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Eliminating ETO Translates to Improved Efficiency for Phoenix Hospital

By Robert Miller, CRCST

Located in the heart of Phoenix, St. Joseph’s Hospital and Medical Center is a 607-bed, not-for-profit hospital that provides a wide range of health, social and support services with special advocacy for the poor and underserved. Founded in 1895 by the Sisters of Mercy, St. Joseph’s was the first hospital in the Phoenix area. The hospital is part of Dignity Health, one of the largest healthcare systems in the West, with more than 40 hospitals in Arizona, California and Nevada.

St. Joseph’s is a nationally recognized center for quality tertiary care, medical education and research. It includes the internationally renowned Barrow Neurological Institute®, the Heart & Lung Institute®, the Center for Women’s Health, University of Arizona Cancer Center at St. Joseph’s, and a Level 1 Trauma Center verified by the American College of Surgeons. U.S. News & World Report routinely ranks St. Joseph’s among the top hospitals in the United States for neurology and neurosurgery. The hospital is also a respected center for orthopedics, internal medicine, primary care and many other medical services.

As a Level 1 Trauma Center and teaching facility, St. Joseph’s Hospital and Medical Center is prepared to handle a variety of acute and specialty procedures, including:

• General surgery, performing approximately 9,000 procedures per year and encompassing virtually all specialties
• Cardiovascular/thoracic procedures, completing approximately 1,500 per year, including lung transplants
• Lithotripsy, performing about 1,600 procedures per year
• A specialty in high risk endoscopy procedures, performing approximately 3,600 per year
• Labor & Delivery, specializing in high risk pregnancies and performing approximately 1,100 procedures per year
• The Barrow Neurological Institute’s neurosurgery residency program, the largest and most south-after in the world, with an annual clinical volume among the highest in modern healthcare. More than 5,000 neurosurgical/spinal procedures are performed per year.
• Cardiac catheterizations

Overall, approximately 420 surgical procedures are performed each week and 22,000 procedures are done annually.

Handling the load -- Processing High Volumes

The sterile processing department (SPD) consists of 35 technicians serving more than 60 departments. Instrument reprocessing for the entire facility is centralized and standardized. To understand the scope and volume of work of this department, some numbers might be helpful. More than 16,000 different instrument sets are being reprocessed; each set may include hundreds of instruments and implants. Each year, the SPD reprocesses more than 225,000 instrument sets, which contain more than 6 million instruments and implants. In addition, more than 9,000 flexible endoscopes are reprocessed annually.

Identifying a Problem

As with all healthcare institutions, focusing on the outcomes of our patients and productivity is essential. However, it can be easy to lose sight of improving the safety of our healthcare professionals, as well as improving process. 

Ethylene oxide has long been known as human carcinogen and the resulting by-products and off-gassing is bad for the environment. St Joseph’s Hospital and Medical Center had long researched ways to improve the safety profile and use of ETO sterilization. We decided to employ a safe ETO system and program, which filtered out the ETO during off-gassing. Though this was a step on the right direction, the process was very expensive to run and took many hours (12 to 72 hours) to process the low temperature sterilization loads. Additionally, more stringent regulation mandated by the EPA for healthcare facilities utilizing ETO continued to make it more challenging to meet the turnaround needs of instrumentation being sterilized using ETO. At this point, we faced the dilemma of how to implement safer practices around ETO, while not compromising productivity. 

Our solution: Eliminating ETO from our hospital had been a goal for several years, and with the acquisition of our V-PRO® maX Low Temperature Sterilization Systems, we were finally able to accomplish that goal.

While still using our four ETO sterilizers, we installed four AMSCO STERIS V-PRO maX Low Temperature Sterilization Systems and placed them into service. Using our electronic instrument management system we first identified all items being processed using ETO. We then referenced the manufacturer instruction for use (IFU) to identify those items that were compatible for sterilization using the V-PRO maX. Most of our devices were easily transitional from ETO to V-PRO sterilizers. However, a few sets required minor adjustments, such as placing them in a V-PRO maX compatible sterilization container. Only one instrument set, the filiforms and followers, was unable to be transitioned due to incompatibility. However we identified an acceptable disposable option that was satisfactory to our physicians. Within one year of installing the V-PRO maX sterilizers, we de-installed our ETO sterilizers and removed them from service. We then relocated our V-PRO maX sterilizers into the room previously occupied by the ETO sterilizers to complete the transition.

Eliminating ETO from our hospital had been a goal for several years. We began with an ETO elimination plan that resulted in a 50 percent reduction prior to using the V-PRO maX sterilizers. We continued to collaborate with our customers in all areas of the hospital and off-site clinics to maintain this reduction until we were able to transition the items requiring low temperature sterilization to the V-PRO maX sterilizers. There were many departments and individuals involved in the success of this process – including the SPD staff, surgical services staff, OR leadership teams, a project manager, safety officer, researcher, corporate office and many more – all of whom played critical roles.

Training was Crucial

Training was conducted to educate SPD staff on the operation of the V-PRO maX sterilizers, including how to validate the sterilizers, the appropriate use of the three cycle types, its lumen restrictions, as well as understanding the instrumentation that is compatible with and/or requires processing using this sterilization method. Staff was also educated on minor process changes required to use Hydrogen Peroxide sterilization, such as no longer placing absorbent materials in the instrument sets or sterilization load. SPD and operating room staff were educated on the quality assurance products being used to monitor the V-PRO maX sterilizers, which include products such as biological indicators and various chemical indicators.

Waste reduction: To close the loop on our ETO equipment, the pieces we removed from service at our hospital were recycled, not only diverting nearly one ton of waste from a landfill, but putting a few hundred dollars back in our pocket.

Improvements in Productivity and Staff Satisfaction

Today we have a safer, less expensive and more environmentally friendly low-temperature sterilization system in place that provides phenomenal short-sterilization cycle times for each sterilizing load. The significantly shorter sterilization cycle time allows us to process more than one load per day per sterilizer as was the case with ETO. Some specific devices required three days in the ETO sterilizer to complete aeration. But after implementing the V-PRO maX sterilizers we immediately increased our output of terminally sterile devices by 250 percent. We’re now processing 175 loads every month.

In addition to dramatic productivity improvements we’ve experienced an increase in physician, staff and patient satisfaction. The increase in efficiency results in terminally sterilized devices being available for 100 percent of our patients requiring a device processed using low temperature sterilization. Many of today’s surgeries are non-invasive procedures requiring complex medical devices, such as high definition cameras, flexible scopes and rigid scopes. And that includes those used with the DaVinci robot, which are unable to be sterilized in a traditional steam autoclave. With the use of V-PRO maX Low Temperature Sterilization Systems we are ultimately able to deliver to our operating room staff, physicians and patients a quality product in a timely manner.

Robert Miller, CRCST, is sterile processing supervisor at St. Joseph’s Hospital and Medical Center in Phoenix.


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