Cleanliness and sterilization are paramount in hospitals, but became even more critical throughout the COVID-19 pandemic. Although there's been a clear emphasis on the use of disposable personal protective equipment (PPE) in healthcare settings, clinical tools haven't received the same level of guidance.

Should providers shift to disposable accessories? If not, how should cleaning protocols for reusable instruments change? The answers to these questions are particularly important during surgical procedures, which rely on countless tools for precision and infection prevention in operating rooms.

Regularly reviewing cleaning and sterilization best practices for ORs and surgical instruments helps keep patients and surgical staff safe from evolving safety concerns—especially during times of increased viral contamination and exposure, such as the COVID-19 outbreak.

5 Pandemic-Prompted Cleaning and Sterilization Procedures

According to a study published in the journal Anesthesia & Analgesia, COVID-19 can survive for at least three days on different materials encountered in an operating room. The article went on to say that standard OR and recovery cleaning practices performed by hospital staff are often inadequate, "especially for noncritical items such as near bedside equipment."¹

The following pandemic-prompted recommendations can help address any human errors made or other areas of concern during the manual cleaning process.

1. Effectively Cleaning Clinical Accessories

Before clinical accessories and other healthcare equipment can be properly sanitized, they must first be cleaned effectively. If there are any contaminants left on the item when it enters the sterilizer, it won't actually be sterilized and the contaminant(s) will still be present.

To manually clean areas without mechanical units or fragile or difficult-to-clean instruments, the Centers for Disease Control and Prevention (CDC) notes that the two most essential components are friction and fluidics.² Friction can be either rubbing or scrubbing the soiled area with a brush, while fluidics (fluids under pressure) can remove debris, soil, and other contaminants from internal channels.

Instruments should be cleaned with a neutral or near-neutral pH detergent solution. Neutral pH detergents with enzymes are compatible with metals or delicate medical instruments, according to the CDC, while alkaline-based cleaning agents should be used for processing medical devices.

2. Ultraviolet Light

The use of ultraviolet light (UV-C) as a cleaning and sterilization enhancement tool has increased in recent years. UV-C is germicidal and reduces bacterial and viral contamination on nonporous surfaces, in water, and in the air. It deactivates the DNA of bacteria, viruses, and other pathogens, destroying their ability to multiply.

According to the Food and Drug Administration, UV-C radiation has been shown to destroy the outer protein coating of SARS-associated coronavirus, a separate virus from the SARS-CoV-2 virus that causes COVID-19.³ UV-C radiation may also be effective for inactivating SARS-CoV-2 in the same manner, though it has not yet been sufficiently studied to support this claim.

Although UV-C radiation is effective for disinfecting, there may be areas of the OR that the UV-C light does not reach, necessitating manual cleaning. UV-C radiation can only inactivate a virus by direct exposure; if the virus is blocked or covered, it cannot be inactivated. Therefore, it is important to note that UV-C light is meant to bolster—not replace—regular cleaning.

3. Increased Airflow

Along with manual cleaning and UV-C lights, mindful use of airflow is now being considered as a virus-fighting agent. Disinfecting personnel should only enter the OR after enough air changes have occurred to remove infectious particles, recommends a study published in Patient Safety in Surgery.⁴

According to the CDC, at 15 air exchanges per hour, 99 percent of airborne contaminants can be removed in about 18 minutes.⁵ The current recommendation for ventilation in the operating room, per the American Institute of Architects, is 15 air exchanges per hour combined with a minimum of three air exchanges of outside or fresh air.⁶

4. Steam and Chemical-Based Sterilization

One viable method of sterilizing reusable surgical instruments is with a steam autoclave. Steam sterilization is readily available, easy to operate, and may achieve the temperatures necessary to inactivate the SARS-CoV-2 virus, according to a letter to the editor published in Dermatology Journal Online.⁷ However, this technique may damage heat-sensitive equipment or cause corrosion.

Other recommended techniques include chemical sterilization (using chemicals such as formaldehyde or methyl ethyl ketone), dry heat, gas sterilization, or cold sterilization. Some of these methods may be more viable than others. For example, dry heat and cold sterilization are inexpensive, while chemical and gas sterilization may be toxic, requiring certain safety materials and ventilation. All of these options have varying degrees of effectiveness against the SARS-CoV-2 virus.

Safer alternatives for sterilization include hydrogen peroxide (H₂O₂) and vaporized hydrogen peroxide (VHP, or VH₂O₂). VH₂0₂ is used in other healthcare applications as an alternative to ethylene oxide (EO), a surface disinfectant that is commonly used to sterilize heat-sensitive tools and equipment, such as plastic syringes. Unlike EO and other disinfectants, VH₂0₂ does not generate carcinogenic or toxic residuals, according to the Journal of Applied Microbiology.⁸ Gaseous H₂0₂can be safely maintained in a chamber environment and can be quickly and efficiently removed from the chamber. It will also have uniform contact with all exposed surfaces and can penetrate medical device materials and packaging. Peroxide sterilization is also faster than EO sterilization.

5. Disposable Surgical Instruments

Reprocessing reusable surgical instruments with any agent is a multistep process of cleaning, disinfecting, and sterilizing equipment to ensure that any blood, tissue, and biological debris is removed before the equipment is used on the next patient.

To ensure the cleanliness and sterilization of surgical instruments, an emerging protocol advises simply switching to disposable tools. Disposable surgical instruments are assuredly sterile; they are shipped in sterile packaging and used only once during an operation. This helps increase patient safety—there is no risk that the tool can be contaminated or infected by another patient.

For patients with a suspected or confirmed COVID-19 diagnosis, interim guidance issued by the World Health Organization recommends using either single-use or dedicated equipment.⁹ Guidance is less clear but equally as important for those without diagnosed or suspected COVID-19.

Infection Prevention During—and Beyond—COVID-19

Regardless of the tools in question, planning ahead is one of the best ways to prioritize risk reduction. According to a study published in Annals of Medicine and Surgery, preparing a surgical instrument tray should involve:¹⁰

Checking that all equipment that may be used for a procedure is already inside the OR prior to the patient's arrival.
Keeping spare surgical instruments on hand to reduce the need for staff to move in and out of the OR.
Placing any equipment being transferred in or out of the OR on a trolley in an anteroom for a runner to retrieve, limiting direct contact.

The pandemic has highlighted the need for thorough infection prevention in operating rooms. That may entail more frequent cleaning and sterilization for ORs and surgical instruments, or clinicians might opt to utilize disposable instruments over reusable ones to reduce the risk of contamination and infection. Either way, taking precautions like these safeguards the health of patients and surgical staff alike—both during and beyond the COVD-19 pandemic.