A Model Policy

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Spic-and-Span or Dangerously Dirty?
A clean central sterile department is imperative to guarantee the integrity of sterilized instruments

By Michelle Gardner

Without a doubt, the physical environment of central sterile (CS) helps preserve sterility of the instruments before, during and after they are processed and wrapped. Slipshod housekeeping can recontaminate instruments and induce peril in the operating room. On the other hand, diligent cleaning in the work area retains trust in the department. Overall, it is uncommon for infections to come from central sterile.

"Less than 1 percent of all post-op infections can be traced back to sterile processing," says Jackie Sandridge, RN, CNOR, supervisor of central sterile supply for Martha Jefferson Hospital in Charlottesville, Va. "You seldom hear of nightmares coming out of sterile processing, unless instruments were not sterilized before they left the department. There is always that potential, (but) by the time the instruments go into the sterilization process, they have been rendered safe for handling. Most of the bioburden would have been washed away with the chemicals in the rinse process of the decontaminators."

Finding someone who is dedicated to cleaning central sterile was a big hurdle for Sandridge, but she lucked out by finding a gentleman on the housekeeping staff who cleans every evening and takes pride in his work. Additionally, the central sterile staff wipes surfaces as needed throughout the day.

"The floors in decontam, processing and sterile storage are cleaned every night," shares Sandridge. "We do not flood them, but they are wet mopped by the housekeeping staff, which is trained by a housekeeping supervisor who follows written policies and procedures for cleaning this department."

The routine at Martha Jefferson Hospital includes vents being dusted and other horizontal surfaces above shoulder height, like ledges around doors, being cleaned on Monday. On Tuesday, housekeeping vacuums under worktables and wet mops. Sinks are cleaned and sanitized daily.

During processing, dust particles in an instrument set being sterilized can still have an infection from a foreign body reaction, says Sandridge. "All dust, foreign flakes or a hair from under your cap has to be cleaned up on a daily basis. You can have infections from sterile foreign bodies. I don't know of any documentation, but if your hospital has a very low infection and cross-contamination rate, it would be because you have a spic-and-span sterile processing department."

Divide and Conquer

Similar to the Martha Jefferson Hospital, the VA Medical Center in Ann Arbor, Mich., divides the cleaning responsibilities in CS. "Countertops and shelves are done by our own people (and) floors, walls, ceilings and air vents are supposed to be done by the Environmental Management Service (EMS)," says Kurt Browne, chief of the sterile processing department. "I am the one who complains, but I am not the one who can make sure it gets done. I buddy up with the infection control people and they help a lot. The relationship is critical because they will go to the industrial hygienist to (get things done)."

Airflow can be difficult to control at the VA Medical Center, says Browne. "The CS department has no control over the filters and if engineering is not changing filters on a timely basis, we get dirty air."

Browne emphasizes the need for positive pressure in the prep room and negative pressure in decontam. "Engineering or industrial hygiene is responsible for recording on a weekly or monthly basis that the room is negative pressure," he says.

Browne has been known to call in his own people for a more thorough cleaning job in CS. "Otherwise it doesn't get done the way it needs to be done," he says. "The trouble is the impression people have of CS being the dishwashing department vs. a department that supports surgery. They have a difficult time seeing the relationship between the instruments that get processed here and the patient on the table in the operating room." He finds that proper training stresses the importance of CS and helps his staff understand its relationship with the OR.

Employees also are taught to move from the cleanest area to the dirtiest area in CS, not vice versa. "It is to avoid having employees change clothes to go into a cleaner area and avoid cross-contamination."

Pat Pratt, central service lead hand for Renfrew Victoria Hospital in Ontario, Canada, agrees that to keep an area clean, the staff doesn't traverse from a dirty area to the clean area. "It is a constant challenge to keep everything in the right area," she says.

Since Renfrew does not have enough staff to set up a proper decontam area, everybody is responsible for keeping central sterile clean. "When we go into that area, we put on protective clothing, gloves and aprons and when we leave, they are removed," says Pratt. "Handwashing helps ensure we don't spread anything. We have a pass-through from the dirty area to the clean area. Everything that is washed is passed through to the clean area and it is packaged on that side."

Following the Central Service Supply guidelines and AORN as best they can, Pratt and her staff do well in many areas of central sterile despite physical and staffing considerations that prevent them from meeting the guidelines precisely. "I have worked here about 20 years and we never had an infection traced back to our department," says Pratt. "Housekeeping cleans the floors and our bathroom. The counters and shelves we do ourselves weekly or as needed. Two or three times a year, housekeeping washes all the walls, floors, vents and windows."

Twenty years ago, says Pratt, people didn't really know what to do. "There were no courses, just on-the-job training," she says. "Consequently, if the trainer made mistakes, you tended to make the same ones. Now our Central Services Association puts out an all-encompassing course that our employees have to take, which trains them in the proper way to do things. We try very hard to improve as best we can. If you don't have the proper environment, you can't guarantee what you are putting out."

A Model Policy

Following is a section of VA policy 7176 addressing the requirements for supply, processing and distribution (SPD) within the VA system as provided by Kurt Browne, chief of the sterile processing department.

"In cooperation with Environmental Management Service (EMS), a written daily cleaning schedule for SPD areas will be developed, implemented and enforced. Cleaning encompasses wet mopping or wet vacuuming of floors with a suitable germicide at least once a day and more often if necessary. Walls, ceilings, vents and filters should be cleaned at least monthly. Sweeping or dry dusting is prohibited in SPD. Dedicated cleaning equipment will be provided for, and maintained in, the SPD decontamination area. This equipment will not be used in other areas of SPD or the facility. Dedicated sanitation/cleaning materials will be used in the clean areas of SPD. There will be written procedures for the cleaning and sanitizing of work surfaces, floors, utensils and equipment used in SPD functions. EMS personnel will never go from the decontamination area to the preparation area while cleaning. Cleaning should start in the sterile storage area, proceed to the preparation area and then to the decontamination area."

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