If you’ve got more than 5% of the instruments that are stained, you need to do a good thorough investigation of what’s going on. You can do a quality assurance study, to determine the causing factor. What’s causing all these stains. Okay? You shouldn’t really be having more than 5%. Sometimes you might be getting detergent, you might be noticing something, okay, but just be sure if you’re seeing it quite often that you do a thorough investigation. All right. Objective number two. We’ll go on to sterilization. Your next question. Steam sterilization is best defined as: Forced ventilation of hot air, saturated steam under pressure, heated air, or combustion of organic substances. Let me know what you think! Awesome. Very good. Saturated steam under pressure. That’s your answer. So we’re gonna go into that. Thank you. All right. So sterilization. Chemical, liquid, gas. We’re talking glutaraldehyde or ethylene oxide, or heating — moist heat. These are the ones I focus on. Because these are the ones you see most often in ophthalmology. One of the questions I get often is: Which one is better? Which one of these is the best way to sterilize an instrument? That’s not the question you should be asking. You should be asking: Which is more appropriate? All of these are great sterilizing agents, but what is more appropriate for your practice, your center, and for what you’re sterilizing? Let’s start with chemical. Liquid or gas. So heating provides the most reliable way to rid objects of transmittable agents, but it may not always be appropriate. Some of the questions I received was: How do you sterilize lenses? How do you sterilize certain tubing? So this is where different methods of sterilization come in. Because heating can cause damage to the heat sensitive materials. Fiber optics, electronics, certain plastics, glass as well. So that’s where you have to get into chemical sterilization. So something like glutaraldehyde. It’s an oxidizing agent. It works as a high level disinfectant agent. And a sterilizing agent. It’s used as a sterilizing agent by completely immersing the items into the solution for an extended period of time. Now, the advantage is: If you’re using infrequent sterilization, it’s inexpensive and it’s very safe for lens instruments. Disadvantages: So it is a toxic chemical. The same properties that make glutaraldehyde a good sterilizing agent also makes it very harmful to humans. It releases toxic fumes, especially when it gets heated. The fumes can have a really pungent odor and can be very irritating. There’s no reliable method of monitoring the sterilization process, and there’s potential for contamination during rinsing and transferring, and it can be very toxic to the intraocular and extraocular tissue. I have it here because I know many practices that use it, on their lensed instruments, on their 20 diopter lenses, and use it in clinic. So it can be used, and as long as you follow your manufacturers’ recommendations and do things safely and correctly, yes, you can use glutaraldehyde, but you need to understand the IFUs, the manufacturers’ recommendations, and you need to understand all the risk it carries. Now, ethylene oxide, this is gas sterilization. EO is an organic chemical. It’s a member of the ether group. So EO depends on four factors. Starts with gas concentration, temperature, humidity, and time. These are the four factors you have to have, in order to run an EO process. So the process consists of a preconditioning phase that moves on to sterilization run, it goes into a poststerilization phase, and ends with aeration. Some of the new gas machines have aeration already in there, as part of the process. Some of the older machines don’t, and you have to remove the objects, and keep them out for 24 hours to aerate in a specific area of your center. So it just depends on the machine and how you’re doing aeration. So the advantages of gas — compatible with packing material that can prolong storage life. It completely permeates porous materials. And it’s non-corrosive. It doesn’t damage items. And then we get into disadvantages again. It can be very expensive. Cycles are expensive to run. Requires aeration. Harmful to the operator. It’s carcinogenic, mutagenic, a long, slow, complex process, and it’s also extremely flammable. I say this, and I don’t want to scare you. And I don’t want to push you away from gas sterilization. Honestly, I’ve been using gas sterilization for almost 20 years, and I look back — probably the only time we’ve ever had an issue in 20 years, the warning light came on, there was a problem, the aeration/ventilation tube that goes out onto the roof — I think there was a bird’s nest up there, blocking it. And that’s the only thing that I can remember happening. If you do things correctly, follow manufacturers’ instructions, it is a very safe and great means of sterilization, but it is expensive to run. Not necessarily the machine. The machine can be expensive, of course, to put in and maintain. But all of the items that you need to sterilize — you need the gas ampules, the dosimeter, humidifying chip, you just need to look at the cost, the risk factors, and go from there. But it is a great way to sterilize. All right. Moist heat. This is one that we’re all more familiar with. Saturated steam under pressure. So steam sterilization is the oldest, cheapest, and best understood method of sterilization. Right? Basically what it is: It’s a pressure cooker. Moist heat kills microorganisms by causing coagulation of proteins. The vibration of every molecule of that microorganism causes the splitting of the hydrogen bonds between the proteins. And then the death is caused by irreversible damage to all metabolic functions of the organism. It’s a pressure cooker. All right? So let’s think in the sense of food. Moist heat versus dry heat. Steam coagulations a microorganism’s cell proteins similar to how we cook an egg. We’ll start with egg white. It coagulates when you poach in boiling water at 100 degrees Celsius. Frying an egg, using dry heat, requires at least 371 degrees Celsius, and takes a lot longer. So the most moisture present, the more heat can be carried, making steam one of the most effective carriers of heat. So think about when you cook beef at home. You’re cooking beef at home. It becomes tough when roasted in a covered pan in the oven. If you add a little water to the bottom of the pan, it will be tender. The temperature and time of roasting is the same, but the results are different. Add pressure to that. By putting the same roast in a pressure cooker, you reduce the cooking time by three quarters and get the same result. So different methods of doing steam sterilization. One is gravity displacement. It’s the simplest steam sterilization cycle. Some of the tabletop machines, the smaller ones, those run using gravity displacement. Steam is pumped into the chamber containing ambient air, steam is less dense than air, so it rises to the top of the chamber and eventually displaces the air that’s in the chamber. The steam fills the chamber, displaces the residual air, which is forced out the drain in the bottom of the sterilizer, and by pushing the air out, the steam is able to directly contact the load and begin to sterilize. So it rises, displaces the air, and contacts the load. A very simple process. Then we get into a vacuum cycle. This is called prevac. This is actually a much more efficient form of sterilization. It’s a much more preferred method for porous loads as well. How it works: It’s equipped with a vacuum system. It starts with a series of alternating steam pressure injections. And vacuum draws. These are pulses. To dynamically remove the air from the chamber. And this allows the steam to be sucked into areas where it would otherwise have difficulty penetrating, like cannulas. The absence of air in the chamber allows the steam to immediately penetrate the load, resulting in a more reliable, more efficient form of sterilization. So you have the vacuum system, pulses that dynamically remove the air, and the steam penetrates the load. So immediate use sterilization. This is IUSS. This is a taboo word, I understand. This used to be called flash sterilization. So it’s used in critical situations. There is not sufficient time to process instruments through terminal sterilization. You can use IUSS. You can use immediate use sterilization. What I’m saying is you can’t use it all the time, for every load, for every patient. It can only be used if you drop an instrument. It is the only instrument you have in that facility. That surgeon is waiting for that instrument. Yes. You can use IUSS. But there are rules involved in that. It must be processed in the same manner and still must be cleaned and decontaminated. It must be placed in containment intended for the cycle parameters to be used. We’ll go into that. It must be used immediately. You can’t use IUSS and store the instruments in a package for later use. You can’t use it for the purpose of convenience. Such as lack of adequate supply of instruments to meet surgical volume. You can’t use IUSS because you don’t have enough instruments to meet the surgical volume. It must be compatible with the instruments’ IFU. And it must be documented. Okay? The reason why you’re using it. So if you were to use IUSS, that’s okay. But document on your printout, in your logbook, why you used that. Dropped an instrument. Have to have that instrument. This is critical. I’ve seen reps come in late with an instrument that they want us to use, the surgeon wants to try it, it’s the only one that we have, came in late, the surgery has already started, we don’t have that instrument in our hand, okay. We’re gonna use IUSS. It’s critical. You have to have that instrument. That’s the only case of the day you’re gonna use IUSS. For that one instrument. And again, one or two instruments. We’re not talking a huge load. You can’t do a whole load in IUSS. All right? This is for one or two small instruments that you can put in the sterilizer, for a very critical situation. All right. Quality control. We’re gonna move on to that. Our next question… Chemical indicator strips are process challenge devices that will show color change indicating… The items are sterile. The cycle length was sufficient. The cycle temperature was sufficient. Or exposure to sterilization parameters. Okay. Very good. Actually, it’s exposure to sterilization parameters. They’re not telling you the items are sterile. Not chemical indicator strips. We’ll talk about that. We’ll go into quality control. We’re gonna start with monitoring devices. Need to check our time. Awesome. Doing good on time. These are tools to validate the autoclave process. They give you a realtime evaluation of the sterilization conditions resulting in a permanent record. These can be printouts, charts, gauges, digital displays. But no matter what it is, it should be telling you the time, the temperature, and the pressure. These three things you need to know. Accountability. At the end of every cycle, the operator should verify the correct parameters were met, before the items are removed. Okay? Whatever your facility policy is, for accountability, most facilities, what they’ll do is: The person taking it out, they’ll initial the printout. The gauge or whatever you may have to show you the parameters — they’re gonna initial it. Okay? You can have a logbook with cycle information, and the person who removes the items — you want to be able to track it. No matter what accountability you have, you need to be able to track those instruments. Should you get TASS, should you get endophthalmitis, you want to be able to go back and see — match the sterilization cycle to what instruments went to that patient. Okay? You want to see who took them out, who initialed it, and this isn’t to call somebody out. This is just for accountability. Okay? This is just to understand who’s taking responsibility for taking those instruments out. No matter how you do it, whether it’s a logbook, whether you’re initialing the printout, you need some sort of policy showing that you’re tracking these instruments, and you know who it is that’s handling them. So chemical monitoring. These are your sterilization strips. Okay? Indicator strips. I think most of us have seen these. They react to change in the physical conditions in the sterilizer. The one on the left you can see — and the one on the right — they have not been run. These are just out of the box indicator strips. But they will change color. The one on the right is a class five or type five, and I’m gonna go into that. But you can see where it says: Dark bar must pass this point. It has to pass that point and into the accept range. If it only goes a little bit and stops, it’s not a good load. The one on the left, it changes color. That’s a type one. The treated paper changes color, when exposed to certain sterilization parameters. There are six different types of chemical indicators. You want to make sure you’re using the right one. The classification structure is only used to denote the characteristics and intended use of each type of indicator. It doesn’t mean one is better than the other. It’s just: Make sure you’re using the correct indicator for the load that you’re doing. So type one was the one you saw on the left. That’s a process indicator. It’s not enough to indicate sterility all on its own. It only serves to differentiate processed packs from unprocessed packs. Designed to react to one critical process variable. To my understanding, you can take these and put them over a pot of boiling water on your stove, and it will change color. All it means is that the sterilizer went through a process. That is it. So when that drawer opens, before you even look at the printout to determine that it’s gone through the correct time, and the correct temperature, you can see that type one indicator change — you know that it at least went through a process. The reason why we use this: It can happen. You’ve opened the door. Or let’s say you’ve cleaned your instruments, you put the instruments in the sterilizer, and something happens and catches your attention, and you get called off. Some of these instruments, they come into the sterilizer, they open the door, the instrument is sitting there, and they think it’s clean and they pull it out. They’re not gonna pull it out if they see the indicator strip has not changed yet. But if it’s changed, they know it’s gone through the sterilization process. That’s just step one. You have to verify a lot of other things. But it’s part of the process. Type two, that’s a specific test indicator and I’m gonna save that for last. Type three, single variable indicator. Reacts to only one critical parameter of the sterilizer cycle. Usually used in gas plasma. Type four, multivariable indicator. Reacts to two or more critical variables. And you have type five, and that was the other indicator on the right hand side. This reacts to all critical process variables. Time, temperature, and saturated steam. As does type six and reacts to all critical process variables as well. Just a tighter tolerance. Now, that type two, to go back to that, that’s a specific test indicator. It’s called a Bowie Dick test. It’s a method to verify air removal from the autoclave chamber. Right? Only used in prevac sterilizers, because of those pumps. We have to make sure that those pumps are working properly. It’s run as the first cycle of the day. Any day you use that sterilizer, if you use a prevac, run as the first cycle before any other instruments, sets, or devices are processed. To give you an indication of what it may look like, it’s used as sterilizers with the prevac cycle. The pumps are intended to evaluate the sterilizer’s performance. It’s not a chemical indicator. It’s just telling you that the pumps are working properly. Prevac sterilizers require a vacuum to be drawn in during the first and last phases of the cycle. So you can see in the picture you’ve got an unprocessed one out of the box, and in the middle it’s passed. All the lines are uniform. They all look the same. The last one is a fail. Some of them is just a dot. You see just one big dot, and all the dots have to match. Six or twelve of them. And if you see discoloration, some of the dots are really light, some are really dark, that’s a fail. So here’s our type five indicator. Okay? And you can see on the left that’s right out of the box. On the right is a pass. It has been accepted. These have to be used in every container that you have. Not just sitting on top of the instruments. Not just sitting in the first container. If you’ve got a container for your phaco handpiece, it goes in there. If you’ve got one for your instruments, it goes in there as well. If you have a container for your sharp devices, it goes in there as well. You want to make sure the sterilant is reaching inside all those containers. It has reached the content of the packages and the critical variables of sterilization process have been met in every package. Okay? That’s class five or class six. Heat and steam — these are your sterilants. Color migrates along the path when exposed to all critical parameters of the process. Ending at a safe or passing point. And let me get into your bug tests. These are biological monitoring. Biological indicators. BIs. Typically called bug tests. These are self-contained supports in a sealed medium. They’re exposed to — we’re gonna expose it to a sterilization process. They’re gonna activate it, you basically crush it. Along the growth medium to create a growth environment for the bug. And then you incubate it. To allow growth of the microbe. The incubation process produces acid by-products, which causes the medium to change color. The spores that were exposed to the sterilization process are killed, unable to produce acid, so there’s gonna be no color change. You always want to use controls when you do a biological indicator. The bug that was not sterilized, you activate it, incubate it out of the package, and it will change color. You want a control to compare it to. Indicator testing should be performed at least once per week. It really should be performed daily so you can track it better, but minimum of weekly. You want to do it during critical assessments. There are different types. Some are incubated for a 24 hour period, some you can use challenge packs, and they have a type five and a biological indicator together, and it goes into an incubator and you have results in 10, 15 minutes. Either way, minimum weekly. Not just that. You also want to do bug tests when you test sterilization installation, relocation, malfunction or failure, or after any major repairs. You want to do three consecutive empty steam cycles, and run with a biological and chemical indicator. Any time you’re doing critical assessment. And then you do three consecutive empty cycles with a Bowie Dick test as well. Each type of steam cycle used for sterilization, prevac, and gravity can be done separately. If your sterilization does both, you want to do both tests. The sterilizer should not be put back into use until all biological indicators are negative, and chemical indicators show a correct endpoint response. You can also do what’s called outside or third party testing. The reality is you have a logbook and you’re writing in your logbook that you tested these sterilizers every day. You did biological testing once per week. But really this is — anyone can be writing in a logbook, saying it’s been performed. And that can be tested. That can be questioned. So when we do third party testing, what you’re doing is sending it out to a third party, an outside vendor, where you have nothing to do with the results. And they’re gonna come back to you and tell you whether you passed or failed. I have seen some facilities do it once a month, I have seen some facilities do it once or twice a year. It depends on your policy and procedure. You need someone else doing it, so you have someone else telling you that the sterilizer is working properly. Not just writing in the logbook. You have a spore strip and control strip, exposure to the sterilization process, cycle parameters are documented, you send it out to a third party for testing, and results are returned. It gives you results from an outside source. All right, so you have ultrasonic testing. Like everything else, your sterilizers, all of your equipment, how do you know your ultrasonic is working properly? So ultrasonic cavitation testing. You really should be doing this on your ultrasonic machines, to make sure they’re working properly, they’re cleaning properly. It’s done by cavitation, the rapid creation and destruction of vacuum bubbles or cavities inside the liquid. Those microscopic bubbles, when forced into contact with a solid surface, they collapse. And the surrounding liquid fills the area that the bubbles once occupied, creating an intense scrubbing action, as the cleaning solution rushes against the object being cleaned. This is how ultrasonic machines work. How do you know it’s doing that properly? There’s different methods that you can use. You can buy SonoChecks, something you buy from the manufacturer. You can see those two little ampules. They go into the sonic machine for a certain amount of time, according to the manufacturer’s instructions, and it comes back, and whether it changed color or didn’t change color, it tells you whether or not your sonic machine is working properly. You can also use frosted glass. This is another inexpensive way of doing it. The frosted glass — you’re gonna see the particles, the frosted glass is gonna show that the particles of that scrubbing action worked, by noticing on that frosted glass all the little particles. You’ll be able to see right on that glass the change. Then you’ve got your foil test. You can see all the holes in the foil. You can basically take tinfoil, put it inside of your ultrasonic machine, pull it out after a certain period of time, and you can see if it worked or not. I can tell you that people have complained with the foil test that after you punch that ultrasonic — punched those holes into the foil, what happens to all those little pieces of foil? They can end up in your instruments, your instrument tray, on your instruments. So I have noticed that people have been saying that that may not be the best way of doing it, just because of that reason. But again, it’s an inexpensive way of testing your ultrasound. But you should be testing it, to make sure it’s working properly. And your last objective, which is sterile storage. Question for you. The shelf life of sterile packaged instruments is determined by? The date, the integrity of the package, the size of the package, or the facility’s policies and procedures? Let me know, guys. So many of you did put the date. Actually, it’s the integrity of the package. The date is something that is included in there as well, but that’s not what’s gonna tell you whether or not — how long the shelf life is gonna be. It’s actually the integrity of the package, and we’re gonna go into that. So sterile storage. It can be wrapped/packaged items, like peel pouches, rigid containers, and wrappers. You have to make sure that the sterilizer and the instruments and the container must all be compatible. You need to select packaging validated for the sterilization process, and the cycle parameters of your instruments. Okay? IFUs. I’m gonna tell you a quick story. This is a true story. Facility uses rigid containers for sterilization. They have an instrument on the floor, and they needed that instrument, so they needed to do IUSS with sterilization there. They cleaned it, washed it, did everything they were supposed to do. Put it inside the rigid container. They had to use gravity displacement on the sterilizer. To be able to do IUSS. They put it in, put in all their controls, their type 5s, their type 1s, everything done. The cycle parameters were complete. Pulled it out. Opened it up in the operating room, and none of the chemical indicators inside changed. None of them changed. Done. Get rid of it. Out. Can’t use it. It’s not sterile. Why is that? How come nothing changed inside? We did everything right. Because that rigid container was not validated for gravity displacement. It’s only validated for prevac cycle. This is where your IFUs come into play. This is where everything has to be compatible. We put instruments inside of a rigid container and ran it under a gravity displacement cycle, and it’s not validated for that. The steam didn’t penetrate it. None of the indicators changed. We couldn’t use the instruments. They weren’t sterile. Gone. So that just gives you an idea of how important IFUs are. All right. Peel pouches. These are small, lightweight — meant for small, lightweight instruments. Most of us have seen these. Choose appropriate size to allow for circulation of steam. Don’t put big instruments in these little wrappers and it’s snug in there. You need to allow room for the steam to penetrate. You need to use tip protectors, which should be used to present compromising the package. They should be steam permeable. The tip protectors should fit loose lie. *loosely. They have to have holes on them. These are rigid containers. Many facilities use these as a way of packing surgical instruments for future use, or also just using throughout the day. Check your IFU for storage. Some of these rigid containers, once you sterilize something in them and it doesn’t get opened, doesn’t get compromised, they can stay sterile in there for — I know some have an IFU for over 300 days, if you store that. As long as the container doesn’t get compromised. You need to confirm which sterilization process and cycles the rigid container is validated for. Match up the sterilization process and cycle parameters that the instruments are validated for as well. And then you have wrappers. You can use these to package instrument trays. Double wrapped to provide the best barrier. You want to keep it snug but not too tight. You want to allow strike through. And indicator tape to secure the packaging. Keep in mind many indicator tapes are latex based. So your latex allergy patients — keep in mind the tape that you use on this packaging can be latex. Labeling. Packages should be labeled for accurate identification. Your packages should have the sterilizer number, if you’re using more than one sterilizer. A, B, 1, 2, 3, whatever you use — it should be on there for sterilizing number. The cycle or load number. The date of the sterilization. The description of the contents of what’s in there. And again, the assembler’s identification number. Their initials. The tracking, accountability. What you’re using needs to be — you need to put it on the package where it’s visible. But it needs to be nontoxic ink. No chemical or toxic substances should be released during use. Immediately dry, waterproof, heat resistant, and acid resistant. Now, Sharpie does make an item, 13601 black ink, that actually meets all of these requirements, and I say that, because I’ve been through so many accreditation and state surveys, and we’ve actually had surveys come in and ask what we’re using to write on our packages. And they recommended this particular Sharpie, just because they know it meets all of these. So this is what I’m typically used to using. We have actually had people ask us what we’re using. What type of pen? What type of marker are you using? So I just mention that to you, because that is a safe marker to use. Storage. The shelf life of packaged items is event related. Integrity of the package. All right? Shelf life depends on the quality and integrity of the package, storing conditions, and amount of handling. Yes, you’re putting a date on it. Yes, you want to know what the date is. Okay? And your facilities, policies, procedures can say: These are no longer sterile after six months. You need to redo them all. But there really isn’t anything to back that up. There’s nothing saying those instruments in there are not sterile at six months. It may be your facility’s policies and procedures to resterilize everything after six months, but don’t just go by that. You need to go by the integrity of the package. If after three months you notice the packages that been crumpled up, something is on top of it, it’s yellow, it’s been sitting somewhere, this wasn’t good circulation, the storage room didn’t have the best quality air, squeezed in a bunch of things, and it turned yellow — you don’t want to use that package. You want to look at your package and look at its integrity. Make sure there’s nothing striking through it. Make sure it’s not discolored. This is what you should be looking at for your shelf life. Yes, you can make a policy and procedures according to date. But you shouldn’t just be relying on just the date. It should be the integrity of the package that tells you how long something can stay on the shelf. Okay? Prior to using a wrapped item, you want to visually look at it. Look at its integrity. You want to be looking at its indicator strips inside as well. Before you open that up. You want to make sure you’re looking at everything. Do not use elastic bands to secure packages together. Do not crunch, bend, puncture, or compress the package. Don’t stack them. These are your heavy ones with the wrappers. Big instruments in wrappers, stacking one after the other. I understand storage space is limited. Believe me, I’ve seen every closet, every square inch of a facility used for every reason. I understand that sometimes you need to think outside the box, when it comes to storage, but you really can’t pile up instrument wrappers and use big instruments on top of each other. You’re gonna cause a problem, as far as integrity goes. Okay? Undue pressure from weight. Don’t store them on the floor or windowsills or any other area other than designated shelves or counter. Tip covers, like I said, they must contain holes. I have seen people use all kinds of things for tip covers. Yes, there are many different plastics that you can put in a heat sensitive — a heat sterilizer. Not necessarily as heat sensitive as others. Good plastic — and I’ve seen people cut tubing. You name it. I’ve seen it, for tip covers. Not to say they can’t be used. They’re really not validated for that. But regardless, just make sure that you can get steam through it. It has hold in it. You can’t have the top completely covered. Okay? So that’s why I recommend these tip covers. And on the bottom, you can also see these… They’re relatively new. They have indicators on them. So you can see the orange and the blue will change color in steam or gas. And it’s a nice way of putting your instruments safely on something. So they’re not running around inside of that package and possibly getting damaged. So these are nice as well. Loading an instrument tray. Must leave room for steam penetration. This picture really gives me hives. It really does. People tend to just… They don’t want to have to run multiple loads. They want to put as much as they possibly can in that load, and think about it — your sterilant is steam. Steam needs to — or gas — your sterilant needs to penetrate through these packages. It can’t do that if they’re stuck up against each other. Okay? So don’t load these instrument trays one on top of another on top of another. You want to leave room. Okay? Transportation to the sterile field. Should be transported using adequate protection, in a way to prevent contamination, like a covered container. Like those rigid containers. So the top ones — yep, these are instrument trays. The one on the left — we all have seen these. And you can see these holes. And the holes are there for a reason. To allow steam penetration. But when you’re transporting instruments in these, you have holes in them. That’s a chance for contamination. Same thing with the one on the right. You put your instruments inside there, stick it in the sterilizer, carry it down the hall to get to an operating room, completely open. Open to anything that could possibly happen to it. All right? So you want to be using something that is a closed system, like the containers you see on the bottom. Doesn’t necessarily have to be those, but you need something that has a closed system, to protect sterile items when you’re bringing it to the sterile field. When you’re bringing it away from the sterile field, all instruments that were on the sterile field, whether used or not, are considered contaminated. Your entire back table. Don’t separate your instruments used, not used. To give the person sterile processing a clue as to what you used and what you didn’t so they know what to wash and what not to wash. I’ve seen that happen. These weren’t used. We’re fine here. Oh, these were used. So we have to wash these separately. Or do something different. Doesn’t work that way. Everything on your table. If it goes on your back table, it gets washed clean. Whether it went in the eye or not. Okay? Containment. Of contaminated items should be achieved using some-type of container that has been identified to prevent staff from coming into contact with it. You need a closed system to prevent these things from coming out of the operating room. They must be leakproof. Puncture resistant. Marked with a biohazard label. Closed carts. Bins with lids. Impermeable bags. Rigid sterilization container systems. Just make sure it’s confirmed by the IFU. But it can be simple. This is a regular storage bin. It’s leakproof, puncture proof, there’s a biohazard label on it. It’s inexpensive and easy. You don’t have to go out and buy anything too expensive. Just make sure you’re following all of these rules. Make sure nothing can poke through it, and you have a biohazard label telling everybody what’s in there. And my last piece for the day is education. Any personnel who performs sterilization activities really should have adequate training and have their skills verified. Competency verification. Unfortunately, this isn’t the type of field where you can see one, do one, teach one. You really have to know and understand sterilization, to be able to perform sterilization. Continuing education. Review and update your knowledge. I think with gas sterilization, you have to get certified to be able to do it. And then it gets — you get recertified. Over and over. Just to make sure that you remember. And that anything new that may be coming along in gas sterilization — you do this. You have to constantly be checking, and constantly be training and be educating yourself. Inservice training on new instruments. Devices. Equipment and IFUs. Education. At the end, I was gonna discuss with you how you get ahold of me. I tell you now that if you have any questions on — what’s out there. How to learn. Education. I’m gonna show you how to contact me. Please feel free to reach out to me. I love to network. I love to share information. We’re all in this together. So if you’re looking for ways to learn and educate, please let me help you. And that is the end, you guys. I think we’re gonna go on to our questions in just a minute. So I’m going to stop my share screen. I think — Lawrence, I don’t know if we have any questions and answers. Let’s take a look here. All right. Can you give us a definition of decontamination? Basically decontamination is what you’re doing to wash and decontaminate these instruments and prepare them for sterilization. This is what you’re doing to prepare your instruments to go into the sterilizer. It can be manual cleaning. It can be using a sonic machine. Either way, decontamination is the first step in sterile processing. This is what you’re doing to prepare your instruments for the sterilization process. You want low foaming because you don’t want — that foaming, that detergent, that soap — there’s so much of it. It’s gonna be harder to rinse off, basically. You want to make sure you rinse, rinse, rinse, rinse. So you want something that’s low foaming. Okay? Sterile water combined with alcohol? Be careful with that alcohol. The question is: What is your opinion on washing and/or flushing instruments with sterile water, combined with alcohol. I would be very careful with that alcohol. Don’t forget, everyone, what you’re doing now with these instruments is gonna get cleaned, washed, sterilized, and then used in another patient. So if you’re using alcohol and that alcohol is not rinsed out correctly, even if it’s mixed with the sterile water, if you’re not rinsing and rinsing and rinsing well enough, you have a chance of this alcohol getting put into the intraocular system. So sterile water with air. You always want to follow it up with air. What kind of lubricant can be used for moistening the instruments? We’ve never used it. There’s all different types of lubricants. There’s so many of them out there. I really can’t say a specific one, whether one is better than the other. But lubricants are mostly used just to provide your hinges to be able to open up easily. I’m sure many of you, myself as well, have given an instrument to a surgeon, and it doesn’t open, or the scissors aren’t opening and closing very well. That’s what lubricants are for. I can’t recommend one that’s better than another. But again, like I said, please feel free to reach out, and I’m sure I can help you find one. Can we use rusted instruments after proper sterilization? You know, not really. Because what happens with rusted instruments — what happens with that rust? It can come off. Even after proper sterilization, you’re sterilizing over rust. Okay? And that rust — those particles can come off. So if you’re noticing rust on your instruments, you need to take that out of circulation. You need to get that rust off before you can use it on a patient. Can you use some light on erosion? I’m not sure of the question. If you’re getting instruments that are possibly causing erosion… It could be from rust. You want to be checking your detergent and your water quality as well. Do a study. Take a look and see what you have for water quality. What you have for your detergent. PH balance as well. So that could be causing erosion. Mass cataract surgery. Opinions about sterilizing and decontaminating for mass cataract surgery? It shouldn’t change. Whether you’re doing 30, 50, 20, or 10 cases in a day, it doesn’t change. Okay? Your process is the same. You have to take the time to clean properly. Sterilize properly. Store to and from the sterile field — everything is the same. Whether you’re doing cataract surgery in mass quantities or whether you’re doing ten cases, you’re not gonna go any faster, you’re not gonna take any shortcuts. You’re gonna do everything sterile, the same. It shouldn’t matter. Decontamination and sterilization. So decontamination is the process of preparing your instruments for sterilization. You’re decontaminating them. You’re washing them. You’re cleaning them. You’re using detergent. You’re scrubbing them. You’re getting that bioburden off. And preparing them for sterilization. Sterilization is ridding your instruments of any kind of materials that are infectious. Decontamination doesn’t do that. You’re sterilizing — you’re killing microorganisms. Decontamination is preparing these instruments, by ridding it of bioburden to prepare for sterilization. What is the most essential standard procedures of maintaining autoclave? The use of the steam autoclave? Really that’s gonna be — maintaining it is gonna be according to the manufacturer’s instructions for use. You shouldn’t be taking these things apart and putting them back together and maintaining them. You want to check and make sure that they’re being maintained properly by doing the bug tests, doing the Bowie-Dick test. That’s how you check to make sure they’re being maintained, but as far as having them maintained and being looked at, that’s according to manufacturer’s instructions. Someone should be coming in who knows how to take them apart and knows that they’re gonna be running properly. Which is the best and worst sterilization process, keeping in view all aspects? So like I was saying, there isn’t really a best and worst of sterilization process. It’s just a matter of what’s most appropriate for what you’re doing. Okay? In view of all aspects — I’m not quite sure of that question. But if you’re looking at what is the best and worst sterilization process, there isn’t one. It just depends on what type of instrument you’re using and what you’re doing, as far as — you’re in clinic and you’re using lenses, you may not have a big sterilizer in clinic, in the operating room, you’re doing retina instruments, many of them do require another type of sterilization, besides steam, because you may be using lens instruments and things like that. So you may have to use gas or another type. Some type of chemical, rather than steam. But either way, it’s about what’s more appropriate. Not so much what’s good or bad. Can we use expired IOLs? I’m not sure if this means you should be sterilizing expired IOLs? I would say no. There’s a reason — typically it’s expired because that manufacturer is saying that after a certain amount of time, what’s in there is not properly sterile anymore. And that they’ve expired. But these are implants. And implants are a whole other ballgame, you guys. This is a whole different animal. I would not recommend sterilizing IOLs in any form. Are there any masks that can be sterilized? I don’t know. I don’t use N95 masks. That’s gonna come from the manufacturer. Whether or not an N95 mask can be sterilized. You’ll have to look at the instructions for that. Sterile items should keep in container? I’m sorry, I’m not quite sure I understand that question. But you do want to keep your sterile items in a closed and covered container, to try to keep away from it being contaminated during the return to the sterile field. Use infective and non-infective cases separately? Universal precautions, guys. You have to pretend everyone is infected. You have to think everyone is infected. You should not be sterilizing instruments any differently for someone who could possibly be infected or someone who is not. You don’t know for sure who is coming into your operating room and who is infected and who is not. This isn’t something you may know all the time. So you have to use universal precautions. No matter what, you have to use the same process for every single patient, as if every person is infected. You’re not gonna do anything different. Okay? Autoclaves again — you can reach out to me. I’m happy to talk about different autoclaves, different processes, and again, same thing with the frosted glass slide test. I don’t use it. I’ve never used it. But I can certainly help you find information on that. Just a good book for sterilization — again, this is why I sent out my conflict of interest. I do sit on the board for the Society of Ophthalmic Registered Nurses. I don’t get paid for that. I get no compensation. It’s all volunteer. But I did edit a book many years ago on sterilization of instruments. It’s a great book. It’ll give you an overview of sterilization for your instruments. I can help you find that. In the United States, we use our processes for sterilization — typically have to follow what’s called AAMI. The Association for The Advancement of Medical Instrumentation. When people come in, they’re gonna ask us: Who do you go to for your regulations? We have to follow AAMI. And typically they’re the ones who set the rules for sterilization. So they’re a great resource as well. Instruments are dipped in alcohol between uses. Any comments? Any thoughts on whether dipping in Betadine… I don’t. I don’t have any thought on that. I’ve never done that myself. Again, it’s gonna be manufacturer’s recommendations of how you should be cleaning them. When you get those instruments, when those instruments come in, there’s always that little tiny package wrapper in there. But that wrapper is what’s gonna tell you how to clean these instruments. If it tells you that you should be dipping in alcohol, you should be dipping in alcohol. Betadine? I’ve never seen that. But you want to go by the manufacturer’s instructions for use. You don’t want to make up your own procedures, you guys. This is where you can really run into problems. The manufacturers are telling you how to clean those instruments. What you need to do, to clean them best. You need to follow those. If you put protectors on instruments during sterilization — yes, you can. As long as it’s validated for that. You can put tip protects on if the IFU says it’s appropriate for sterilization. You don’t want capsulorrhexis forceps to be inside a set with other instruments that can possibly get crushed, so you do want to use tip protectors. Just make sure they’re validated to be able to sterilized with whatever you’re using, and that they have holes or some type of means for the steam or whatever you’re using, gas, steam, to be able to penetrate through. But definitely, you can certainly use tip protectors. Decontamination solutions with appropriate concentrations. There are so many out there. I couldn’t really recommend one or the other to you. There are so many out there. You just want to look for one that has a neutral pH and all these characteristics I talked about. One of the things with TASS that you want to be careful for and look out for is when you’re trying these things over and over again. We’ve also found that when it comes to TASS, it’s very difficult to narrow down what caused it. When you’re using different means for detergents. So if you’re using a different detergent every week, that’s not good for being able to track something like TASS. If you find something that is working, and working well, stick with it. If you do want to change something, that’s okay, but document it. Document that on this date, we changed to this one. We think this one is less expensive, and still gonna give us good quality. Giving us everything that we need. So you can track it and you can go back. Because when you change things over and over again, that’s when you have a hard time tracking. Can we use formalin gas? I’m not sure if that means can you put formalin inside of a gas sterilizer? I would check with the manufacturer’s instructions. Maybe not. I’m not sure. If you can gas formalin? I don’t know. You want to check with the manufacturers’ instructions on that. I would hate to tell you that certain things you can put in there and be wrong. I would want more information. I really don’t know that. How do you remove the lubricants? It’s gonna depend on the instructions. Typically the lubricants, they get dipped and they get set aside. And they dry on there. All right? So typically sometimes lubricants just stay on there. And it’ll dissipate on the instruments, so to speak. Many of these don’t get washed off. If you wash them, it tends to defeat the purpose. So just look at the instructions, but typically, you dip them and set them there to dry. Sterilization of the operating room… Does the centralized HEPA system… Still suitable in the COVID-19 era? From what I know, yes. I’ve looked at AAMI to see if anything has changed. Nothing has changed as far as I can tell. The HEPA systems have all stayed the same. Right now I can tell you that nothing has changed with COVID. I don’t know if that will change in the future, but during these pandemic times, from what I can see so far, everything has stayed the same. I’m not sure if they use lubricant… The company sterilized our instruments… So you’re using an outside vendor? Check with them. If you’re using an outside vendor to sterilize your instruments and it comes back to your facility, you want to check with them and see what you’re doing. If they’re sterilizing your instruments, you need to be checking all of their processes. If you’re using instruments that someone else sterilized, you need to be checking all the processes. To make sure all the processes are in place to make sure that the instruments are sterilized, and they’re being taken care of. So check and make sure they’re getting lubricated, they’re doing the bug tests and all the testing. What temperature can we put phaco handpieces in prevac? The instructions for use must be compatible with each other. Okay? I can’t tell you the correct process. But the little insert on that phaco handpiece that came in from the manufacturer… That’s what it’s gonna tell you. You have to make sure that’s compatible with the sterilizer. Many sterilizers work at 270 degrees Fahrenheit. That seems to be an average one. But that may not be the best for your phaco handpieces. That manufacturer is gonna tell you: On that little piece of paper, if you don’t have that, look it up. Call your manufacturer. Look online and see what they’re saying. You have to sterilize this at this temp for this amount of time, at this pressure, and make sure your sterilizer does that. Make sure it’s all validated. Can tap water be used? So the manufacturer will typically tell you whether tap water can be used. I would say no, only because tap water can have so many impurities. But it depends on what you’re using tap water for. A lot of people use tap water in the sonic machines, but they’re rinsing and rinsing and rinsing with distilled, treated water. So yes. Many places use tap water in their sinks to clean instruments with, but they’re not rinsing with the tap water. The last rinse, with everything out, should be with treated, sterile water. You can use tap water. I would check with the manufacturer. Because all those impurities with tap water, when you overuse tap water, that’s when you’re gonna get some of those stains and spots on your instruments. Some of you have a good filter system in your facilities. Some put a water filter in just for their decon room. But yes, typically you can use tap water. Just make sure you’re rinsing, rinsing, rinsing, the last step is with the distilled or treated water. Which type of autoclave? I can’t tell you what’s best. It’s really what’s more appropriate. Generally used for rinsing. Check the manufacturer’s instructions. I don’t know the pH for rinsing. I’m not 100% sure. I just know pH for detergents should be between 6 and 8. Otherwise, as far as water generally used for rinsing, I’m not 100% sure. You really want to check and see what you’re rinsing and what those instruments — if there’s any recommendation of what you should be rinsing with. How do you make sterilization your face mask usually? Very fine your presentation. So your face mask that you’re using in the decon room can be… It needs to be fluid resistant. Okay? Either your goggles and a fluid resistant mask, you can have the mask with the shield on top. Either way, it needs to be fluid resistant. Needs to have adequate protection for your eyes. Not just regular glasses. If you wear glasses, you have to wear goggles or something over them. Steam sterilization sets have to come out wet? Yes, they can. Especially the tabletop ones. If they’re coming out wet, typically they need to be going through the drying process. You need to check and make sure that the sterilizers are running properly. But they shouldn’t come out soaked. They should not come out dripping. But sometimes they do come out a little bit wet. If they do, you need to take those instruments, in the rack, you sit them down and you let it dry. You do not want to be handling wet packages. Because that’s when it’s gonna just go through your instruments. You may not even know it. And get contaminated. If your instruments are coming out wet, it depends on how wet. You don’t want it to be soaked. But some of the tabletops can get out a little bit wet, so you want to make sure they’re dry, dry, dry. I think I only have one or two minutes left. Okay. Can you sterilize expired or unused? No. I would not. Anything unused I would not sterilize them. You really have to have it validated for sterilization. If it’s gonna go intraocular, you don’t want to resterilize them. I wouldn’t do that. Can you soak cannulated instruments? I wouldn’t soak them in detergent or lubricant. You risk the possibility of it getting left inside of there. Even though you’re rinsing, rinsing, rinsing, I would not soak them in detergent or anything that can cause TASS. Okay? Some facilities do put them in the detergent and that’s okay. It’s just: Make sure that you’re rinsing, rinsing, rinsing, rinsing. But it is an accepted practice, from what I can see, for many centers, that they’re rinsing it or they’re putting it in solution, just distilled water, followed by air. They’re not using detergent. But if you are using detergent, that’s okay. Just make sure you’re rinsing, rinsing, rinsing. Okay? Okay. And I think you guys… I apologize. I think that’s probably — our time is up. Again, thank you so much for joining me today. I hope this was helpful. Cybersight, if you would like to reach out to me, you can reach out to me through Cybersight. Send me your questions. Send me any cases you have in mind. I love to talk and network. And I would love to get to know you better. So please feel free to reach out to me with any more questions. I hope that you stay well and you will be safe. Thank you.
October 5, 2020