By Kelly M. Pyrek
Their locations in the hospital may be disparate, but the infection prevention and sterile processing departments share a common goal -- protecting the welfare and safety of patients. To achieve the level of communication and collaboration necessary to uphold this objective, both departments must understand the role they play, says Sharon Greene-Golden, CRCST, FCS, sterile processing manager for DePaul Medical Center, a part of Bon Secours Health System in Virginia.
"Infection prevention, sterile processing and even the operating room are part of what I consider to be the trifecta necessary to produce a quality product for our patients," Greene-Golden says. "Infection prevention must know what is going on in the sterile processing department (SPD) in order to be able to ensure that we are doing a good job. There are some infection preventionists (IPs) that have never set foot in the SPD, and that's not good. They need to put on scrubs and PPE, and get into the SPD."
Steven J. Adams, BA, RN, CRCST, manager of sterile processing/anesthesia at Greater Baltimore Medical Center, says it is critical for the in-fection prevention and sterile processing departments to collaborate and communicate with each other. "In this day and age, there are numer-ous identifiable microorganisms with which our patients can become infected," Adams says. "More specifically, as technology has advanced with more minimally invasive procedures, the surgical instruments have also become smaller, more delicate and more complex, which presents challenges to the SPD staff in reprocessing this equipment. Keeping an open line of communication with your infection prevention department can help serve as an ally for each other when identifying new equipment as well as developing processes for cleaning, disinfecting, and sterilization."
Adams says he utilizes the infection prevention team's expertise when he establishes or revises policies. "Since the infection prevention staff are kept more current with the latest CDC guidelines, this helps ensure that the policies are reflecting the most up to date guidelines from the CDC and APIC," he says. "Our infection prevention team has also been very supportive and influential in working with our facility/engineering team, as well as other vendors, when testing and analyzing water and steam quality, as well as ventilation requirements for the SPD. Working as a team has been much more successful than attempting to get results on my own as a single department. With their support and recom-mendations, we have been able to properly assess and improve both our water quality and ventilation controls."
Adams continues, "Additionally, our infection prevention team has been very knowledgeable in regard to the updated statement related to immediate use sterilization. Therefore, not only does the OR team hear from myself as the SPD manager about reducing the need for immediate use sterilization, but IP also reinforces this practice when discussing tactics to reduce surgical site infections. The SPD serves as a catalyst of change for the OR by providing them appropriate terminally sterilized items in a timely fashion which avoids the need for immediate use meth-ods. As a result, infection prevention obtains a sense of relief that this is one area they do not have to target which allows them to focus on other areas of practice. Overall, our infection prevention and sterile processing departments make a great team in keeping our facility as safe as possible for our patients, visitors and staff. By being a welcomed member of the team on the infection prevention committee, I am exposed to other issues as they may arise during these committee meetings. The sterile processing team is frequently asked to offer insight on cleaning, disinfection and sterilization practices as it relates across the entire facility. As a partner with infection prevention, we can assess specific practices across the organization and offer input if any changes are recommended. Our interdepartmental relationship has also helped other departments as well as members of the executive team recognize the importance that central sterile processing plays in the daily life of our healthcare facility."
Greene-Golden emphasizes the need for IPs to understand the basic principles and practices that govern the SPD, and to assist SPD managers with ensuring compliance. "For example, they need to know that we run a BI on all of our processes -- be it steam, hydrogen peroxide, peracetic acid -- we have to be able to determine that we have killed the bacteria. The IP needs that monthly report that says the SPD has had no positive BIs and that therefore, we are able to stand behind the product we are putting out to the OR. If IPs don't visit the SPD and see our processes, they don't know if we had a positive BI or not. So we could give them a report for 50 years that said we never had a positive and that's the song they are going to sing to whomever is surveying them -- only to come to the SPD during a survey and maybe find the right per-son who says 'We have positives all the time.' And there stands the IP in the dark. So it is very important that IPs come into the SPD, are hands on, and they know what we are doing."
"IPs have to be a part of our team," Greene-Golden emphasizes. "They can no longer just stay in their offices. What I used to do years ago is once a month I would send a report that said 'We had no positive BIs, no recalls, all is well.' And that's what the IPs wrote down. What if in actuality we had 50 recalls but we still used these products on patients and the IPs would never know this because they never came down to the SPD for a visit -- it's like they are scared of sterile processing. They are not going to catch anything as long as they follow instructions and don their PPE. So they should be able to put on PPE, come in, walk through this department and ask the important questions: Have you had a recall? Why did you recall? A recall means something went wrong in our processes -- we have to try to get everything back, similar to what the automotive industry does when it issues a recall. We need to ascertain where everything is because we don't want it to be used on a patient. Then we have more paperwork and talk to the surgeon -- the tray wasn't sterile, so watch the patient, as we don't know what may happen. So our objective is to get everything back and to rerun it and report that whatever the error was, it has been fixed. Sometimes it's our ma-chines didn't come up to par. Sometimes we have a bad batch of BIs. And it just won't turn. But we have to determine what the issue is before we can put the equipment back into place. And our IP needs to be our No. 1 cheerleader when recalls happen."
Essential to an IP's education about the SPD is knowing the intricacies of instrument care and the impact that reprocessing non-compliance can have on patient outcomes.
"The care of the instrument at the point of use is critical," Greene-Colden explains. "Used instruments are covered in blood, other bodily flu-ids and fatty tissues, so if you do not wipe off this gross contamination it can cause damage. They have to clean these instruments as they use them, even before they are sent to the SPD. One of the most common mistakes made is in the cleaning process -- if an instrument isn't clean, we cannot go to step two, period. And if you do not clean it according to the manufacturers' instructions for use (IFU), it doesn't matter that you cleaned it if you didn't follow the instructions -- it is not clean. Following the IFUs is critically important because and you have to read the whole story -- a lot of people read one line and go off running half-cocked. You must read the whole story to be assured that you are doing it correctly."
Greene-Colden continues, "For example, we have DaVinci instruments, which are the most complex and hard-to-clean instruments on the market today. The IFUs are very good but without someone experienced with these instruments standing next to you, they are not user friendly. So for years people have had DaVinci systems and they have been manually cleaning these instruments. That is a big no-no, even by their own instructions. In the beginning they told people they can clean manually but in reality we have to perform a manual assist, meaning I do some parts manually but I need a machine to actually get these instruments clean. So their instructions start off with a manual scrub, with a brush and running water to remove the gross contaminants. Their second point is we have to flush -- and they have given us a piece of equip-ment to facilitate that because we have to do it at 30 psi -- none of us knows what 30 psi is, we don't have any gauges that tell us -- we have to assume that if you hook it up to the sink correctly and you use it, it is coming out at 30 psi. Then the third step says ultrasonically clean -- we now have to have a machine. But many hospitals don't have them. So they are bypassing step three, which must be important because it is step three and not step 10, and they go right to step 4 which says to repeat the flush."
She says the result has been patients acquiring infections, and when DaVinci manufacturer Intuitive investigated, they found that hospitals didn't have ultrasonic cleaning capabilities. "Hospitals had to stop performing cases until they could clean the instruments following the IFU," Greene-Golden says. "If you cannot clean the instruments, technically you are just cooking whatever's still on the instruments. And it has the ability to fall into my surgical site and cause me harm if my immune system is compromised. So now I have had a successful surgery but I can't heal, and when you go to your doctor and say 'I'm not feeling well,' they never say, 'I wonder if the instruments were clean?' That's not the first thing that comes to their minds. We have harmed a patient, and now they require additional surgery because they are not healing -- all because processes were not followed. So we need IPs to help us get the machinery and equipment we need to do our jobs properly. When we need something like an ultrasonic machine that cleans DaVinci instruments, IPs are the ones who can go to the hospital administration and say 'SPD cannot function unless we get the machine.' Administrators are going to listen to the IP because they know that is the person that any surveyor is going to start with when there are infections. So they are our champions for administrators in the C-suite -- they say that SPD cannot do their jobs if you don't give them the tools they need."
In institutions where collaboration is lacking between the infection prevention and sterile processing departments, Adams and Greene-Golden share advice for ways to "break the ice” and improve communication.
"All efforts need to be made in getting to know your infection prevention team," Adams advises sterile processing professionals. He says this can be achieved in a number of ways:
1. Seek some input when developing and revising policies. This will help “break the ice” as long as you are willing to listen and act on any feedback provided. Remember, communication is a two-way process.
2. Seek input if you are thinking about changing a detergent for cleaning, a lubricant, or you are instigating a new sterilization process. Keep your infection prevention team informed.
3. If not part of the infection prevention committee, ask if you can become a member, even if an ad-hoc member at first. Put your best foot forward.
4. If you are planning a renovation or construction project, contact your infection prevention team and seek their input. Most often, your in-fection prevention team will be part of completing a life safety assessment for these projects. Getting them involved sooner instead of late will go a long way.
5. Ask your infection prevention team to take a tour of the sterile processing department. By us working in the environment every day, there are things we tend to miss or gloss over. Having your infection prevention team visit is almost like having an unannounced survey. By showing that you are open to receiving input will help strengthen that relationship.
"Lastly, we as CS department leaders have to exhibit our knowledge and professionalism," Adams says. "If we feel strongly about a process (good or bad), make sure we have the facts to back up an argument. By referencing our professional standards and recommended practices, it will display that we are not just the 'squeaky wheel,' but rather making efforts to improve processes for patient safety."
Greene-Golden advises that IPs introduce themselves and say "I'm here for an hour or two, can you show me what you do?" "I have found that when people do not know what you do, that intimidates them," Greene-Golden adds. "They know we wash things and they kind of put us in a box, washing dishes. We are washing some of the most expensive 'dishes' ever, because these things are going in your body. The tattoo artist can give you a bloodborne disease, and so can we. We can pass along a little AIDS, a little tuberculosis, a little hepatitis, a bevy of things. So people should be concerned with what we're doing and how well we are doing it. I like to stand up and say this -- realistically, SPD accounts for a small percentage of SSIs but any percent is too much when someone has to have their leg amputated or ends up dying. You have to be sure I am following the recommended practices. If I was a soothsayer, I would say we'll be regulated in the next 20 years because you go to too many hospitals and everyone is doing their own thing. Some people are cleaning with water and other folks are just praying. But we are all putting instruments in people's bodies and patients get infections. In the SPD, someone has to be the watchdog, and to me that's the IP. They come in and see we are not killing each other and falling down dead daily, maybe they can visit more often. My IP just had JC in August and the surveyor stayed here for three hours. They went to the wrap-up meeting, they said SPD does a good job. When come in and know what I do, you can visit them any day of the week because they are doing it the same way every day. We don't learn for the surveyors and then dump our brains -- we learn and we continuous education -- IAHCSSM helps us stay up to date with what's new so we do it right every day. I am going to impact someone's life every day."
Sometimes it can be helpful to acknowledge what each department may not understand about each other, to identify knowledge gaps and establish better work relationships.
"IPs very often don't know what we do, and sterile processing personnel only know that the infection control nurse may write you up if you don't have your gloves on, Greene-Golden says. "I tell my IP, 'You are my best friend and hero, and when I tell you something, I expect that you are on your way to the C-suite to tell them please get Ms. Golden a machine because she can't work without it!' I have taught my people that there are things you must have to do your jobs -- if there is no PPE, for example, we will never clean a thing without it. We need the right tools and to be protected, especially in decontam. What we need to know is that infection prevention is not the enemy, but is an essential part of the team. And they are here for us to make sure we have what we need, even though over the years the price tag for the things we need to do our jobs has gone up astronomically and most pencil pushers say 'Why do you need a machine?' IPs are our friends, and they need to under-stand that the people who work in sterile processing really want to do a good job, we don't want to harm anyone, and we sometimes just need guidance."
Adams says that there is much each department can learn from the other. "In reality, we do not need to understand every detail about each others’ department, but the more we know certainly helps," he says. "Again, the important thing here is that this needs to be a profes-sional relationship. It is not just about having the infection prevention department serve as an ally for the CS department and help fight all of our battles. It is also about the CS department being there for infection prevention when the needs arise. IPs may make a suggestion that certain items are just better off being cleaned and disinfected in the CS area, as opposed to certain point-of-use areas. By having your IP visit the CS Department, it will be obvious that certain items are impractical due to space and workflow limitations."
Adams outlines the following key components of each departments role that should be shared:
1. CS needs to be aware of the structure and roles of the IP team members. This will assist in understanding which preventionist to seek out for a specific situation as it arises.
2. CS also needs to be aware of its own scope of responsibility across the department and organization as a whole. Do not create an adversarial role and work against the infection prevention team.
3. CSP staff need to have basic knowledge of microbiology and the nature of disease transmission. IP professionals want to communicate with staff who have a general understanding of these principles as opposed to having to explain every detail.
4. IPs should be aware of the layout of the CS department as well as the workflow of the department.
5. IPs need to be aware of the general cleaning, disinfection, and sterilization methods that the CS department performs.
6. IPs need to know about the equipment/instruments that CSP processes for all point-of-use areas outside of the OR’s, and for which are-as/items they do not.
Infection preventionists and sterile processing managers share the responsibility of boosting compliance with infection prevention principles and practices, Greene-Golden says, adding that "IPs can help us by knowing what policies we use in the SPD, and by holding the hospital and the staff to those principles, practices and policies." She continues, "They can help us with explaining issues such as microbiology principles that apply to the SPD. Microbiology is deep and challenging, and we understand the bottom line that we should not send something through to the OR with visible bioburden on it. We understand that the lockboxes on instruments have to be open. We understand that we have to have hot water to make enzymatic products work correctly. Some people think that water in and of itself is enough of a cleaner, but we need water temperature and a certain amount of enzymatic product to clean instruments correctly, ridding them of bacteria and endospores. Some people think that if you have a little water and a brush you can go to it and be ok. But we can't. My washers have to wash correctly all of the time, every time. We have the best intentions and we really try; the biggest thing is you get what you pay for and many administrators don't want to pay for the expertise that they get. You pay them $5 an hour, but you want them to clean the instruments completely. You want them to reassemble instruments correctly and put them in a tray and set it up nicely. Then you want them to run it in a processor and sterilize it. Then you want them to take it out and get it on a case for a patient in the OR. You can't get all of that for five dollars. But you can get people who say 'I did two of the five steps, and that's worth five dollars.' What I try to instill in the people who work with me is that I know money is im-portant but it's not everything. You took the job, so do the job correctly because you will impact many patients' lives."
Adams emphasizes that one of the easiest ways for the IP to help is to engage the CS leader(s). "Ask your CS team/leader(s) if they can assist in any way with any issues the department may be facing. For example, having the point of use areas comply with using an instrument pre-treatment spray goes a long way in preventing infection as well as preserving the life of our instruments. Perhaps IP can offer some support when they discuss SSI initiatives with the OR and procedural areas."
Adams continues, "Another area that infection prevention can offer assistance is with soiled item transport from around the facility to CS decontam. Is soiled equipment being transported using covered carts? Are transporters wearing gloves and perhaps other PPE when collecting the soiled equipment from patient care areas? I think another critical opportunity is to have an IP come to the department and offer an in-service to the CSP staff. It can be on the importance of wearing PPE, handwashing, or just a simple Q&A to see how things are going. I have found that if I, the manager, is the only individual providing information, and training, etc. it all gets diluted coming from the same source all of the time. Having an IP provide this opportunity gives a “new face” to the CS team which offers a variety of positive results. information may be retained a little better since it is coming from a different source. CS staff feel respected, and better overall, about the work they perform by having another department manager/director take their time to spend that time with the CS team. Some staff may find it easier to address other issues/concerns that they may not necessarily do at other department meetings."
"CS and infection prevention teams do need to communicate and collaborate with each other," Adams adds. "CSP’s two main priorities are to provide material support and prevent infections. We have stated numerous times that CSP is the heart of the hospital. If CSP does not perform their roles properly for many numerous reasons, we have the capability to cause a lot of damage through many avenues of cross-contamination throughout all areas of the healthcare facility. Having infection prevention work together with CSP as a team, will offer support, guidance, and education in keeping the CSP department as up to date as possible in their reprocessing techniques."