Flash sterilization has been a debatable issue probably since its conception. The many issues relating to flash sterilization run from overuse to misuse all the way to the reportedly increased risk for postoperative infection and the accompanying increased costs for these infections.¹
One factor that drives the use of flash sterilization is “preservation of capital,”² which is a fancy way of saying an entity does not have enough instruments on hand to cover its volume of procedures. Other factors within this “preservation of capital” include fewer loaner sets or instrument consignments. Other factors that may drive increased flashing are operative settings being located too far from the central processing areas, the driving demand for rapid turnaround times and the overuse or misuse of not leaving the practice to only instances of “emergency.”
According to the guidelines set forth by the Association for the Advancement of Medical Instrumentation (AAMI) and its bible of flash sterilization of instrumentation — the AAMI ST79:2006 — flashing should only be considered if all of the following conditions are met:¹
Instruments must be decontaminated and cleaned properly according to facility policy and in compliance with AAMI ST79:2006 and with Association of periOperative Registered Nurses (AORN) Recommended Practices.
Inspection of all items is conducted per facility standard processes.
Sterilized items are directly delivered to point-of-use.
The facility has procedures that are followed and audited to show compliance.
The item must be used immediately.
It is important to note that powered instruments and most implants — unless specifically approved by the manufacturer — are not recommended for flash.²
Certain protocols should always be met when using flash sterilization. Thomas K. Moore, who recently retired from Getinge Sourcing, LLC, after 39 years in the healthcare sterilization industry, says that keeping the flashing times in check and performing proper cleaning before flashing, are among those most important.
“The traditional gravity flash cycles are the three-minute exposure at 270 degrees Fahrenheit to 275 degrees F for nonporous items and the 10-minute exposure at 270 degrees Fahrenheit to 275 degrees F for porous items. These two cycles are efficacious but only if the items have been cleaned properly and in accordance with the facilities established cleaning practices and procedures used in central supply,” he notes.
Moore, who now has his own consulting business named S.A.M. — the Sterilization Answer Man — says cleaning is commonly omitted during the flashing process. Adequate cleaning is the first step in the decontamination and sterilization process, and failure to adequately clean and rinse instruments before flashing may result in ineffective sterilization and increase the patient’s risk of infection.¹
“Why cut down?” he asks. “Just do it right. Clean it properly. Select the right cycle (gravity or vacuum), and flash it in a container designed for flash/immediate use.”
Overused and Under-Supplied
Flash conversations will almost always turn to two things: its overuse due to lack of instrument inventory and its overuse in fast-paced high-volume surgical environments such as ambulatory surgery centers (ASCs).
“Most articles I read indicate such, however, in our facility we have worked very hard to truly only flash in urgent situations,” shares Linda C. Nimmo, RN, CNOR, CRCST, assistant nurse manager at Greenville, NC-based Surgicenter Services of Pitt. Nimmo says her ASC has met its goal of zero flashing.
“In the last year, we have maintained a zero percent flash rate most months with an occasional 0.1 percent due to urgent situations that could not be avoided,” she says.
Nimmo explains that she and her team investigated under what circumstances flash was being used and they went through incidence by incidence to initiate change. “We obtained information from our autoclave log book each day to indicate what instruments we were flashing and studied the cases being performed needing such instruments,” Nimmo shares. “We increased our inventory and still maintain this log each day to prevent backsliding to frequent flashing.”
Inventory is a widely blamed culprit for the use of flash because it is said that flash sterilization may be overused to “compensate for insufficient inventory of instruments.”¹
“In our research into the volume of instruments used at different facilities, it became apparent that flash sterilization was much more widely practiced than we would have thought. To economize, facilities have accepted flash sterilization as the standard of care,” writes Robert Edelstein, president and chief executive officer of Millennium Surgical. Millennium initiated a program last year to help surgical facilities decrease their dependence on the flash sterilization process (see sidebar on “Seven Tips”).
On the flip side, some may not be able to see around the money saved from not buying all of those additional instruments. For example, one study examined postoperative infection rates for 100 surgical procedures in which a total of 121 flash sterilizations were performed.³ These researchers determined that of these cases, infection rates were found to rest at 3 percent. The researchers specifically note that the overall cost of diagnosing and treating these postoperative infections was lower than the cost of buying the additional instruments that would be required to reduce the use of flash sterilization.
Some excellent talking points on the cautions to be considered when using flash sterilization was delivered by Trisha Barrett in her presentation titled, “Flash Sterilization: What Are the Risks?” where she points out the following thoughts:²
Monitor what is being flashed and why.
Ensure proper cleaning.
Physical layout should ensure direct delivery to point-of-use.
Practices audited and monitored to provide for aseptic handling and personnel safety during transport of sterilized items.
Avoid burns in patients (ensure ample cooling time before use of flashed item).
Record keeping and documentation are imperative in tracking postoperative infections. Both can help to show misuse of the practice and to help make the case to administration for the need for more supplies. All documentation should include the reason why the item was flashed.
Documentation of flash sterilization must include the following information:2, 4
the sterilizer identification and cycle number
the item(s) that was sterilized
the temperature of the cycle
the type of cycle used (prevacuum or gravity)
the identification of the staff member processing the item(s)
the date and time of the cycle
the results of the chemical integrator
any process indicator used
the medical record number and patient name for traceability purposes
The Centers for Disease Control and Prevention (CDC), the Joint Commission, and AORN all state that flash sterilization should be kept to a minimum and should not be used as an alternative to purchasing additional instruments, to save time, or for convenience.¹ AORN documents also state specifically that “flash sterilization may be associated with increased risk of infection to patients because of pressure on personnel to eliminate one or more steps in the cleaning and sterilization process.”
Any added vigilance in flash sterilization will be brought about by national demands for patient safety,¹ and this is a win-win for all.ICT
1. Carlo A. The new era of flash sterilization. AORN J 86 58-68. July 2007. Accessible online at http://findarticles.com/p/articles/mi_m0FSL/is_1_86/ai_n19448211.
2. Barrett T. Flash Sterilization: What are the Risks? UCSF Medical Center. Accessible online at http://www.ucsfmedicalcenter.org/matserv/misc/trainin/Flash%20Sterilization.pdf.
3. Yukiko L., et.al. Evaluating use of flash sterilization in the OR with regard to postoperative infections. AORN J 83 (March 2006) 672–680.
4. Matthews T. Infection Control: Sterilization guidelines in a flash. OR Nurse. Vol. 1, No. 2., pg. 16. March/April 2007. Accessible online at http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=715134
For more on appropriate temperatures and other flash sterilization guidance, check out the STERIS Study Guide #002; The Hot Issues of Flash Sterilization: A Continuing Education Study Guide. Accessible online at https://eservice.steris.com
Seven Tips to Help Avoid Flash Sterilization
1: Use Flash Sterilization Appropriately
Flash sterilization should be used only when there is insufficient time to process instruments by the preferred wrapped or container method. It should not be used as a substitute for insufficient instrument inventory.
2: Establish and Enforce Guidelines
Define the rules for flash sterilization at your facility and establish appropriate guidelines for everyone to follow. Require use of a flash sterilization log.
3: Build More Efficient Instrument Sets
Inventory your facility’s instruments and determine those that are most frequently used. Streamlined instrument sets should be built to include only those instruments. Fewer instruments per set allows for faster overall processing. With streamlined sets, money isn’t wasted on rarely-used instruments.
4: Dedicate Someone to Instrument Reprocessing
Ensure that all instruments are sterilized through proper reprocessing by dedicating someone to this responsibility. Patient safety is an important measure for all facilities, and the reprocessing of instruments is a crucial element of a sterile and safe environment.
5: Seek Outside Support
If your budget or systems can’t keep up with your demands, seek outside help. Certain companies can serve as outsourced sterilization services or even provide sterile instruments on a just-in-time and charge-by-use basis.
6: If You are Going to Use Flash, Do it Right
Use closed sterilization containers or a patented system such as the Flash-Guard system, so instruments are protected from contamination from autoclave to point-of-use. Such a system is easy-to-use, sterilization is fully validated and instruments can be transported through non-sterile areas safely and within guidelines.
7: Weigh Cost of Instruments versus Patient Safety
Although properly stocked instrument sets can be a significant investment for any facility, the cost pales in comparison to the detriment of declining patient safety and contamination. Not only does this put the patient at risk, it also potentially jeopardizes the facility’s reputation and Joint Commission accreditation; and opens the risk of lawsuits.
Source: Robert Edelstein, chief executive officer of Narberth, Penn.-based Millennium Surgical Corp.