Understanding the Sonic Cleaning Process

Professional Education & Training Understanding the Sonic Cleaning Process by Stephen M. Kovach, B.S. Objectives 2. A surgical instrument that is not properly cleaned After completion of this self-study activity, the learner will be could fail to be effectively sterilized. able to: A. True B. False 1. Explain the factors that influence the sonic cleaning process. 3. De-gassing conditions the bath/solution for 2. Describe the role de-gassing plays in sonic cleaning. maximum efficiency and should be done for each 3. Identify test to use to determine if a sonic cleaner is functioning new fresh bath/solution. properly. A. True B. False 4. Develop a quality improvement program for sonic cleaning. 4. Decontamination Holding Time (DHT) is the Test Questions amount of time that elapses between an instru- True or False ment’s last use and the start of the cleaning process. 1. Presently the Association for the Advancement of Medical A. True B. False Administration (AAMI) and the Association of periOperative Registered Nurses (AORN) recommend 5. The sonic cleaners used in hospitals work via that automatic cleaning equipment like a high-frequency sound waves (usually above 20kH) sonic cleaner be tested during routine use to produce an effect called cavitation—tiny at least weekly. bubbles of vaporized liquid that implode (rapidly A. True B. False collapse) and create high pressure shock waves. A. True B. False 6. The SonoCheck™ is a device that tests for caviation in a sonic cleaner. A. True B. False 7. No sonic cleaner has 100% distribution of sonic energy throughout its tank and testing in many areas of a tank is important. A. True B. False 8. Monitoring the key factors of the sonic cleaning process helps ensure that surgical instruments are getting clean. A. True B. False 9. Both Joint Commission and AAMI encourage the use of quality improvement programs within Photo is courtesy of Ultra Clean Systems, Inc Central Service Sterilization Departments (CSSD). A. True B. False 10. CSSD staff should understand how the sonic equipment works; such knowledge is key to Figure 1. Ultrasonic Cleaners by Ultra Clean Systems: 1150V ensuring that instruments are safe to proceed to Floor Model is an example of one of the many sonic cleaners the next step in their reprocessing cycle. available to CSSD. A. True B. False 70 healthVIE.com June 2011 Professional Education & Training Introduction Reduce risk to staff from airborne and blood-borne “Cleaning is critical because residual organic material pathogens created by manual brushing; (e.g., blood, bone, proteinaceous material) can inactivate Improve patient care by reducing risk of exposure to disinfectants; moreover, if a device is not cleaned thoroughly, cross-contaminants; sterility may not be achieved.”1 Reduce time spent trying to manually clean places that Surface cleaning is a crucial aspect of any Central Service cannot be seen or reached; Sterilization Department’s (CSSD) cleaning process. Effective Reduce internal and external instrument damage cleaning of any surgical instrument is important regardless of caused by manually brushing, tapping, or bending; the complexity of the instrument. There is no such thing as and “sterile dirt”. Reduce instrument-repair budgets. Almost all surgical instrument manufacturers recommend sonic cleaning in their guidelines for care and cleaning of From an instrument manufacturer’s point of view, surgical instruments: ultrasonic cleaning is an essential part of the cleaning “Ultrasonic cleaners are used to remove soil from joints, process and should be used as frequently as possible. crevices, lumens, and other difficult to access locations. The Today’s CSSD professionals must understand how sonic use of enzymatic detergent in the ultrasonic cleaner is recom- cleaning works and are responsible for ensuring that their mended. Ultrasonic Cleaners should be monitored routinely department’s ultrasonic equipment is working properly. to ensure that they are working properly.”2 (See Figure 1 on page 70.) Instruments have become more advanced and complex, What is sonic cleaning? so has the sonic cleaning equipment that can be purchased Sonic cleaners are designed for fine cleaning of by hospital CSSDs. These advancements have taken a simple medical devices, not for disinfection or sterilization. “They tank with transducers to a level where sonic equipment now are used to remove soil from joints, crevices, lumens, and can combine the power of irrigation (pulse/retro flow tech- other areas that are difficult to clean by other methods.” nology) with sonic energy to clean lumen instruments better (ANSI/AAMI ST79 Section 7.5.3.3)5 than ever before. Add the advancements that have been A sonic cleaner can have a single tank or as many as made with cleaning solutions, and today many sonic equipment three tanks in a hospital setting. In a multi-tank system, the manufacturers (such as Geddis and UltraClean ) claim first tank is usually for cleaning, the second is for rinsing they can:3,4 and the third is for drying. In a two-tank system, one tank Improve consistency of cleaning in internal areas of surgical cleans and the other rinses and dries. When a single tank instruments; system is used rinsing and drying after the sonic process is important and done separately from the sonic tank. The sonic cleaners used in hospitals work via high- frequency sound waves (usually above 20kH) to produce an effect called cavitation—tiny bubbles of vaporized liquid Many thanks to the team at 3M Health Care for that implode (rapidly collapse) and create high pressure working with healthVIE.com to provide the following shock waves. Ultrasonic transducers create this high- accredited course. IAHCSMM has awarded 1.5 contact frequency sound by converting high-frequency electrical points for completion of this continuing education lesson power to mechanical energy (vibrations). This energy is toward IAHCSMM recertification. The CBSPD has preap- transmitted to the cleaning solution via a bank of transducers proved this inservice for 1.5 contact hours for a period of attached to the underside of the cleaning tank. five (5) years from the date of publication, and to be used Cleaning takes place as the cavitation dislodges soil only once in a recertification period. This inservice is 3M from the surface, tiny crevices, and other areas that are Health Care Provider approved by the California Board of difficult to clean on contaminated instruments, which are Registered Nurses, CEP 5770 for 1 contact hour. This form placed in the tank with a cleaning solution. Cavitation liter- is valid up to five (5) years from the date of publication. ally sucks soil off the instrument like a vacuum. Instructions for submitting results are on page 92. Most sonic cleaners have multiple transducers healthVIE.com and 3M Health Care will be working producing the cavitation energy. If one or more of these collaboratively to provide continuing education courses at transducers is not functioning, the sonic cleaner tank can healthVIE.com. have what are known as “cold spots”—areas within the tank where there is no cavitation. Obviously it is important 72 healthVIE.com June 2011 Professional Education & Training to know the location of any cold spots. In a machine with temperatures above 110ºF (45ºC). When blood denatures, it several cold spots cleaning time will be extended and sonic becomes highly insolvent. It bonds strongly to the substrate activity might not even take place in those areas of the tank. (i.e., the surface of the instrument) and dries out, becoming very resistant to any cleaning action. Thus it is very important Outside factors that affect the sonic to keep Decontamination Holding Time (the time between cleaning process when the instruments were last used and the cleaning process Like any cleaning process, sonic cleaning is affected by starts) to a minimum. The sooner the cleaning process begins outside factors. Factors that influence the effectiveness of sonic the better. cleaning are: 1. Energy—created by the mechanical action of the genera- De-gassing tors and transducers to produce the cleaner’s cavitation; De-gassing is the process of releasing dissolved air 2. Target Soil—the type of soil being cleaned (mostly blood); bubbles within the cleaning solution. In order for the degassing 3. De-gassing—freeing trapped air; process to work, it must be done with the detergent/enzyme 4. Chemical activity—the type and amount of the cleaning mixed in the bath solution. It is important to expel these air solution chosen; bubbles because they have a direct effect on the ability of the 5. Type of instrument to be sonic cleaned (simple or equipment to clean. The presence of dissolved air weakens the complex) cavitation force of the sonic cleaner. 6. Water quality—hardness and pH; Degassing is done after the cleaning solution has been 7. Water Temperature—hot or cold cleaning solution; added and in an empty tank. The amount of time will vary 8. Time—length of exposure to cavitation; depending on the type of chemical used (e.g., aqueous or 9. Human factor—training, loading procedures, proper use solvent), temperature, size of the tank, and water quality. of equipment; Generally the process takes as long as one cycle without any 10. Other issues—such as pre-cleaning and safety; and instruments in the filled tank. Consult the ultrasonic cleaner’s 11. Verification of the process. written Instructions for Use (IFU) on the length of time required to de-gas a tank full of solution. The various combinations of theses factors determine how Remember that degassing conditions the bath/solution clean an instrument can or will be when placed inside the for maximum efficiency and should be done for each new bath/solution of a sonic cleaner. The first factor, Energy, has fresh bath/solution (change bath as per the manufacturer’s been explained above in the section on cavitation.

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