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May 2011 Vol 93 No 5 CLINICAL ISSUESthrough the skin as a liquid. Formaldehyde is a carcinogenthat is linked to nasal cancer and lung cancer,and is a sensitizing agent that can cause an immunesystem response on initial exposure. 4 Acuteexposures to airborne concentrations greater than0.1 ppm are highly irritating to the eyes, nose, andthroat, and can cause coughing and wheezing. Subsequentexposure may cause severe allergic reactionsof the skin, eyes, and respiratory tract. Longtermexposure to low levels of formaldehyde in theair or on the skin can cause asthma-like respiratoryproblems and skin irritation, such as dermatitis anditching. Pulmonary edema has been diagnosed afterexposures to 50 ppm. A 30-minute exposure to100 ppm is immediately dangerous to health andcan be fatal. These levels can be generated by smallformaldehyde spills of only 1 pint or less, even inventilated areas. 4 Blindness can result from splashesin the eyes, and dermal contact causes varying degreesof reactions, including sensitization. 5For these reasons, the safest approach is to dispenseand store formalin in a separate, wellventilatedroom in a centralized location other thanthe OR. The room should have a ventilation systemthat incorporates negative pressure and an exhausthood. 1,3 The material safety data sheet for formalinshould be kept in this room for reference in case ofan accidental spill or injury. 1,6,7 Individual specimencontainers can be filled and stored under controlledconditions close to eyewash, cleanup, and decontaminationfacilities. Using this process minimizesthe risks of hazardous spills or injuries.The OSHA standard requires that employers select, provide, and maintain personal protectiveequipment, including goggles, faceshields, aprons, impervious clothing, andgloves 5 ; ensure that employees use the personal protectiveequipment to prevent skin and eye contactwith formaldehyde 5 ; provide emergency showers 4,5 ; provide eyewash facilities in the immediatework area 4,5 ; label all containers of formalin 5 ; and provide employee education and training thatincludes safe handling, containment andcleanup of a spill, and other measures to minimizerisk of exposure. 1,5AORN recommended practices and OSHA standardsshould be followed to minimize hazardousexposure to formalin. The material safety data sheetshould be consulted in the event of a spill for firstaid treatment. 2,7 An emergency clean up protocolshould be included in a policy and procedure. 2,7Formalin should be disposed of according to stateand local regulations. 7MARY J. OGGMSN, RN, CNORPERIOPERATIVE NURSING SPECIALISTAORN CENTER FOR NURSING PRACTICEReferences1. Recommended practices for the care and handling ofspecimens in the perioperative environment. In: PerioperativeStandards and Recommended Practices. Denver,CO: AORN, Inc; 2011:283-290.2. Formaldehyde: 1910.1048. Occupational Safety andHealth Administration. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_tableSTANDARDS&p_id10075. Accessed January 7, 2011.3. Guidelines for protecting the safety and health of healthcare workers. National Institute for Occupational Safetyand Health. http://www.cdc.gov/niosh/docs/88-119/pdfs/88-119.pdf. Accessed January 7, 2011.4. Substance technical guidelines for formalin. 29 CFR1910.1048 App A. September 1988. Occupational Safetyand Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_tableSTANDARDS&p_id10076. Accessed January 7, 2011.5. Recommended practices for a safe environment of care. In:Perioperative Standards and Recommended Practices. Denver,CO: AORN, Inc; 2011:215-236.6. OSHA directives: Enforcement procedure for occupationalexposure to formaldehyde: CPL 2–2.52.Occupational Safety and Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_tableDIRECTIVES&p_id1566. Accessed January7, 2011.7. OSHA fact sheet: What is formaldehyde? OccupationalSafety and Health Administration. http://www.osha.gov/OshDoc/data_General_Facts/formaldehyde-factsheet.pdf. Accessed January 7, 2011.620 AORN Journal
CLINICAL ISSUESwww.aornjournal.orgf fImmediate-use sterilizationQUESTIONRecently, I needed to run a flash sterilizationcycle for a pair of scissors and a suction tip. Isterilized the two items together in the samepan for a sterilization cycle of three minuteswith no dry time and no cooling time. My coworkerinformed me that this was incorrectbecause hinged instruments and instrumentswith lumens must be sterilized for 10 minutes.I was under the impression that as long asthere were fewer than 10 instruments, itemscould be sterilized on a flash sterilization cycleof three minutes. What is the proper amountof time for flash sterilization of surgicalinstruments?ANSWERSterilization time is determined by several factors,including the porosity of the instrument, the complexityof the instrument, the presence of a lumen,the manufacturer’s instructions, and the type of sterilizer.1 The number of instruments does not determinethe amount of time required for sterilization.Historically, the term flash sterilization hasbeen used to describe shortened sterilization cyclesduring which unwrapped medical instrumentsare placed in a rigid container, subjected to steamexposure at a specific temperature for a preciselydefined period of time followed by a reduced orno dry time, delivered directly to the point of useunder aseptic conditions, and used promptly withoutbeing stored. The term flash sterilization isproblematic, however, because the parameters ofa shortened cycle vary based on the sterilizer, thedevice being sterilized, the load composition, andother factors.AORN has endorsed a multisociety positionstatement on immediate-use steam sterilization. 2This consensus document represents the evidencebasedopinions of key organizations, accreditationbodies, and agencies, including AORN, the Associationfor the Advancement of Medical Instrumentation,the Accreditation Association for AmbulatoryHealth Care, the Association forProfessionals in Infection Control and Epidemiology,the ASC Quality Collaboration, and the InternationalAssociation of Healthcare Central ServiceMateriel Management. Discussion in theposition statement concludes that, although theprocess is sound, the term flash sterilization isantiquated and does not fully describe the shortersterilization cycles currently in use to process instruments.Likewise, it does not encompass thecritical steps of cleaning, decontamination, andaseptic transport that must accompany any sterilizationcycle. These processes in total are moreaccurately reflected and described by the termimmediate-use sterilization. 2Immediate-use sterilization should be kept to aminimum, performed in a controlled manner, andused only in selected clinical situations (eg, whenthere is insufficient time to process the item bythe preferred wrapped or container method). Allitems should be subjected to the decontaminationprocesses described in AORN’s “Recommendedpractices for cleaning and care of surgical instrumentsand powered equipment.” 3 Items should besterilized for immediate use only if all of the followingrequirements are met:The device manufacturer’s written instructionson cycle type, exposure times, temperaturesettings, and drying times (if recommended)are available.Items are disassembled and thoroughly cleanedwith detergent and water to remove soil, blood,body fats, and other substances.Lumens are brushed and flushed under waterwith a cleaning solution and rinsed thoroughly.Items are placed in a closed sterilization containeror tray that is validated for immediateusesterilization. The items must be placed ina manner that allows steam to contact allsurfaces.AORN Journal 621
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