Infection Control Today - 03/2002: Success Story

Teamwork Resolves Wrapping Issues for OR and CS

By Mary Olivera, BA, MS

It is 7 am and the OR is calling the sterile processing supervisor announcing that there is a hole in the wrapper of the set they need. They are extremely upset and are expecting you to repair the damage in time for them to begin the case without delay. You have a detailed QA process to ensure that all of the packages leaving your department have not been compromised but yet you fail to fulfill their expectations. You are expected to have the solution to the problem although once the goods are delivered to the OR, the Sterile Processing Department (SPD) has no control over how the sterile packages are handled. This is not a simple problem to resolve unless the two departments work as a team to brainstorm the problem and implement changes.

At the New York University Medical Center, we created a performance improvement team (PIT) for our surgical services and central sterile supply departments to deal with some problems. Our first challenge was to resolve the "hole in the wrapper" problem. Our team was comprised of staff members from the OR, SPD, infection surveillance and management, and our first step was to follow a sterile instrument pack until it reached its destination: the OR. An instrument set must go through a rigid process during its stay in the SPD. After a set is used in the OR, it is sent to the decontamination area to be cleaned. The nurses bag the instruments to prevent cross contamination. In the decontamination area the technicians disassemble and thoroughly clean the instruments through manual or mechanical washing. After decontam, the sets are sent into the prep and pack area to be inspected, assembled, and packaged. The package is then sterilized. The sterilization technician places a liner on the sterilizer-loading cart shelf to prevent the friction of the carrier metal against the shelf and therefore prevent holes on the wrapper. The instrument set load is logged in and pushed into the autoclave. Once the sterilizing cycle is finished the load is removed from the autoclave and placed in the cooling area. The sterilization technician then transfers the sets to the designated transport carts. The transported logs out the load and it is then that the instrument set begins its journey into the OR.

The chances of surviving the journey might be 50-50. Why can't a set survive its journey 100% of the time? Too many people, and too much handling of the instruments! There is no heavy-duty, extra strong disposable wrapper that can survive that kind of journey beyond SPD. But what could be done in a 30-year-old OR where there is no room for case carts and the volume of sterile instruments sets delivered is more than 300 per day?

The best solution was to purchase rigid sterilization containers. However, we wanted to ensure that we selected the most efficient one. The immediate solution was to segregate instrument sets into transporting carts according to services. Once the instrument sets were delivered to the OR, they needed to be placed on the shelves before the rush began. We needed an OR staff member to arrive an hour earlier to restock the sterile sets before the cases began. Meanwhile, the team obtained information from rigid-container manufacturers, selecting a few systems to put them through the trial process. The team considered the following factors in selecting the proper rigid sterilization container:

• Can the container reach sterility?
• Can the container maintain sterility during transport and storage?¹
• Is the rigid container compatible with the departments' sterilization process?²
• Is the container easy to handle through the process, during packaging, and transportation?³
• Can using rigid containers help reduce labor hours in the department and improve the process?
• Can the container allow good aseptic presentation and reduce risk of contamination during presentation?⁴
• Is the container environmentally friendly or will it still generate garbage?
• Is the container cost effective?⁵
• How much out-of-pocket capital is required to begin the transition from wrappers to containers?
• Did the container manufacturer obtain a 510(k) from the FDA as a Class II device?

The team had the opportunity to work with the different container systems and complete an evaluation form. The product was evaluated at the sterile processing area, the site of surgery, at the transportation, and handling area. We collected and compared the results of the data and we had two rigid container systems with the highest scores. When the staff was asked to compare the containers with the current method of wrapping, 99.9% of the staff graded all containers superior and less time consuming. Sterile processing staff took less than a minute to wrap, and the OR nurses no longer had to bag the contaminated instruments. It was proven to be less labor intensive for both departments and a way to improve the process. The only disadvantage to the container system was that they increased the volume of items to be washed in the decontamination area.

A usage report was generated to assess which instrument sets were going to be transferred to rigid containers. Our computerized instrument tracking system was an essential tool in generating this report. We took into consideration the number of sets in the inventory vs the number of maximum daily uses. We had instrument sets that were immediate candidates for the conversion since we used them throughout the day. For other instrument sets the expense was not justified since the number of uses did not exceed the inventory.

When considering the purchase of rigid containers the team kept in mind that not all instrument sets are good candidates for rigid containers. A thorough evaluation of the usage data is necessary before deciding which sets should go into sterilization containers. An assessment of the process using rigid containers is also necessary. Evaluate your capacity in areas such as decontamination, sterilization, and storage:

• Decontamination area: Rigid containers must be decontaminated as well as an instrument set. They will double or triple the amount of items processed through the mechanical washer. Can your washer sterilizer/decontaminator handle the volume?
• Sterilization area: Is the sterilizer chamber large enough to accommodate the rigid container size? Is the sterilization capacity going to be decreased or improved?
• Storage area: Is the current storage space enough to accommodate the new rigid containers configuration? Neglecting to consider storage space might result in failure to comply with sterile storage guidelines. Do the containers fit in your case carts?

The success of a rigid sterilization container project can only be obtained through teamwork. The OR staff's cooperation is essential in completing the conversion. Transfer sets one service at time, and it will be easier to track your progress and improve the process in phases. Rigid containers might not be an option for every hospital or every instrument set; the institution must carefully study the advantages and disadvantages of the purchase.

Mary Olivera, BA, MS, is the central service manager at NYU Medical Center in NYC. She has been an active member of IAHCSMM and the local NYC chapter for CS Professionals.