The Right Protocol for Pre-Cleaning

Developing a Protocol



Writing a pre-cleaning protocol for your facility helps solidify and standardize the agreed upon process for pre-cleaning.  

When developing the facility pre-cleaning protocol, consult local, state, and federal regulations (OSHA, FDA, etc.).  Review device instructions for use (IFUs) and professional guidance (AAMI, AORN, etc.). Reference these documents in the facility protocol to demonstrate that the product and process selected are compliant with best practices. 

Keep in mind that the more specific you make the protocol for your facility, the closer you will be held to the process by a surveyor.  Avoid naming a specific product in your policy; use language like “a product designed for pre-treatment.” 

If the policy says “wipe all bioburden from instruments during the procedure,” a surveyor will expect to find no bioburden on instruments in decontamination.  Joint Commission suggests using language like, “During operative procedures, instruments should be wiped with a gauze moistened with water and lumens should be flushed, as needed."
 
This type of policy allows some room for variation, while still holding the staff accountable to wipe off and flush instruments.
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