How Far Do Water Droplets From Sterile Processing Procedures Travel?

During Sterile Processing Week, ICT® recognizes the job of sterile processing personnel as highly skilled labor in an uncomfortable work environment. It is also dangerous to those individuals who may pass through the room the sterile processing personnel are working in.

Despite the complexity of the sterile processing personnel’s work, some people think of them as not much more than glorified dishwashers. However, their job is intense, physically demanding, and highly skilled. With retaining health care workers at any level a problem, making their jobs easier, safer, and more comfortable should be the goal for every facility.

To consider what requirements are needed to make sterile processing personnel safer, Cori L. Ofstead, president and CEO of Ofstead & Associates, did a follow-up study to an earlier pilot study she and her colleagues had done in 2021, which was a real-life examination of how well personal protective equipment keeps sterile processing personnel dry. This new study examined how far water droplets would go if the sterile processing personnel followed manufacturers’ instructions of use. Ofstead spoke with Infection Control Today® (ICT®) about their studies published in the American Journal of Infection Control.

ICT®: Please give ICT®’s readers a summary of the key findings of the follow-up study and why they're important?

Cori L. Ofstead: In this study, we found that board certified sterile processing techs were drenched from head to toe when they followed the manufacturer's instructions on how to manually clean ultrasound probes that are used for gynecology (GYN) procedures. The techs also got wet when they were cleaning gastrointestinal tract (GI) endoscopes.

The most surprising thing was about the GYN probes. During their routine activities, the work environment was also heavily splashed. The droplets hit transport cardsstationed about 4 feet back, and the droplets also hit walls 6 feet away, and they got all over the floor up to 7 feet—or a little bit more than 7 feet—away from the sink where the sterile processing technicians were cleaning these devices. So that is the core key finding.

The other thing is that observers who were stationed 3 to 4 feet away from the sink—so they weren't even at the sink doing anything—got hit with numerous droplets. That means that any personnel in the area, whether they are other technicians, a supervisor, an infection preventionist, or surveyor, are walking through the area, and they could get exposed. Sometimes those people don't wear full PPE. They'll put it on when they're at the sink, and they know they're going to be doing messy work, but the people walking through the area might not be [in full PPE]. What we demonstrated is that, if you're in the area, you're at risk. [Additionally,] all those fluids ended up getting tracked all over the place, so they are throughout the unit, and then out the door into the hallway.

Even the techs must shift from what they're doing at the sink to take the instrument to the next place for high level disinfection or sterilization. And as they move around, the [movements] are spreading all that [contaminated water] everywhere.

In the 2 studies we did on splash, [the techs] were using instruments that had already been thoroughly processed, so they were not contaminated. The areas had been cleaned and terminally disinfected. We were going through the motions of these steps that are recommended for processing. [However,] these medical devices normally would be highly contaminated. That's why we're sending them to sterile processing, of course, but that is concerning because if you have these cleaning fluids that have blood and tissue, and patients’ secretions with all kinds of germs in them, and you're trenching [individuals in the processing rooms] head to toe, that's a whole different thing than with clean water and pristine instruments.

[Further,] the study showed that the PPE didn't work. Relying on PPE as the only layer of protection for the worker is concerning because it didn't cover their skin, didn't fit well enough, and didn't offer the fluid resistance that we need for PPE that's going to be used in this very wet environment. The wrap on that study is the sterile processing personnel don't face hypothetical risk of exposure. They live in it all day, every day, so they need to be prioritized for these solutions that could minimize their exposure and contain a splash to ensure that the techs have a safe work environment to do the critical tasks that they're doing for patient safety.

ICT®: Do you have any recommendations for to protect the observers or the people walking through the room?

CO: Start off with anyone who enters the decontamination area, which is the dirty side of sterile processing, should have full PPE on if they're walking through the doors. No more walking in there with only scrubs, and what they call their hospital shoes. Everybody should have full PPE on, and they should have shoe covers that are truly fluid resistant, which these [in the study] weren't at all. The fluid soaked through into the shoes with this highly contaminated fluid. Then they walk all over the hospital and maybe even go home with those shoes.

We must consider an “Authorized Personnel Only” zone where we take seriously that need and better solutions we call engineering controls, which would minimize or contain splash. Because once it's on the floor, it is going all over everywhere. We're fighting a very tough battle. Hopefully, infection prevention is coming up with solutions to do a better job of minimizing the splash from happening in the first place and containing it. That's where we make sure that the decontamination workstation is isolated enough with plexiglass barriers or with stationing carts, so we don't have droplets going 7 feet and getting on all the surfaces and anyone who is walking through the area. Those solutions may be feasible. Challenging, sure. But relying on individuals to remember to do things and do them correctly is always going to be higher risk than designing the work area for safety.

[It doesn’t help that] sterile processing is tucked away out of view. Many people, even infection prevention experts, aren't aware of what the sterile processing professionals’ job is or what the risks are. Also, almost every guideline or standard talks about doing hand hygiene when you remove gloves. When you take off your PPE, you're supposed to wash your hands or use alcohol hand rub. But so far, no guideline or standard says, if you are working in an area and you are getting splashed, you should also wash every other part of skin that got splashed.

In both of our studies in the splash pilot and [the follow-up study], we documented that the face shield is not protecting the face from getting wet. The neck and chest here are getting exposed, even when reprocessing 1 instrument, and they're obviously doing more than that in a workday. Then the gloves did not prevent fluid incursion, and the fluid was getting in the forearms and wrist areas. We need to revisit thinking about our guidance that says how to take off your thoroughly, disgustingly drenched PPE, where you have literally been plunging your arms into fluid that has patient blood and tissue and secretions in it.

We, as sterile processing personnel, take off PPE then:

  • Are we washing our hands?
  • Are we saying wash your arm to your elbow, to your shoulder?
  • What about the face mask getting wet, presumably, wicking those fluids through?
  • How are we making sure that we are not going home picking up our 2-year-old child, who go around your necks, our heads, our hair?

These should be addressed. That's a provocative finding from our splash pilot [study], and this one in both studies. Every time they processed an instrument, they got wet [around the neck]. Our current PPE, even with a face shield, is not protecting this zone, which is the toddler zone. That's the baby zone. That's where our pets or children are going to go straight to when we pick them up.

It's a tough job in sterile processing. Some people think of them, as they're downstairs. They're just glorified dishwashers. However, this job is incredibly complex. They're dealing with literally 1000s of different surgical instruments and medical devices. And they need to know all the intricacies of all those instruments, and how they can be safely processed to make them be safe for use in another patient. They have this very technical, high knowledge and skill level. They must have this constant attention to detail and do work that's physically very demanding, and they're going to do it in an environment that's very hot, wet, and steamy.

Many or most institutions now are struggling with staffing issues. Recruitment or retention of sterile processing is a huge challenge. But part of the issue is when you get someone new, and they come in and realize that wearing all this PPE is uncomfortable, it's hot, steamy, it's complex, there are time pressures, and patient safety depends on them; it is intense. We need to be thinking about ways to support them better, to make their jobs safer and more comfortable. To give them acknowledgement and credit for how critical their work is to patient safety all day, every day.

ICT®: What do you think the biggest challenges are for sterile processors?

CO: The biggest challenge now is time pressure. They're supposed to do incredibly complex work very rapidly, to turn over the instruments as quickly as they can. It's tough under time pressure to remember all the steps in it.

As an example, to process a flexible endoscope that's used for a GI procedure or respiratory procedure, it's more than 100 individual steps. They're supposed to remember all the things that must be done in the order they have to do them in, and then execute that properly. Meanwhile, people are asking them for other things, or they hear other alarms, the phone's ringing, someone's paging them. It's different for every single instrument, and they're going to see in a workday, dozens, or hundreds of different instruments. So that level of intellectual capital, and that level of attention to detail needed should be in an optimal work environment that provides them with that whole work environment—the sounds, the smells, the comfort level—to concentrate and do those tests, essentially, perfectly every time because their work is critical.

There is no margin for error; it must be done perfectly every time. So providing them with the time to do that is the number 1 challenge.

The pilot study can be found here. The follow-up study can be found here.