American Journal of Infection Control 41 (2013) S111-S117

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Original research article

High-level disinfection, sterilization, and antisepsis: Current issues

in reprocessing medical and surgical instruments
Rose Seavey MBA, BS, RN, CNOR, CRCST, CSPDT *
Seavey Healthcare Consulting, LLC, Arvada, CO

Key Words: Technology is rapidly changing many aspects of health care. The intricate design of instruments, the
Decontamination configuration of instrument trays, and evidence-based practice have resulted in the need for complicated
Cleaning and specific reprocessing recommendations from instrument manufacturers. Patient safety depends on
Devices
instruments that are appropriately cared for and adequately reprocessed. This article covers current
Processing
issues that sterile processing and operating room professionals must deal with regarding reprocessing of
medical and surgical instruments.
Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Technology is rapidly changing many aspects of health care. The
intricate design of instruments, the configuration of instrument
trays, and evidence-based practice have resulted in the need for
complicated and specific reprocessing recommendations from
instrument manufacturers.
Patient safety depends on instruments that are appropriately
cared for and adequately reprocessed (ie, cleaned and disinfected
and sterilized). This article covers some current issues that sterile
processing and operating room professionals must deal with
regarding reprocessing of medical and surgical instruments.
MANUFACTURERS’ INSTRUCTIONS FOR USE
Manufacturers of reusable medical devices and surgical instru-
ments must receive clearance from the Food and Drug Adminis-
tration before the product can be made available for purchase and
use in the United States. Part of the labeling claim process requires
that manufacturers produce validated instructions for use (IFU) for
reprocessing of the reusable device. The medical device manufac-
turer’s (MDM) validated IFU for each device must be provided in
writing to the health care facility purchasing or borrowing these
devices. The instructions should describe, in detail, the validated
steps for disassembly, lubrication, cleaning, disinfecting, packaging,
and sterilization.1 Written recommendations from MDMs for
reprocessing surgical instruments and medical devices should be
on file and consistently followed by health care facilities.2-5
* Address correspondence to Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSPDT,
Seavey Healthcare Consulting, LLC, Arvada, CO 80002.
E-mail address: rose@seaveyhealthcareconsulting.com.
Publication of this article was supported by Advanced Sterilization Products
(ASP).
Conflicts of interest: None to report.
Extended cycle times
The MDM IFU may recommend sterilization cycle times beyond
the standard procedures practiced in health care facilities. These
are commonly referred to as extended sterilization cycle times.
The need for additional processing times may be the result of the
complex design of a device (eg, very long or narrow lumens) the
dense configuration of a tray, multiple layers in the tray, the weight
of the set, or the design of the containment device itself. To help
ensure sterility the MDM-validated recommendations for cycle
times must be followed.
Manufacturers of steam sterilizers validate their autoclaves
according to specific cycles spelled out in American National
Standards Institute (ANSI) and Association for the Advancement of
Medical Instrumentation (AAMI)2 standard (ST) 8, Hospital Steam
Sterilizers6 (see Tables 1 and 2). This validation process does not
include extended cycles; therefore, when facilities run longer
exposure times to comply with MDM IFUs they are essentially
performing an off-label use of the sterilizer.7
Some MDMs recommend 5, 8, 10, 18, or 20 minutes or longer
exposures (see Table 3).8 In addition, some IFU recommendations
require devices to be run in an otherwise empty chamber. If
an extended cycle time is used and devices that have not been
validated at the longer exposure time are placed in that load,
the functionality or the lifespan of those devices may be damaged.
To avoid this, facilities often run additional loads, which is
inefficient.7
The AAMI technical information report (TIR) on process chal-
lenge devices and test packs for health care facilities known as
TIR31:2008 focuses on extended sterilization cycles. The TIR
includes some recommendations for MDMs to target just a few
cycles, such as 10- or 20-minute extended cycle times at 270
F

0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2012.09.030
S112 R. Seavey / American Journal of Infection Control 41 (2013) S111-S117

Table 1
Minimum cycle times for gravity-displacement steam sterilization cycles

Exposure time at Exposure time at Exposure time at

121
C (250
F) 132
C (270
F) 135
C (275
F) Drying times

Item Min
Wrapped instruments 30 15 15-30
10 30
Textile packs 30 25 15
10 30
Wrapped utensils 30 15 15-30
10 30
Unwrapped nonporous items (eg, instruments) 3 3 0-1
Unwrapped nonporous and porous items in mixed load 10 10 0-1

NOTE. This table represents the variation in sterilizer manufacturers’ recommendations for exposure at different temperatures. For a specific sterilizer, consult only that
manufacturer’s recommendations. Reprinted from ANSI/AAMI ST79:2010, A1:2010, A2:2011, & A3:2012 (Consolidated Text) with permission of the Association for the
Advancement of Medical Instrumentation, Inc. (C) 2012 AAMI (www.aami.org). All rights reserved. Further reproduction or distribution prohibited.

containing moisture inside the container system should be

Table 2
Minimum cycle times for dynamic air removal steam sterilization cycles considered contaminated because there are no scientific studies to
prove otherwise.
Exposure time at Exposure time at Drying
Wet pack issues should be explored to resolve the problems.
132
C (270
F) 135
C (275
F) times
Internal or external moisture has the potential to provide pathways
Item Min
for microorganisms to go into the package, contaminating the
Wrapped instruments 4 20-30 contents. Moisture found on the outside of a package is usually
3 16
caused by condensation dripping from above. This is sometimes the
Textile packs 4 5-20
3 3 result of improper loading of the cart. Moisture found on the inside
Wrapped utensils 4 20 of a package can also be the result of a too-large metal mass that can
3 16 trap water, an overloaded tray, or lack of absorbent material such as
Unwrapped nonporous items 3 3 NA
towels or textiles.
(eg, instruments)
Unwrapped nonporous and 4 3 NA
Precondition of the load is 1 method frequently used to mini-
porous items in mixed load mize wet pack issues. To precondition a load, place the instruments
inside the steam sterilizer with the door closed for 10-15 minutes
NA, Not applicable.
NOTE. This table represents the variation in sterilizer manufacturers’ recommen- before starting the cycle. This will heat the instruments, helping to
dations for exposure at different temperatures. For a specific sterilizer, consult only resolve some wet pack problems not related to steam quality or
that manufacturer’s recommendations. Dynamic air removal steam sterilization inadequate packaging or loading configurations.4
includes prevacuum sterilizers. Reprinted from ANSI/AAMI ST79:2010, A1:2010,
Sterilized packages should not be touched until after the cool-
A2:2011, & A3:2012 (Consolidated Text) with permission of the Association for the
Advancement of Medical Instrumentation, Inc. (C) 2012 AAMI (www.aami.org). All
down period. Cooling packages is an important step in preventing
rights reserved. Further reproduction or distribution prohibited. wet packs. According to sterilizer unloading procedures in ANSI and
AAMI ST79 section 8.8.1:
in prevacuum cycles and 40- or 60-minute extended cycles at
All items removed from the sterilizer after sterilization pro-
250
F for gravity cycles.9 These new recommendations should make
cessing, including items packaged in rigid sterilization container
dealing with extended cycles a little less challenging in the future.
systems, should remain on the sterilizer cart until adequately
cooled. They should not be touched during the cooling process.
WEIGHT LIMITS FOR INSTRUMENT TRAYS Rigid sterilization container systems should remain on the
sterilizer cart until container surfaces are cool to the touch and
AAMI and the Association of periOperative Registered Nurses can be handled safely by the operator with bare hands. The cool-
(AORN) recommend a maximum weight limit of 25 lb for instrument down period begins within the sterilizer chamber. The door may
sets.2,4 Overweight sets can create concerns with sufficient steam be opened slightly at the end of the cycle and the items left
contact and a problem with drying that may results in wet packs.10 inside for a period of time in order to reduce the potential for
Each surgical instruments set may be lifted an average of 12 to condensation formation.2
15 times every time the set is used. This repetitive lifting can be
The time allowed for cooling should take into account the type
a real ergonomic issue when multiple sets weigh >25 lb. The health
of sterilizer being used, the design of the device being sterilized,
and safety of health care workers should be protected through
the temperature and humidity of the ambient environment,
limited tray weight limits.10
and the type of packaging used. A minimum cooling time of
Every facility should have a scale specifically assigned to weigh-
30 minutes is recommended. During cooling, the sterilizer cart
ing instrument sets. Sample scales are shown in Figures 1 and 2.
should be placed in a low-traffic area where there are no air-
conditioning or other cold-air vents in close proximity. Warm
WET PACKS items should never be transferred from the cart to cold metal
racks or shelves for cooling or placed within dust covers before
A package is considered a wet pack if moisture in the form of completion of the cooling process.2
dampness, droplets, or puddles of water is found on or within
a textile pack, instrument, basin set, or rigid container or contain- UPDATES IN PACKAGING
ment devices after the sterilization and cool-down process.2 If
packs are found to be wet after sterilization, they should not be The purpose of any sterilization packaging system is to allow
released for use. ANSI and AAMI ST792 recommends any set sterilization of the package contents, maintain sterility of contents
 Table 3
Examples of devices that require extended cycle times for sterilization

Device Phase I conditions Temperature Sterilization time (min) Dry time (min) Comments Device type
Tract trial with uniball clamps Prevacuum preceded by 15-min 132
C [270
F] 10 None listed None Solid
conditioning and purge
Endoscope 132
C-134
C [270
F-274
F] 5 None listed None Solid
Pediatric Bivona tracheostomy tube 121
C [250
F] 40 None listed Do not use deep vacuum flash cycles or Hollow
pulse vacuum cycles. Gravity only
Autoclavable fiber-illuminated 132
C [270
F] 5 20 It is recommended that all telescopes be Solid
laparoscoope gas sterilized to achieve maximum
life expectancy, unless otherwise
required
Spine surgical instruments 4 pulses 132
C-135
C [270
F-275
F] 6 None listed Prevacuum multiple (3-4) insert sets at Solid/hollow
or or 275
F for 40 min or single and dual
134
C-137
C [273
F-277
F] 4 insert sets at 275
F for 14 min
Prosthetic ring models 4500 and 4400 121
C [250
F] 30-40 None listed Flash sterilization Hollow
or or
132
C [270
F] 15-20
132
C [270
F]

R. Seavey / American Journal of Infection Control 41 (2013) S111-S117

Spine instrument sets 15 90 Maximum chamber contents: 9 cases Solid or hollow
Empty chamber: preheat 15 min
Silicone resuscitation 132
C-135
C [270
F-275
F] 15 None listed None Hollow
Large bone 4 prevacuum pulses 132
C-134
C [270
F-274
F] 8 20 (metal) None Solid or hollow
or or or
134
C-137
C [273
F-277
F] 5 45
(poly)
28-lb instrument set 132
C [270
F] 15 None listed Weighs 28 lb Solid or hollow
Congruent bone plate system 132
C [270
F] 15 None listed Also states to follow ST79 Solid or hollow

NOTE. Reprinted from AAMI TIR31:2008 with permission of Association for the Advancement of Medical Instrumentation, Inc. Ó 2008 AAMI (www.aami.org). All rights reserved. Further reproduction or distribution prohibited.
a wrapped tray, such as all-paper peel packs, foam, woven

instrument trays are assembled. AORN recommendations state,

some items together, containment devices are frequently used when
systems (see Fig 3). To help protect sharp or small items and keep
fabrics, nonwoven materials, peel pouches, and rigid container

Sterilization packaging options

sterilized in a health care facility.11

ded to be used to surround another medical device that is to be
Food and Drug Administration as a class II medical device inten-
without contamination. Sterilization packaging is classified by the
until the package is opened, and permit delivery of contents
There are several other options for containing devices within
by packing and container manufacturers.4
ized sets has not been validated as appropriate and efficacious
pouches and then including them in wrapped or container-
drying. The practice of confining instruments in paper-plastic
tioned to ensure adequate air removal, sterilant contact, and
or containment devices because the pouches cannot be posi-
Paper-plastic pouches should not be used within wrapped sets

A variety of packaging systems are in use, including woven

Fig 2. Example of a scale that could be used to weigh instruments.

Fig 1. Example of a scale that could be used to weigh instruments.

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S114 R. Seavey / American Journal of Infection Control 41 (2013) S111-S117
Fig 3. Examples of packaging systems.
Fig 4. Example of all-paper peel packs container for containing devices within
a wrapped tray.
material, or basket-type accessory containers that are designed and
tested for this purpose (see Figs 4-6).
At least 1 chemical indicator/integrator (CI), should be used
within each package. The internal CI should be placed in the area
of the package considered to be the least accessible to sterilant
penetration and air removal. AORN-recommended practices for
selection and use of packaging systems4 identifies specific place-
ment of internal CIs within wrapped and containerized sets in the
geometric center (ie, not on top). For wrapped packages the
updated recommendation states to place the CI in the geometric
center (ie, not on top) of the devices. In addition, a CI should be
placed in the geometric center of each level of all multilevel sets.
For ridged containers, AORN recommends 2 CIs, 1 in each of 2
opposite corners of the inner basket. If ridged containers have
multilevels there should be 2 CIs placed in 2 opposite corners (ie, 1
in each of 2 corners) of every level.4 Before opening a sterile
package, personnel should ensure the external CIs have changed
appropriately ensuring the package has been exposed to the ster-
ilization process.
Protection of the sterility of a device to the point of use is vital.
The majority of packaging does not provide an absolute microbial
barrier; therefore, it is important that environmental contamina-
tion be minimized to avoid compromising the sterility of devices
Fig 5. Example of all-paper accessory container for containing devices within
a wrapped tray.
Fig 6. Examples of basket-type accessory containers for containing devices within
a wrapped tray.
during storage. Immediately before opening any package the end
user should visually inspect the sterilized package or container’s
integrity looking for holes or worn spots in the fabric or paper and/
or the effectiveness of the seal.4
There has been much discussion and debate over where and
how instrument inventory count sheets should be placed. Accord-
ing to the latest AORN recommendations,4 these papers should not
be placed inside wrapped or containerized instruments sets.
Chemicals used in the manufacture of paper and toner ink may
pose a risk of reaction in some patients. Further, ink used to print
inventory lists have been known to bleed onto instruments and
containers (see Figs 7-9).
Because paperwork materials have not been shown to be safe for
patient use, the best practice is to leave the instrument inventory
count sheets outside instrument trays. Some facilities attach the
lists to the outside of containers or wrapped packages (see Fig 10).
LOANED OR BORROWED INSTRUMENTS
Facilities frequently borrow surgical instruments or implants for
specialty operative procedures. The management of loaner instru-
mentation and implants is recognized as a concern by many health
care professionals.12 AORN recommended practices documents4
state: “A formalized program between healthcare organizations
and healthcare industry representatives should be established for
the receipt and use of loaner instrumentation.”
 R. Seavey / American Journal of Infection Control 41 (2013) S111-S117
Fig 7. Ink transfer from papers placed inside instrument container.
Fig 8. Ink transfer from papers placed inside instrument container.
A collaborative, well-written policy with specific controls must
be in place to ensure successful management of these instruments
and implants.12 The International Association of Healthcare Central
Service Materiel Management (IAHCSMM) agrees13 that health care
facilities that borrow surgical instruments should have a well-
developed loaner program and written policy that establishes
standardized receipt and use of all loaner instrumentation. Because
of the need for consistent controls this policy should be established
with input from sterile processing units, surgeons and operating
room staff, and various departments such as infection prevention
and control, administration, materials management, and risk
management. The IAHCSMM sample policy13 states that health care
facilities should have loaner trays at least 2 business days before the
scheduled use and, if it is a first-time vendor, the loaned sets should
be obtained 3 business days before the scheduled use for in-
servicing, inspection, testing, and processing. The IAHCSMM posi-
tion paper and the policy template can be downloaded from the
association’s Web site (www.iahcsmm.org).
Loaning and borrowing of surgical instruments and implants
should be consistently managed according to the written policy of
each facility. Tracking loaners, either manually or automatically, is
necessary for quality controls as well as asset management of
loaners.12
S115
Fig 9. Ink transfer from papers placed inside instrument container.
Fig 10. Examples of ways to attach inventory count sheets outside instrument trays.
IMPLANTS
ANSI and AAMI’s and AORN’s current recommendations state
that a biologic indicator and a class 5 CI should be run with every
implant (eg, heart valve, prosthetic joint, and screw). Implants
should be quarantined and not used until the biologic indicator
reads negative. In the case of an emergency, when an implant must
be used before the biologic indicator results are known, docu-
mentation should be made on an exception form stating the
reasons for early release.2,4 Annex L in ANSI and AAMI ST792 gives
examples of necessary documentation of premature release of
implants.
WATER QUALITY
Water quality is a vital concern in all steps of reprocessing
surgical and medical instruments. The quality of water used is very
important to prolong the life of the medical devices as well as
minimizing the risk to patients.14
There are 2 general methods used to deal with water impurities
related to reprocessing of surgical and medical instruments. The
first is the use of a water treatment system that reduces or removes
impurities before use. The second method involves adding chem-
icals to address water impurities during the decontamination
process.15
Steam quality is affected by the quality of the water being used
to generate the steam. Pretreatment of water may be required to
eliminate the possibility of residuals or deposits when the steam is
used for sterilization, especially in flash sterilization.14
Water purification systems
There are many different types of water purification systems.
The most common water treatment is a water softener. A water
S116 R. Seavey / American Journal of Infection Control 41 (2013) S111-S117
softener purifies with a process of ion exchange. Other treatments
commonly used to purify water are deionization system and
reverse osmosis. Deionization removes ions to purify the water and
requires tank exchanges. Reverse osmosis purifies by using a sem-
ipermable membrane to remove or reduce impurities. Reverse
osmosis generally requires more space and has a higher start-up
price; however, reverse osmosis systems do not require tank
exchanges.14,15
For devices that will come in contact with the bloodstream or
sterile areas of the body, high purity water is recommended for the
final rinse of the item. Health care facilities should evaluate the
water used in the various steps of reprocessing.15
Water impurities can also affect the functionality, effectiveness,
and life span of automated reprocessing equipment. There are
several tools and test strips available to monitor the quality of water
used in sterile processing.15 Sterile processing staff members
should work closely with water service maintenance personnel to
establish and monitor the water treatment systems used for
cleaning, disinfecting, and sterilizing all reusable devices.
VERIFICATION OF CLEANING
In the past, health care personnel relied only on visual inspec-
tion of the cleaning process. We now have many tools, such as
adenosine triphosphate, or protein, that can be used to verify that
cleaning processes are adequate. These tests can help us determine
if we have done a good job of manually cleaning items and if our
automatic washers are working properly.
REPROCESSING INTRAOCULAR SURGICAL INSTRUMENTS
Toxic anterior segment syndrome (TASS) is an acute inflam-
matory response caused when foreign material is introduced into
the anterior chamber of the eye. TASS may lead to severe visual
impairment or blindness. Special processing considerations are
necessary for eye instrumentation because of the nature of the
instruments themselves and the sensitive nature of the eye.2
Annex N of the ANSI and AAMI ST792 addresses TASS and the
processing of intraocular surgical instruments. According to AAMI,
the introduction of TASS may be associated with specific products,
such as contaminated balanced salt solution, detergent residues,
endotoxins, preservatives, foreign matter, and residues from ster-
ilization processing. Therefore, particular care must be taken in the
processing of intraocular surgical instruments. Many eye instru-
ments are complex and delicate and must be cleaned manually.
Manual cleaning methods may be less controlled, so additional care
must be taken during processing to ensure effective cleaning and
rinsing.
Specific eye instrument cleaning and sterilization recommen-
dations are published by the American Society of Cataract and
Refractive Surgery and the American Society of Ophthalmic Regis-
tered Nurses. Annex N of AAMI ST792 highlights those existing
recommendations for reducing the risk of TASS. Important
elements of a processing program for intraocular surgical instru-
ments include, but are not limited to, maintaining an adequate
inventory of eye instruments, allowing adequate time for process-
ing instruments according to MDM instructions, processing intra-
ocular surgical instruments separately from general surgical
instruments in a designated cleaning area with dedicated equip-
ment, and following manufacturers’ current written instructions
for the cleaning and sterilization of eye instruments. Auditing the
cleaning process will ensure procedures comply with manufacturer
instructions and that personnel performing cleaning procedures
have received documented training and have demonstrated
competency in the cleaning process.2
Only cleaning agents that have been recommended by the
specific eye instrument’s manufacturer should be used on intra-
ocular instruments. Particular attention should be directed toward
ensuring that the specified concentration of the recommended
cleaning agent and water quality are used. Final rinsing of in-
struments should be performed with the volume of sterile,
distilled, or deionized water recommended by the manufacturer.
Single-use brushes of the correct size should be used and then
disposed of.2
Eye instruments should be sterilized using the methods and
conditions recommended in the MDM IFU. The sterilization process
should be effective, monitored, and documented. AAMI ST792
provides detailed recommendations for sterilization processing,
including quality control and restrictions regarding the use of flash
sterilization.
Maintenance of processing equipment
Cleaning and sterilization equipment, boilers, and water filtra-
tion systems should be properly maintained. Otherwise, foreign
materials such as endotoxins, heavy metals, or chemical contami-
nants or impurities may be deposited onto the instruments during
processing and induce TASS. Because many different materials can
elicit a TASS response if they are inadvertently introduced into the
anterior chamber of the eye, the importance of following the proper
intraocular surgical instrument processing procedures cannot be
overemphasized.2
CONCLUSIONS
Reprocessing plays a very important role in helping to prevent
infections. Technology is changing how procedures are performed
and requiring more complicated devices to be reprocessed. Published
recommended practices are constantly being updated to reflect
evidence-based practices and validated practices. Patient safety
depends on instruments that are appropriately cared for and effec-
tively reprocessed; therefore, the most current best practices should
be identified and followed. Some of the most current issues relating to
reprocessing surgical and medical devices are the importance of
following the manufacturer’s written IFUs, including cycle parame-
ters; a pan weight not exceeding 25 lb; investigating the reason(s) for
wet packs; being aware of updates in packaging; managing loaner
instrumentation efficiently; monitoring water quality needs; and
handling of intraocular instruments appropriately.
References
1. Sterilization of medical devicesdinformation to be provided by the manufac-
turer for the processing of resterilzable medical devices. ANSI/AAMI ST81:2004/
(R)2010. Available from: http://marketplace.aami.org/eseries/scriptcontent/
docs/Preview%20Files/ST811003_preview.pdf. Accessed February 12, 2013.
2. Comprehensive guide to steam sterilization and sterility assurance in health
care facilities. ANSI/AAMI ST79:2006 and ANSI/AAMI ST79/A1:2008 (consoli-
dated text). Available from: http://marketplace.aami.org/eseries/scriptcontent/
docs/Preview%20Files/ST791110_preview.pdf. Accessed January 16, 2013.
3. Recommended practices for cleaning and care of surgical instruments
and powered equipment. Association of periOperative Registered Nurses Web site.
Available from: http://aornstandards.org/search?fulltext¼Recommendedþ
PracticesþforþCleaningþandþCareþofþSurgicalþInstrumentsþandþPoweredþ
Equipment&submit¼yes&x¼8&y¼9. Accessed January 16, 2013.
4. Recommended practices for selection and use of packaging systems. Association of
periOperative Registered Nurses Web site. Available from: http://aornstandards.
org/search?fulltext¼RecommendedþPracticesþforþSelectionþandþUseþofþ
PackagingþSystems&submit¼yes&x¼0&y¼0. Accessed January 16, 2013.
5. Recommended practices for sterilization. Association of periOperative Regis-
tered Nurses Web site. Available from: http://aornstandards.org/search?
fulltext¼RecommendedþPracticesþforþSterilization&submit¼yes&x¼0&y¼0.
Accessed January 16, 2013.
 R. Seavey / American Journal of Infection Control 41 (2013) S111-S117
6. Hospital steam sterilizers. ANSI/AAMI ST78:2008. Available from: http://
marketplace.aami.org/eseries/scriptcontent/docs/Preview%20Files/ST80812_
preview.pdf. Accessed February 12, 2013.
7. Klacik S. It’s about “Time”: extended cycles. Healthcare Sterilization Horizons
2008;27.
8. New guidance examines process challenge devices. AAMI News Feb 2009;44:8.
9. Process challenge devices/test packs for health care facilities. The Associ-
ation for the Advancement of Medical Instrumentation Web site. Available
from: http://marketplace.aami.org/eseries/scriptcontent/docs/Preview%20Files%
5CTIR310811_preview.pdf. Accessed January 16, 2013.
10. Seavey R. Just say no! Don’t get weighed down by instrument sets that are too
heavy. Manag Infect Control 2006;6:86-97.
S117
11. Seavey R. Packaging for sterilization: it’s not just a box, a bag or gift wrapping!
Manag Infect Control 2008;8:82-97.
12. Seavey R. Loaner instrumentation: SPD and OR working together to manage
loaner instrumentation. Healthcare Purchas News 2008;32:78-92.
13. IAHCSMM position paper on the management of loaner instrumentation. Avail-
able from: http://www.iahcsmm.org/CurrentIssues/Loaner_Instrumentation_
Position_Paper_Sample_Policy.html. Accessed January 17, 2013.
14. Water for the reprocessing of medical devices. Available from: http://marketplace
.aami.org/eseries/scriptcontent/docs/Preview%20Files%5CTIR340710_preview.pdf.
Accessed January 16, 2013. P. 37-46.
15. Lyon S. Water quality and its impact on the decontamination process. Manag
Infect Control 2008;8:82-97.