Banner sterile processing personnel (from front to back): Weixing Zhu, Veronica Franco (on the table), Patricia Fonseca, Lizet Hidalgo, Beth Chapman, Nick Devaney, Dora Vanlenzuela, Rick Barajas, Nat Logo. Photo courtesy of Tim Brooks
By Karin Lillis
“Can’t you just hand-wash that piece of equipment and put it in the sterilizer?”
That’s one question Tim Brooks hears often—especially from surgeons.
The answer is usually, “No.”
“I don’t think people really understand what it takes to get instruments back on the shelf,” says Brooks, BS, CSPM, senior manager of sterile processing at Banner University Medical Center in Tucson, Ariz. “Many doctors have no idea what the functions of the sterile processing department (SPD) are. The only real exposure they have is what they’ve been told by scrub techs and nurses in the OR suite. In my 28-plus years in this industry, I’ve only seen three surgeons come and walk through SPD. There is a standard of care for every patient. Every time we make an exception, we are changing things for the next patients.”
When Brooks came on board with Banner, he conducted a two-hour presentation for perioperative services staff.
“There are perceptions that OR staff and SPD staff have of one another—and then there is the reality of what takes place,” Brooks says. “We had to answer questions like, ‘Why does it take four and a half hours to sterilize instruments?’ The answer was, ‘When you’re sterilizing 500 instrument sets, you can’t immediately stop for one to be flashed or recycled.’ From the time an instrument set leaves the OR, goes through the washing and sterilization process and ends up back on the shelf or case cart, it takes an average of four and a half hours.”
It Starts with the Preference Card
At Banner, each surgical case starts with the preference card—the document that identifies resources and preferences for individual surgeons and specific procedures, from instruments, equipment and supplies to instructions and set-up.
“When the preference card is not correct, staff must rely on memory—which adds stress for people working in sterile processing and the OR,” Brooks says.
Three operating systems have to work together to make the “perfect preference card,” he explains.
First is the OR scheduling system’s preference card database—which relies on three material libraries, OR equipment, surgical instruments and disposable sterile supplies, he notes. OR equipment consists of two to six different kinds of surgical tables, along with 30 to 40 different kinds of mobile equipment and mobile surgical tables.
“The instrument library consists of 500 to 2,000 different instrument sets—more than 100 of those sets have special single instruments. There are also hundreds of vendor/loaner instrument sets that come and go from hospital-to-hospital,” Brooks says. “The materials management systems feed some 3,000-plus disposable supplies and 6,000 to 10,000 implants into the OR preference library.”
SPD staff who then that pull the case cart—complete with both disposable sterile supplies and reusable surgical instruments—must retain knowledge of more than 1,000 disposable supplies and as many as 1,500 instrument sets and peel pouch single instruments, he explains.
Delays and Conflicts
At Banner, an electronic scheduling system is designed to prevent conflicts in schedule, staff, rooms, equipment and supplies—but conflicts and delays can still happen. Information might have been entered incorrectly into the system, the preference cards might not be up to date, or a surgeon has found a workaround that essentially bypasses the alerts.
“There are delays—patients and doctors are getting upset. You have patients sometimes waiting for hours because of those conflicts—and it happens a lot. You end up bouncing things around and looking at inventory. If you’re lucky enough to be an SPD person with some operational dollars and you can build instrument sets, you can gradually start acquiring new equipment,” Brooks says.
If Brooks encounters an issue, he consults Roxanne McGovern, BSN, RN, CNOR, control desk manager at Banner University Medical Center.
“A key person in SPD needs to be in contact with the scheduling/resource coordinator. If something is happening in SPD, they need to let that person know as soon as possible—such as a sterilizer dropping out or slow equipment processing,” Brooks says.
Suppose a doctor has scheduled three cases requiring a set of hand and foot instruments—but there are only two sets.
“There’s a possible delay on that third case,” Brooks says. That means a conversation with staff in the OR where the second case is being confirmed, and a request to send the instrument set to sterile processing as soon as that case is complete.
That’s no guarantee the request can be accommodated. Sometimes the request comes before the patient is wheeled out of the OR, or surgical staff hasn’t completed the instrument count, Brooks says.
“If they’re able to release the set, SPD will take it and do immediate sterilization. But that also causes problems on our end,” Brooks says. “If you’ve tied up one washer with just one tray, there’s a bottleneck in sterile processing. If you’ve got four or five requests, there are even more delays because staff can’t run the washers efficiently.”
Brooks also would like to see a designated person update ongoing changes to preference cards—which are especially rapid at Banner. OR staff, he says, may be reluctant to give up that responsibility.
“OR staff often think they need full control over the preference cards and updates, but it would be more efficient to delegate those updates to a resource person,” Brooks says. “Instead of waiting two or three weeks for someone from OR to update a pile of 50 cards, the updates can happen immediately. All you need to do is give that data entry person the appropriate terminology and a card number.”
Increasing OR Turnaround
The surgery department also has taken steps to ensure faster turnaround of instruments in general—and to decrease the risk of damaged instruments, says McGovern.
A surgical support attendant is now an OR assistant, with increased duties.
“We now bring in the SPD folks into the OR at the end of a case so they can ensure the instruments are placed on the cart correctly—instead of piled up and ruined. They make sure the scopes are wound up and put back correctly. This also has cut down on any recycling and decontamination time.”
“One of the biggest challenges was actually having someone able to lead the OR team. You have to have someone with strong leadership skills,” McGovern says. “Even though you may call and ask for SPD to come up and retrieve a cart, it doesn’t always happen, but if that lead person is strong enough, he or she can ensure it does happen. We want that to occur before the patient is out of the room. One example might be a cardiac room, where everything isn’t broken down until the patient is stable and on the way to the recovery room.”
Raising Red Flags
A high rate of immediate-use steam sterilization—also known as ”flash sterilization”—should throw up a red flag, Brooks says. Taking unnecessary shortcuts ultimately places patients at risk.
It is important to note that currently ”’flash sterilization’ is an antiquated term that does not fully describe the various steam sterilization cycles now used to process items not intended to be stored for later use,” according to guidance from International Association of Healthcare Central Service Materiels Management (IAHCSMM) and the Association of periOperative Registered Nurses (AORN). ”’Immediate use’ is broadly defined as the shortest possible time between a sterilized item’s removal from the sterilizer and its aseptic transfer to the sterile field.”
Brooks stresses that the procedure is a last-resort procedure that should be reserved for emergency or urgent cases; it is not a replacement for full processing through the sterile processing department.
“It’s one thing if there is an emergency situation and you have to change gears—but if you have a high flash rate for procedures booked through the scheduling system, there is a problem,” Brooks says.
Immediate-use steam sterilization is an ongoing issue, notes consultant Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSPDT.
In the instances where it must be performed, “the facility is either abusing immediate-use steam sterilization or not performing it correctly,” she says. “Or, it’s being done in a hurry. One facility left it up to a vendor to put the instruments into the autoclave, and he never pushed the button to turn the machine on. Later, the instruments got put back on the table—and it was discovered they weren’t sterile. The OR staff did catch it in time.”
Brooks adds, “There is always a risk—especially with the more complex instruments. Laparoscopic instruments, for example, have to be taken apart to go into the sterilizer, and then put back together. They’re not designed for that. The cycles of heat and cooling can damage the instruments. I have actually seen tips of laparoscopic instruments crack during surgery—flash sterilization can create a high risk of metal fatigue.”
When immediate-use steam sterilization is unavoidable, Seavey suggests having a dedicated sterile processing person running the OR-based autoclave.
“It the OR has something that has to be run for immediate use, the staff calls sterile processing. Sterile processing staff decontaminate the instruments in the appropriate area, then put them in the autoclave with the correct chemical indicators—and in line with the instructions for use,” Seavey says. “Once the instruments are ready, OR staff can remove them from the autoclave.”
Both OR and sterile processing staff sign a printout that indicates the aforementioned procedure was performed.
IAHCSMM and AORN offer further guidance, “Personnel involved in reprocessing should be knowledgeable and capable of exercising critical thinking and judgment, and should implement standardized practices. The supervising organization is responsible for ensuring appropriate training, education, and competency of staff and ensuring that the necessary related resources are provided.”
Education and certification resources can be obtained through organizations like the Certification Board for Sterile Processing and Distribution (CBSPD) and IAHCSMM. Standards and practice guidance are available through AORN, the Association for the Advancement of Medical Instrumentation (AAMI) and the Centers for Disease Control and Prevention (CDC)’s Healthcare Infection Control Practices Advisory Committee (HICPAC), according to IAHCSMM/AORN.
The organizations also recommend that “Sterilization personnel should be educated regarding the different types of steam sterilizers (i.e., gravity-displacement and dynamic air removal—prevacuum, high vacuum, and steam-flush-pressure-pulse sterilizers) and the different types of steam sterilization cycles (i.e., gravity-displacement and dynamic air removal cycles) used in healthcare facilities.”
‘We Need More Instruments’
“A high recycle rate or high flash rate and low inventory equals a need for more instruments. If you understand the relationships between those two items, you can easily justify purchasing more instrumentation,” says Brooks. “You might hear that your hospital has no budget to buy more instruments—but the risk of harm is more expensive than those instruments.”
Brooks says he is fortunate to work for a large healthcare system—where it’s easier to allot funding for additional instruments and supplies than at a smaller community or rural hospital.
Brooks manages a surgical instrument inventory worth $14 million -- 86,000 instruments. That includes nearly 3,000 sets. When he first joined Banner, at least 300 of those sets had equipment that was missing or damaged, or around 3,000 instruments every day.
“By decreasing scheduling delays and focusing on room turnover, the number of sets missing instruments is about 50 a month,” he says.
“We had to build our inventory from the ground up, and it grew quite a bit over time. There is also tracking system to show when we were having demand and volume issues.”
Tracking Instruments and Supplies
John Willi, FAHRMM, CMRP, CPM, APP, CPCM, vice president of supply chain management at NYU Langone Medical Center, says real-time locating systems can greatly reduce the chances of instruments—some of which cost tens of thousands of dollars—going missing. Similar to the systems used in department stores, a special tag will trigger an alarm when an instrument crosses certain barriers—like the opening to a laundry chute or a loading dock bay.
“As these instruments become more sophisticated and micronized—smaller and smaller—they can easily get lost,” Willi says. “There is always a human element. The instrument could have fallen into a crevice or gotten lost in a bed. The EVS folks might have bundled it up with the bedding and thrown it down a laundry chute.” He continues, “We have these devices on a Web-based system so we can see where all items are—right down to a certain supply in room 222 on the second floor. “My team controls the loading dock, in the event that a supplier is able to back in and use the limited bays we have. Let’s say we’re working with a linen supplier, and an instrument got swooped up in the sheets when EVS stripped a bed. An alarm triggers and that brings attention to the cart.”
The appropriate hospital staff member—wearing the required protective equipment—would search through the linen cart. Willi says he can only recall one instance where something like that happened. In that case, the staff member was able to retrieve the item.
The Name Game
Brooks says he’s amazed how many nicknames one instrument may have. “OR staff turnover and travelers have been a huge problem for us lately. New RNs or surgical scrubs just learning the OR fall into the incorrect naming of supplies and instruments,” Brooks says. “Travelers from other hospitals from across the country have different names for the same things as does surgeons who move from one place to another. SPD techs learn over time all the nicknames and surgeon made up names. The bigger and older the hospital the more names.”
‘That Redhead Over in Sterile’
Seavey recommends that all sterile processing staff should spend a few days—not just a couple of hours—observing cases in the operating room.
“Every OR staff member—even those who have been there a long time—need to spend time in sterile processing as well,” Seavey says. “That means working in decontamination, assembling instruments, running the autoclave and picking case cards. I also think there should be joint staff meetings so they can introduce new (hires), so everyone knows each other by name—not just ‘That redhead over in sterile.’ Knowing each other’s ‘names helps foster an attitude of, ‘We’re all in this together.’ That’s the attitude we need to have,” Seavey says.