Disclosure. Today. Why are we here today. The College of Clean The Foundation Part 1. This is why you are here today. Watch this short video 3/26/2015

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1 The College of Clean The Foundation Part 1 Stephen M Kovach Director of Education Healthmark industries Disclosure I am an employee of Healthmark Industries Fraser, Michigan USA I am involved with the manufacture and distribution of medical products to healthcare facilities and healthcare professionals No compensation has been received for this presentation or for travel to and from the seminar All opinions are those of the presenter I will show you the Good Bad Ugly Why To drive home the point that cleaning verification must be part of ever Sterile Processing Department (SPA) montra Today Why you are here today? ANSI/AAMI ST79 recommends that "continuing education should be provided at regular intervals to review and update worker knowledge and skills and to maintain their competency and certification. * ANSI/AAMI ST79 recommends "that all personnel performing sterile processing activities be certified as a condition of employment. At a minimum, all such personnel should successfully complete a central service certification examination within two years of employment and should maintain that certification throughout their employment. ** The Joint Commission requires that facilities evaluate an employee's competency to perform their job. *ANSI/AAMI ST79 Comprehensive guide to steam sterilization and sterility assurance in health care facilities, 4.3 Training and continuing education **ANSI/AAMI ST79 Comprehensive guide to steam sterilization and sterility assurance in health care facilities, Section Sterile Processing Personnel Why are we here today The Joint Commission is also adding to the pressure for reprocessing quality improvement. As the Top 10 Health Technology Hazards Report for 2013 explains, "Data from the Joint Commission suggests that the reprocessing function warrants attention in many facilities. The agency reports that 36 percent of accredited hospitals surveyed in 2011 were noncompliant with its standards to reduce the risk of infection associated with medical equipment, devices and supplies. Failure to adhere to the standard, which includes measures to properly decontaminate, clean, disinfect and sterilize medical equipment, was among the top 10 standards compliance issues for hospitals, ambulatory settings, and office based surgery practices in Improper Reprocessing Targeted as One of Healthcare's Most Dangerous Hazards ICT 05/1/ reprocessing targeted as one of healthcares most dangeroushazards.aspx This is why you are here today. Watch this short video 1

2 Housekeeping Issue Who is here today? Questions during all of the presentations? Raise your hand any time Pictures help tell a story, you will see a lot of them today Cell phones off Ready lets go One last note I need to help us make a change in how we think of our selves. Let us look at are self differently Why We all love to go to the SPA What do we do each day at work Sterile Processing Area (S.P.A.) Rejuvenate instruments We are the experts With out the S.P.A the surgical team can not do what they do AAMI ST 79 uses the term Sterile Processing Area thus the S.P.A. We have many processes Each Process has various tools Brushes for cleaning Sterilizer for killing Tests to make sure scissors are sharp Pouches to keep things in Racks to store supplies Testing your heat sealer Objectives To understand Cleaning you must understand The role the IFU plays in cleaning The definition of Cleaning The 9 factors of cleaning and how they interact We will review all of these points to increase your knowledge of cleaning and how it relates to Manual Sonic Medical washer Let us look at some Clean Facts first and class is in session Clean facts 16% of the loaner instruments tested positive for blood ( AORN Journal;3/2007,Volume 85,#3; page 566) When placing the tissue protector on the drill, old dry blood and tissue came out (Pennsylvania Patient Safety Authority 2006;page 1) Particles of tissue were found in cannulated instruments (Pennsylvania Patient Safety Authority 2006;page 1) The investigative report said a surgical tool used for inserting a screw in a broken bone was not properly prepared before being sent to be sterilized, containing biomatter from a previous patient that should have been removed, the report said.* *6/22/12- Is this really hard water? There has been a growing concern about the effectiveness of decontamination technique for reusable medical instrumentation in healthcare facilities. Studies have shown the ability of sterilization technologies, which under normal conditions, achieve acceptable sterility assurance levels, to be greatly impaired by the presence of residual soil containing serum and salt.* *Alfa,M.,et al, Comparison of Ion Plasma, Vaporized Hydrogen Peroxide, and 100% Ethylene oxide Sterilization to the 12/88 Ethylene oxide gas Sterilizer, Infection Control and Hospital epidemiology, 1996; 17:

3 Really what is an I.F.U. What is an I.F.U.? Is a D.F.U the same as an I.F.U.? Instructions for Use Directions for Use 2012 Association for the Advancement of Medical Instrumentation ANSI/AAMI ST79:2010 & A1 & A2 & A Manufacturer's Written Instructions for Use (IFU): Written recommendations provided by the manufacturer of a device that provide instructions for operation and safe and effective processing. The I.F.U gives a Sterile Processing Area direction on what they need to do and what that need to do the job right Best Practice FDA Guidance to Manufactures has been updated 3/17/2015 Page 23 of this document Following the IFU A validation of the cleaning and sterilization procedure by the manufacture For cleaning it is a procedure to remove residual patient soil and must be completed by the device manufacture This validation should be part of the submission package and will be examined by the U.S. Food and Drug Administration (FAD) during its review The goal of cleaning validation is to prove that when the instructions in the IFU are followed, the residual soil levels on the device will have been reduced to acceptable levels It is important to mote that completion of a successful cleaning validation alone does not ensure that devices reprocessed by the end user are clean The end user s ability to perform the cleaning by understanding and following all steps in the IFU is vital The Process Manufactures of reusable medical devices provide users with reprocessing instructions, including cleaning instructions Cleaning instructions should be validated by the manufacturer as being effective to remove soil Manufacturers validate cleaning by performing simulated soiling and cleaning of the device, followed by some measurement of residual debris Users follow these Instructions for Use (IFU) Reprocessing of Medical Devices : Who is responsible for What?? Manufactures validate that an instrument can be reliably cleaned and sterilized / disinfected and is therefore reusable. Users verify that cleaning / sterilization equipment is working and that in hospital cleaning / sterilization methods are consistently performed Why must I follow the I.F.U Legal Provide the best outcome Doing the process the right way each and every time JC is asking you about the I.F.U You should have them readily accessible for staff The I.F.U is ever changing Gives you data and information to help purchase the correct tools for your job Be a label reader 3

4 We are told to follow the IFU. Is this type of brush in the IFU? Ask your self this question. Would you go to the Dollar store to buy your cleaning brushes for any medical devise? Others are now using this brush. Why no tooth brush? Not in the IFU Scratch the optic-costly repair The bristles are not made to brush medical devices Can not get into the right places Was this in the IFU? TV news is not always the best source. CDC report on Epi-Aid Trip Report: Cluster of plasmid-mediated AmpC-producing carbapenemresistant Enterobacteriaceae (CRE) Washington, 2014 (Epi )* Manual cleaning items used at facility that deviated from the manufactures IFU Use of a tooth pick Use of stiff bristle brush *Trip Report, Epi CDC Thank you Ofstead group for this inforamtion Following the IFU is not easy for a the SPA Some feel they are not practical Time is a factor Staff do take short cuts Pressure to get the medical device clean, assembled, sterilized Medical facility takes on the legal aspect and liability when they skip steps in the process Need for monitoring and testing of the cleaning process Three examples 4

5 Poster AORN 2014 Annual Meeting Perioperative Nurse s Knowledge of the Cleaning and Decontamination Process of Surgical instruments Mary A Hillanbrand,DNP,RN,Major,USAF,NC,CNOR Example # 1 Your Customer Example #2 Cleaning your Flexible Scope Endoscopes poster at IAHCSMM* Endoscopes poster at IAHCSMM* 57 % did not brush all channels and components 55% did not dry with force air 22% leaked tested with sudsy water 10% skipped final wipe down 45% missed multiple steps 99% missed 1 or more steps or done incorrectly 1% all steps completed correctly Hawthorne effect Factors Leading to Outbreaks from Endoscope/Bronchoscope Contamination Contaminated water supply Contaminated brushes for cleaning scope lumens Improper manual cleaning prior to disinfection Biofilm inside automatic washer Improper use of automatic washer Contaminated or expired disinfection reagent Inability or neglect to clean the suction channel Mechanical or design issues related to the Endoscope/bronchoscope Bottom line Training Not following the IFU *Information taken from a poster presentation at IAHCSMM Annual Conference May5-8,2013 Ofstead & Associates Endoscope Reprocessing : evaluating Guideline Adherence 5

6 Example #3 The Shaver Example # 3 The Shaver The Shaver Problem A highly publicized outbreak at Methodist Hospital in Houston, Texas, was caused by biofilm transmitted between patients who underwent arthroscopic surgery. Upon investigating the outbreak, the FDA noted small pieces of tissue remained inside shavers, which reportedly resulted in biofilm colonization inside the hand pieces. The organisms were transmitted even though the central sterile staff had followed the manufacturer's reprocessing instructions and the instruments had been steam sterilized between uses. SPD/CPD now has a Shaver Issue The FDA has become aware of events in which tissue has remained within certain arthroscopic shavers, even after the cleaning process was believed to have been completed according to the manufacturer's instructions (April 2009). Reports submitted to the FDA suggested that the tissue retained was not evident to the naked eye. Multiple manufacturers of these devices recently informed their customers of this situation and reiterated the importance of proper cleaning procedures. The Real Problems Highlighted Must brush both ends June 8 9,2011 FDA Summit on Clean Report by Smith and Nephew on following concerning the shaver and following the cleaning steps in the IFU 12 Facilities practices were audited 78 devices(shavers) were audited ( observed) None of facilities complied with all of the cleaning instructions found in the IFU 95% of devices had observations of residue on internal surfaces Majority of residue in two areas ( lumen step, drive fork area) Hawthorne effect Clean inside the lumen step area Clean inside the drive fork area 6

7 IFU changes you must inspect inside Arthrex Adapteur Power System II (APS II) Shaver Hand pieces DFU 0154r10* INSPECTION AND MAINTENANCE Step 4 in the DFU (IFU) Check device for visible soil. It is recommended that the cannulation be inspected with an illuminated, magnifying scope. Clean the device using the guidelines for manual cleaning if any soil is visible. * STRYKER Shaver HandPiece R 2012/10 * INSPECTION EN 21 Step 9 Visually inspect the hand piece, including all internal surfaces, for remaining soil. Use an endoscopic camera and endoscope if necessary to see the inner surface of the lumen. If soil remains, repeat the manual cleaning procedure, focusing on those areas * What does this picture tell you abut the IFU? This sums up the IFU issue How let us look at Cleaning Define Cleaning Standard is Visual clean Define the 9 factors of cleaning Everybody has a part in cleaning Instruments sets that have come back to the S.P.A. for rejuvenation Definition of Cleaning Removal of contamination from an item to the extent necessary for further processing or for the intended use. In health care facilities, cleaning consists of the removal, usually with detergent and water, of adherent organic and inorganic soil (e.g., blood, protein substances, and other debris) from the surfaces, crevices, serrations, joints, and lumens of instruments, devices, and equipment by a manual or mechanical process that prepares the items for safe handling and/or further decontamination Association for the Advancement of Medical Instrumentation ANSI/AAMI ST79: The Power of Cleaning By cleaning, the population of micro organisms residing on the materials (known as the bioburden) is reduced considerably. The initial contamination for a subsequent disinfection or sterilization is considerably lower and thus these processes will be more effective, as much less organisms have to be killed. 7

8 Steps in the Cleaning Process Users role How it is used How it is sent back Sorting S.P.A. Role Pre rinse/soaking Washing Manual Scrub &rinse Automatic Medical Automatic washer Medical Sonic cleaner Medical Cart washer Combination process Inspection of the medical device is ongoing constantly Let us look at the 9 factors Talk about the first 5 factors together Medical device to be cleaned ( simple or complex) Type of soil to be cleaned (blood,synovial fluid ) Water quality (ph, hardness ) Temperature (cycle, cleaning solution ) Chemical activity ( cleaning solution) Than the last 4 together Mechanical action (manual, automatic) Human factor Standards and guidelines ( AAMI, FDA,AORN ) Verification of the process (what do I use) Cleaning factor # 1 medical device to be cleaned Back in the day..1950,1960,not much changed Since 1970 change has taken place Long narrow lumens Tiny serration's Multiple parts Various metals and plastics M.I.S. is now the norm not the exception any more Incomplete information from the manufacture on how to clean the item Two group of Instruments #1 medical device to be cleaned Equipment Feed pumps.. Focus on Instruments Back in the day..1950,1960,not much changed Since 1970 change has taken place Long narrow lumens Tiny serration's Multiple parts Various metals and plastics M.I.S. is now the norm not the exception any more Incomplete information from the manufacture on how to clean the item Two group of Instruments Simple Devices without challenging design features Bone spikes Osteotomes Simple surgical instruments Two Groups Complex Devices with challenging designs Did you really follow the IFU? Multipart Instruments.aspx 8

9 Universal Drill Guide Care Maintenan.aspx Synthes homepage Did you really clean this chuck? Instruments Provide Physical Challenge to Washing Nooks and crannies (Box lock) Instruments are stacked one on top another in washer. Take apart Lumen items Rongeurs 9

10 Kerrison Rongeurs Solutions take apart Kerrison Rongeurs VIKON from IMS Brochure_ pdf Examples Investigations into reproducible cleaning of instruments based on a worst case model Critical box locks various gaps ( mm) (Central Sterile 1/2011;G.Kirmse) Gaps MIS Instrumentation Three types Non ported Ported not take apart Ported and take apart They have lumens and this is an issue We will talk about lumens after MIS instruments in general Non ported MIS Instruments difficult to clean get rid of them NOW!!!!!! 10

11 What was inside of a Non ported Instrument Why we should only have take aparts Suctions any Lumen item Inside a suction 11

12 #2 type of soil to be cleaned The presence of organic material such as blood, can result in the failure of sterilization or disinfection. This may be because either the organic material protects the microorganisms from exposure to the process or because the process may be inactivated by contact with organic material. What is on the medical device? Where used? Bio burden Blood Fibrin Protein Fecal matter other Out of All of the Concerns Blood Seems to Be the Hardest to Clean and Poses the Highest Risk so Let Us Look at Blood Key Components of Blood Soil Blood is #1 Challenge Hemoglobin becomes highly insolvent when it dries out. Fibrin, the coagulating agent in blood, is inherently water insoluble. Blood denatures at temperatures above 45 o C (110 o F). When blood denatures, it become highly insolvent. It bonds strongly to the substrate (e.g., the surface of instruments) and it dries out becoming very resistant to the action of solvents. Quality of water Hardness ph Know the source of your water Impacts your cleaning chemistries choices Purest source for rinse Examples of poor water quality Staining Pitting BioFilm #3 Water Quality Water Quality TIR 34 This TIR defines two levels of water quality suitable for medical device reprocessing, and it describes the water treatment processes that can be used to obtain the correct water quality. To provide optimal water for medical device reprocessing, reprocessing personnel and water maintenance personnel should collaborate with administrative personnel to implement the following procedures. Updated TIR 34 provides answers to water quality questions TIR 34 Section 4.2 Defines two categories of water quality Utility as water coming from the tap and usually in need of no further treatment» Primary used for flushing, washing and a general rinse Critical water is treated extensively to ensure that microorganisms and inorganic and organic material are removed» Typical used for final rinse or steam generation The decision regarding the need to treat incoming tap water to provide adequate water for medical device reprocessing should be undertaken in every facility that reprocesses medical devices 12

13 ph The ph scale measures the acidity or alkalinity of a liquid. The ph scale is logarithmic, which means that the steps in between the numbers increase by 10 times. Therefore as you move up the scale from 7 each step is 10 times more alkaline than the last, and moving down the scale from 7 each step is 10 times more acidic. Hardness Water Hardness is defined as the concentration of calcium and magnesium ions expressed in terms of calcium carbonate. These and other minerals bind with the cleaning agents in detergents and prevent them from reacting with the soil on instruments. Types of Water Potable Water that has been treated and delivered in a manner so that it meets EPA guidelines as suitable for drinking. Softened Technique that removes ions that cause water to be hard (usually calcium and magnesium, but iron ions may also be removed by softening). Deionized Water treatment process that uses specially manufactured ionexchange resin to remove ionized salts from the water. R.O. Membrane separation process for purifying water that is based on molecular sieving and ionic rejection and that is effective in removing ions as well as dissolved organic contaminants with molecular weights above 100. Who Is Telling You What Type of Water to Use? Equipment manufacture of your washer, cleaning solutions label, catalog, IFU The government (EPA,FDA,CDC)? AAMI ST What is the quality of water required for the various decontamination processes, manual and mechanical? What methods will be employed to monitor the quality of water? Annex D Professional groups (IAHCSMM, AORN, APIC) in their guidelines What markers should be used for user verification for cleaning Literature supports using the three most predominant contaminants that are the main components of bodily fluids are protein, hemoglobin, and carbohydrates as markers.* Regulatory authorities (like the FDA) will be looking for results from device manufactures for two markers of the test soil chosen (for example, protein, hemoglobin, mucus,..).* Alfa has shown that for flexible scope that: Protein; < 6.4 µg/cm2, Carbohydrate; < 1.8 µg/cm2, Hemoglobin; < 2.2 µg/cm2, are excellent markers for cleaning validation and verification.** At this time ATP is not a marker accept by the FDA for cleaning validation Users should look at testing for the same markers to verify there process as the manufacture of the device *The source for all of this information is taken from : A White Paper ;The New Scope of Reusable Device Cleaning Validations-By: Patrick Kenny;Microtest-2011 **Alfa MJ et al A Survey of reprocessing methods, residual viable bioburden and soil levels in patient-ready ERCP duodenoscopes used in Canadian centers. Infect Control Hosp Epidemiol 2002;23: At the half way point the Clean Brothers say STAY AWAKE!!! 13

14 # 4 temperature Hotter is better. Except that this would be wrong. Get the temperature right. The proper water temperature is different for each type of cleaning and for each stage of cleaning. The proper temperature also varies with the cleaning agent (e.g., Enzyme cleaner, detergent) used. Are you using the right temperature at each stage? Low temperature to start (to prevent denaturing) and higher temperature later to maximize detergent cleaning efficiency. The denaturing action of heat on blood makes it insoluble enough to interfere with rapid cleaning. Start with a cool rinse. Use the recommended temperature for all cleaning agents TempaChekDL Datalogger Washers fail to clean for many reasons. Temperature is one of the reasons. A data logger provides a means of monitoring the temperature at various stages within the automatic washer that influence the effectiveness of a washer. Temperature & dilution Example of a washer cycle notice prewash temperature is High Using a data logger Temperature monitoring At the half way point the Clean Brothers say STAY AWAKE!!! 14

15 Factor # 5 Cleaning solutions Need good water quality Hardness ph Lot s of choices each have their own + or The four basic classes of enzymes are : Lipase breaks down fats and greases Protease breaks down protein Cellulase breaks down cellulose such as wood, cotton, and paper Amylase breaks down carbohydrates and starches Manual detergent cleaners Low foaming neutral Cleaners for ultrasonic equipment Cleaners for mechanical washer (cart /instruments) Acid & Alkaline cleaners Selected for suitability to job How do Cleaning Solutions work? Three types of energy that is needed for good cleaning Chemical energy ; provided by cleaning agent (poor water = poor outcome) Thermal energy ; provided by warm or hot water Mechanical energy ; provided by a machine or manual (hands) Pictures dealing with the first 5 factors of Cleaning Even Block products have issues 15

16 NO Dilution get it right! 16

17 # 6 Mechanical action Manual Machine or Automated Manual cleaning: The vast majority of the cleaning action is caused by the mechanical action Machine cleaning: A large share of the cleaning action is now taken over by chemistry, temperature and time 17

18 Manual Cleaning Manual process Brushing, the right size brush for the task at hand Flushing, rinsing Time and tools Try to have a three tank sink Try to have an air hose Try to have a water hose Monitor the cleaning area temperature and humidity Monitor the air flow negative pressure Use the Proper P.P.A. for each type of cleaning Meter / monitor temperature and dilution of all solutions Use ST 79 as your guide Understanding Manual Cleaning Any device should be able to be manually cleaned 2013 Association for the Advancement of Medical Instrumentation ANSI/AAMI ST79:2010 & A1 & A2 & A3 & A4 page 57 Lots of different items They arrive in various states and conditions from your customers for you to clean and get ready again. 18

19 How to stop this practice.use your customers guidelines. Standards, Recommended Practices, and Guidelines 2013 Edition RP 4 page 423 should be kept free of gross soil during surgical procedures D.H.T This stands for Decontamination Holding Time. This is the time from when the instrument is last used to when it is received in decontamination and the cleaning process begins. This can very in length of time from just a few minutes to hours or even days. Keep this as time as short as possible Keep them moist Now let us talk about Manual Cleaning Manual Cleaning Everything can be manually cleaned and you must have that on file Have the right tools to do the job Understand your process Train your staff The Ideal Manual Cleaning Process A three compartment cleaning sink is used in the following sequence: wash sink, intermediate sink, and final rinse sink An ideal sink 36 inches from the floor 8 to 10 inches deep Width and length to allow a tray or container basket for instruments to be placed flat for pretreatment or manual cleaning Now have automatic adjusting sinks No 2 CPD / SPD are alike some times you have to make do with what you have. 19

20 The Ideal Manual Cleaning Process Continued Forced air should be provided at the sink, as well as faucets or manifold systems for flushing lumened devices. The decontamination area must have an emergency eyewash/shower station Ergonomic factors affecting worker safety and comfort should be considered when designing work spaces. The Ideal Manual Cleaning Process Continued When manually cleaning, instruments should be washed in a manner that provides proper decontamination Although automated methods are preferred, some delicate instruments (eg,eye,microsurgery) power equipment require manual cleaning Aerosolization, injury from sharps are possible when manual cleaning is performed AORN 2008 Recommended Practices page The Ideal Manual Cleaning Process Continued Luke warm water and detergents At temperature range of F Prevent coagulation and thus assist in the removal of protein substances Temperature should be monitored and documented Also water hardness, ph, temperature Thoroughly rinsed to remove debris and detergent residues The Ideal Manual Cleaning Process Continued Temperature in the decontamination area C Relative humidity 30 60% Air Exchange Must document Temperature General work areas should have a temperature controlled between 20 C and 23 C (68 F and 73 F). The decontamination area should have a temperature controlled between 16 C and 18 C (60 F and 65 F). The temperature in sterilization equipment access rooms should be controlled between 24 C and 29 C (75 F and 85 F) or as recommended by the equipment manufacturer. The temperature in sterile storage and personnel support areas (e.g., toilets, showers, locker rooms) may be as high as 24 C (75 F). Independent monitors should be located in each of the areas where temperature should be controlled; temperature should be recorded daily. Processing personnel in each work area are responsible for monitoring and recording the temperature to ensure that the correct temperature is being achieved. Air Flow 20

21 Watch this video on negative pressure Room Monitors The Ideal Manual Cleaning Process Continued Lighting requirements Physical Separation NonPorous material Floor, ceiling, work surfaces Workflow is important Adequate space for activities The Ideal Manual Cleaning Process Continued Space For everything Hand washing Body fluid disposal systems Computers You name it Everything stated so far is right from ST 79. Just as a carpenter needs special tools to do their job correctly.so does a Central Service Professional they also need those same special tools to Get it Clean!, when doing manual cleaning here are some examples Spray guns Vertical soakers Proper Brushes Verified equipment Magnifying glass Quality Improvement Program You need the right tools to Get it Clean 21

22 Personal protection when cleaning A spray gun is essential for rinsing/flushing of hollow instruments. Various nozzles are available for a range of specific cleaning applications The hand shower can be used for an initial rinse of instruments. Use a deep basin, which will help to prevent splashing sideways. Make sure that the water pressure is not too high in order to limit splashing. Only use cold water for blood removal! Protect yourself by wearing gloves and mask, or use a splash screen Must use the right size brush Delicate instruments such as optics may be cleaned by soft towel (low linting) or sponge. It's absolutely necessary to use the appropriately sized brush diameter of the brush is critical to letting bristles create friction against the walls of the lumen. If you use one that's too big, the bristles will bend back and won't scrub debris away, and you risk scratching the inside of the cannula. Too small, and you won't create any (or at least not enough) friction between the bristles and the inner walls. 22

23 Brush Sizes Many styles many kinds The standard French, or Charriere, Scale (abbreviated Fr.) is generally used in the size calibration of cathers and other tubular instruments. It is based on the metric system, with each unit being approximately 0.33 mm in diameter between consecutve sizes. A simple guide 1mm =.039 inches = 3Fr 2mm =.079 inches = 6 Fr 3mm =.118 inches = 9 Fr 4mm =.158 inches = 12 Fr 5 mm =.179 inches = 15 Fr 6 mm =.236 inches = 18 Fr mm = millimeter Fr = French For flat surfaces Lumens items Orthopedic Endoscope Special design for specific purposes Example of just 3 sizes Close up notice the size Closing words of advice on Brushes Brushes size does matter Right size is important Pick the right brush for the task at hand Be sure to keep the instrument completely under the waterline when you brush. Never brush outside the water, as you want anything you pull out to stay under the water. If single use use only once If brush is reusable follow the IFU to properly re use that brush Story of TJC and brushes in NJ 23

24 Now apply the 9 factors of cleaning to the manual process Break Time Water quality (ph, hardness ) Temperature (water,cycles, cleaning solutions,..) Chemical activity (cleaning solution,dilution,time) Mechanical action (manual or mechanical) Items to be cleaned (simple or complex) Type of Soil to be cleaned off the item (blood, sputum,..) Human factor (following the IFU, training, loading,..) Verification of the process Quality Improvement Program It is the combination of these factors that get something clean. 24