235 - Validating Surgical Instrument Cleanliness with Adenosine Triphosphate as Adjunct

Description: Clinical Problem: Visual inspection has historically been the primary method to validate surgical instrument cleanliness following decontamination in the Sterile Processing Department (SPD). However, this method cannot always detect microbes which may not be visible to the naked eye.

Background: While loaned surgical instruments (LSI) from vendor sources should be decontaminated prior to arrival at a gaining facility, they are particularly complex and hard to clean due to their complicated designs. Often used in orthopedic and neurosurgical procedures, these sets contain large numbers of implants and lumened devices. The inadequate decontamination of LSI could lead to harbored infectious agents and cause subsequent patient harm. Adenosine triphosphate (ATP) testing is a method of determining the presence of living microorganisms following the cleaning process. The aim of this evidence-based practice (EBP) project was to determine if the use of ATP, in addition to visual inspection, improves the detection of contaminated instrument sets prior to and after manual cleaning, as well as mechanical and thermal disinfection.

PICO: When assessing the quality of decontamination procedures of loaned surgical instruments, does the use of adenosine triphosphate for verification testing as adjunct to visual inspection, compared to visual inspection only, improve the identification of inadequately decontaminated loaned surgical instruments over 6 months?

Methods: The authors performed a comprehensive search of the literature in PubMed, CINAHL, and Ovid from 2015-2025, which resulted in 12 peer-reviewed articles. Using the Johns Hopkins EBP Model and Tools, the articles were reviewed by two independent reviewers for evidence level and quality. Four SPD supervisors were trained on the use of the Neogen Clean-Trace ATP tester by the Neogen vendor. For six months, all inbound vendor sets were swabbed upon arrival prior to decontamination, and immediately following decontamination. Visual inspections were recorded on a scale of 1-3, with 1 being no soil and 3 being a high amount of soil. Numeric ATP levels were recorded alongside visual inspection numbers, with passing scores recorded as ≤150 relative light units (RLU) and failure rates as anything > 150 RLU.

Result: This project is in its third month of data collection of six. However, preliminary results indicate visual inspection alone is insufficient to detect residual organic debris. To date, 43 orthopedic and neurosurgical instrument sets have been ATP tested upon arrival to our facility. Of these, 47% of the instrument sets (n=20) failed ATP testing. More concerning, of the 20 that failed, 85% of them passed visual inspection (n=17). 100% of the instrument sets (n=43) passed ATP testing and visual inspection after the first decontamination process at our facility before patient use.

Conclusions: The complex design of LSI and state of contamination they arrive in underpins the extreme importance of strict adherence to decontamination procedures and the need for verification testing. Minimally invasive surgery has created intricate instruments, subsequently making the reprocessing cycle exceptionally challenging. Technological adjuncts are a must now in the validation process, particularly where visual assessment is hindered or not feasible.

Implications: ATP testing is a rapid, effective way to ensure successful removal of organic debris, while providing quantifiable documentation to meet compliance standards.