SPD Experts Tackle Instrument-Related Issues in the OR

February 22, 2010

ICT asked sterile processing experts to tackle a few thorny issues related to instrumentation and the operating room (OR). Our experts are:

Lisa Huber, CRCST, BA, ACE, FCS, sterile processing director at Anderson Hospital in Maryville, Ill. and president of the IAHCSMM

Natalie Lind, CRCST, CHL, educational director for the IAHCSMM

Sharon Greene-Golden, CRCST, FCS, CSSD manager at Mary Immaculate Hospital in Newport News, Va.

Nancy Chobin, RN, AAS, ACSP, CSPDM, corporate consultant and educator at Saint Barnabas Health Care System in New Jersey

Michele DeMeo, sterile processing manager at Memorial Hospital in York, Pa.

Bruce T. Bird, CRCST, central processing director at Primary Children’s Hospital in Salt Lake City

Q: The surgical team gets anxious about the quality of the reprocessing done on instruments and devices – what can you tell them to remind them of the care that the sterile processing department (SPD) takes to ensure the proper steps have been taken in the cleaning, decontamination and sterilization process?

Huber: It is important to keep the OR staff informed regarding training, in-servicing and other professional development measures taken by the central sterile supply department (CSSD) to ensure that staff members are not only competent, but indeed the experts in the realm of instrument processing. It is also important to share with the OR staff successes in quality measures, such as accuracy rates. When things do go wrong in any of the processes, communication is essential for remedying the problem and reassuring OR staff members that CSSD professionals will do their part to prevent such errors from occurring in the future. For example, if a sterilizer malfunctions, CSSD staff should communicate the status of the repair, promptly identify if there is a positive biological indicator and keep the OR (among others) informed of the recall status. If a cleaning or assembly error is made, CSSD staff must communicate to the OR that follow-up measures have been promptly taken to ensure that the mistake is not repeated.

Greene-Golden: The CSSD team members are always aware that they play an important part in patients’ overall surgical experience. The OR team must understand that their team members in the CSSD always obtain and follow the instrument/device manufacturers’ written instructions for cleaning, packaging and sterilization. They make sure that all items are clean and properly working. Then they process the instruments, ensuring that all the parameters of sterilization are met. CSSD teams are now also using challenge packs which allow them to release the load to the OR with confidence that the cleaning, decontamination and sterilization processes have been followed.

Chobin: All devices must be reprocessed in accordance with the device manufacturer’s written instructions. Due to the sophistication of surgical instrumentation needed today for today’s advanced surgical procedures, many devices require extended cleaning protocols and may also require extended sterilization cycles. Both of these factors will impact on the turnaround time of the instrumentation. It is important for the SPD manager to keep OR personnel advised of special processing protocols which would impact on the turnaround of surgical devices and sets.

Bird: If they receive a quality product 100 percent of the time, they have no need to question whether something has been properly processed. They see and experience the end result that reflects quality processing. Also, showing is sometimes better than telling. If the surgical team can observe, and maybe even participate in, the cleaning, inspection, packaging and sterilizations processes, they can see for themselves the level of expertise of the CSSD staff and the quality processes they follow. The CSSD should be proactive in regard to all instrumentation. When surgical services purchases new instrumentation, CSSD should expect surgical services to provide the written guidelines from the manufacturer before the item is placed in the system for use. This will help the surgical team understand how serious CSSD is about processing items correctly. A top-performing CSSD will become resource to its customers on all processing issues.

DeMeo: The anxious state comes from somewhere. Either there have been incidents that have caused the breakdown in trust, or the members have had bad experiences else where. So, this is a difficult question to address. I think you cannot begin to address the anxiousness until you are sure there isn’t really an issue. Regardless of the scenario, there are a few initial suggestions to try to correct this:

• Make sure that all key stakeholders are aware of the concerns. Perhaps concerns have only been voiced to the OR manager by the OR members, or only to the SPD techs by the OR members or only to the SPD manager by the OR members, etc. To get to the reason why this concern is surfacing, everyone needs to be on board that there is a concern.

• Emotions must be removed to be able to have active listening and helpful participation by all of the key members; otherwise, a breakdown in effective communication will hinder any attempts to fix the issues and address real or perceived issues.

• Remember that assumptions will also not solve real or perceived issues either.

• An analysis is needed first; it might be a simple one as not all problems require an extensive review, but a true analysis helps to get the crux of the matter, removing emotion and assumptions and leaving the real considerations.

Scenario 1: Instrument processing had been “fine” at a particular facility, until recently:

• An obvious thing to check is to see if there are any new SPD members on board. If so, are they working independently too soon? Are they struggling with one or two elements that need to be addressed or are they not competent at all yet?

• Is something impeding the technicians charged with the inspection and sterilization tasks of instrumentation? Are they short staffed in this area? Did someone rotate into this from another part of SPD to cover another temporarily, but isn’t properly trained?

Scenario 2: Instrument processing has long been a concern at a particular facility:

• Is the team run by a competent member?

• Does the team and department have the right resources (labor, materials, information, access to processing standards, skills, leadership, manufacturers instructions, space, etc)?

• Are the tasks associated with reprocessing instrumentation disjointed within the facility, i.e., does OR conduct any of the steps, with SPD just sterilizing them? Is there another set of people in the mix, maybe even managed by a different person or team?

• Is SPD considered part of the OR team? Are they including in the decision-making process for instrumentation (if the OR buys something SPD cannot process, there is an immediate issue before the product even arrives at the front door, etc). Is SPD included in vendor in-services? They should be. They need to know how things come apart and are put together and used. Are they told of surgical schedule changes? If not, perhaps they have no idea an item will be needed earlier...and so, if it is called for at the last minute, rest assured short cuts might be happening, etc.

Scenario 3: No identified problems or specific problems, just an unidentifiable general concern or question:

This is harder to address. I think it starts with an honest conversation with the OR and SPD manager. Probing questions by both parties will likely hit a sensitive concern that one or the other might not have even known was on the radar.

General suggestions:

• Assess what the current circumstances are, and try to refrain from old history.

• Concentrate an the current resources of SPD and look for disconnects and possible gaps in the necessities.

• Consider including SPD in the morning and afternoon report. They need to know what changes have occurred with the OR schedule for the rest of the day and for the next day.

• Assess the infection rates...but remember a lot needs to be reviewed before determining the cause or potential contributing factors to surgical infections...both pre-during and post surgery. However, take note of the amount of flashing. Who is prepping the instruments before flashing? Is the item being flashed because of a quick turn over or because it was dirty or missing from a set?

• Are the items being processed according to manufacturers specific guidelines? Does SPD have these instructions? Is the OR processing Flash appropriately -- not everything is 3 or 10 minutes as usually assumed.

When the elements that are causing the concerns are reviewed and answers are to whether or not the processing is being done correctly occurs is only when the anxiousness will be alleviated. Otherwise, there will be naysayers...and for good reason. None of us can afford to say SPD is doing the right the thing, unless it can be verified. This is the case for most everything in healthcare. It is no different than saying a goal isn’t a goal unless it can be measured. Dissecting the processing steps in SPD is appropriate. It is the business of the OR to know what and how it is occurring. How this review done though, will be critical. SPD is a separate unit and deserves the respect to be treated as the professional entity it is.

Q: Sometimes, the OR receives wrapped packages with obvious breaches, such as tears or holes. What can be done to ensure a safe journey for instruments from the SPD to the OR?

Huber: An important first step is to determine which step in the journey the breach occurred — sterilization, transport or storage. Training in proper handling and storage of packages is vital and should take place in both the CSSD and the OR. Other factors to consider include wrap weight and the condition of storage shelves and transport carts.

Greene-Golden: A safe journey from final processing in the CSSD requires careful handling of the instrument trays and packs. The CSSD team members can ensure that trays are lifted and not dragged from shelves and carts. They can put tip protectors on sharp items to prevent them from puncturing a package. The use of tray liners, corner protectors and tip protectors will help keep the packaging intact. The OR team members can aid the CSSD members by carefully handling the instruments while preparing for the surgical case.

Natalie Lind: If there are obvious problems it is a good idea to start at the source and work backwards. Check the instrument tray. Does it have sharp edges that could have cut or punctured the wrap? For example, a tray that has been dropped or bumped may incur a nick that creates a sharp edge. If the tray appears fine, check the transport cart(s). All equipment is subject to damage and even carts, shelving and racks will begin to wear out over time. Loose rack wires or sharp metal edges can puncture and cut packaging. If the transport cart(s) appear fine, continue working backwards to the storage location and then to the autoclave cart. Check any surface that the wrapped set comes in contact with. If there are no obvious sources for nicks and tears, look at handling. Does everyone who handles sterile items handle them with care? Barrier packaging is not an impermeable barrier and yet many employees treat wrapped packages as if they were encased in a suit of armor. Observe both CSSD and OR staff, and identify any failures to meet sterile product handling protocols.

Chobin: Everyone handling sterile packages must be knowledgeable in proper handling. Excessive handling of packs, stacking, crushing, etc. can all impact on packaging integrity. Most often this problem occurs with heavy orthopedic sets. If the weight of the set is excessive (over 25 pounds – AAMI, AORN) then the set contents should be reduced to conform to the recommended weight. Plastic transfer trays can also be used to reduce damage from pulling trays on and off sterilizer racks. There are also several products such as single use or reusable corner guards which can also reduce damage to packaging materials. The use of tip protectors can reduce damage to plastic-paper packages. However, a full review of how packages are handled and stored should be performed to make sure everyone understands the impact of improper handling and storage on packaging integrity.

DeMeo: This really begins and nearly ends with SPD and members putting items into storage and whoever pulls for the surgical case. Part of sterilizing properly includes inspection of the sterilizer rack, prior to placing any packages on it. It also means not placing too many items on the load. Besides saving the integrity of the external wrapper, it also promotes a safe product, even when wrapper breaches have not occurred. In steam sterilizers, items cannot be placed right up and against another anyway. There needs to be adequate space around each item for proper processing. Without this, the item has the potential to be compromised, regardless of if there is tear or hole in it or not. Secondly, choosing the right size wrapper is imperative. Many technicians love (and OR members love receiving) a package that looks like a crisply wrapped item, similar to a tightly wrapped Christmas package. This is a very poor practice; not only does it promotes tears, because it is taunt, it does not allows for “give” when the item is placed on a rack and the rests between the bars of a cart or storage system. This practice also potentially compromises the sterility of it as well, even without an obvious tear. The wrap is a medical device. It must be used properly and according to the manufacturer’s instruction. If it is pulled too tightly the sterilant may not be able to penetrate and exit appropriately. SPD technicians need to remember that if an item is placed on the top, it will more likely be dragged across and off of the sterilizer carriage, due to the weight. Also, take a look at the case carts used; some have wire racks in them. When multiple trays are placed on top of them inside the cart, the feet of some trays, particularly orthopedic specialty sets, will have a tendency to get stuck between the thin bars, often resulting in a tear. Solid racks are best for case carts; however, remember that the sets will need to be fully cooled before placing them in the cart. They should be anyway, but the solid metal base will promote moisture even more if they are not properly cooled. The associates responsible for either placing the items into storage or removing the items from the case carts or transport carts must use proper body mechanics. This will not only save their backs and body from injury, but it, too, will help elevate the tendency to drag instruments off of the carts to move them to their next destination before re-use.

Q: What can the OR do to help SPD take care of instrumentation after it is used in the OR?

Huber: Point-of-use care of instrumentation is often a missing link. An effective way to address this issue is to develop an interdisciplinary team of CSSD and OR staff members. This collaborative team can then develop a procedure for proper post-use instrumentation management, and provide in-servicing to offer OR staff hands-on education on key steps, such as rinsing or wiping off gross soil, flushing of the lumens, and transporting moist instruments – in closed containers – back to the CSSD. Allowing fluids, tissue and bioburden to dry on instruments makes decontamination much more difficult and labor-intensive for CSSD technicians. Something as simple as spraying instruments with a wetting agent or covering instruments with a wet towel can help tremendously.

Greene-Golden: The OR team can assist the CSSD team members by caring for the instrumentation during and immediately following the surgical case. All instruments should have the gross soil removed during use and immediately post-case. Instruments should never be stacked unless they are in rigid container. When returning instruments to a tray, items should be carefully placed by the surgical technician, and never dumped inside the tray. Rinsing instruments in sterile water is accepted. Many CSSD use sprays and gels to help keep contaminated instruments moist until they can be decontaminated and cleaned. Following these steps only helps the CSSD in their process of caring for the instruments.

Chobin: The OR scrub person should be keeping instrumentation clean during the procedure (wiping with a sponge and sterile water). At the end of the surgical procedure, all instrumentation should be accounted for (to avoid loss), replaced in its respective container or basket then sprayed with an enzyme foam product to keep instruments moist and begin the soil breakdown process. OR compliance with these practices make turnaround of sets more efficient in the SPD and facilitates the cleaning process.

DeMeo: While the processing of instrumentation does belong to the SPD, there is a lot that the OR can to do to help preserve the devices and instruments -- not necessarily with the goal of helping SPD. I think that when we phrase it as “helping SPD,” the hair on the back of many OR members get raised. After all, they see their role, as they should, as direct-care providers, not instrument processors, hence, “doing SPD’s job” is not going to sit well when many OR members feel they are already overextending with the push to turn rooms over to get their next patient in. However, when you flip the coin, if instruments are not “passed over” to SPD in the correct manner, precious time can be lost, just when the same caregivers may want to use those devices or set of instruments again. Or worse, they become damaged, but not at the hands of an SPD member. It should be a shared task, the process working collaboratively, but not as one team helping another do “their job.” As for the actual tasks that would help for smoother and safer instrumentation processing, have the OR team neatly place the items in case carts -- this means heavy items at the bottom and lighter, more delicate instruments at the top.

Bird: Here are some tips:

Wipe off any gross soil on instruments after they are used.

Place all used instruments in sterile water after they have been used and wiped of gross soil to prevent any residual debris, visual or invisible, from drying.

Separate sharps from other instruments. This prevents sharp edges from damage as well as protects the tech in decontamination from injury.

Always place larger, heavier instruments below more delicate instruments.

Neatly coil (not too tightly) cords and cables and place them in such a way that they do not become damaged and/or tangled.

Do not submerge items such as power equipment.

Separate delicate instruments, such as laparoscopes, and place them on the cart in such a way to protect them from any possible damage.

Ensure that scalpel blades, saw blades, needles and other sharp objects are properly disposed of in the OR before items are sent to decontam for processing.

Remove all single use items from hand pieces, the jaws of clamps etc.

Purchase enough instruments to allow for proper, unrushed processing.

When purchasing new instruments and equipment, always think of what is necessary to prepare items for reuse and purchase adequate amounts to support projected use. Be prepared to purchase additional if use is greater than anticipated.

Always purchase the proper packaging/trays/containers with new items at the time they are ordered to ensure all is in place for proper processing.

Ensure that CSSD is part of the evaluation and selection process to ensure that processing and training needs are known prior to purchase.