Infection Control Today - 03/2002: Success Story

Teamwork Resolves Wrapping Issues for OR and CS

By Mary Olivera, BA, MS

It is 7 am and the OR is calling the sterile processing supervisor announcingthat there is a hole in the wrapper of the set they need. They are extremelyupset and are expecting you to repair the damage in time for them to begin thecase without delay. You have a detailed QA process to ensure that all of thepackages leaving your department have not been compromised but yet you fail tofulfill their expectations. You are expected to have the solution to the problemalthough once the goods are delivered to the OR, the Sterile ProcessingDepartment (SPD) has no control over how the sterile packages are handled. Thisis not a simple problem to resolve unless the two departments work as a team tobrainstorm the problem and implement changes.

At the New York University Medical Center, we created a performanceimprovement team (PIT) for our surgical services and central sterile supplydepartments to deal with some problems. Our first challenge was to resolve the"hole in the wrapper" problem. Our team was comprised of staff membersfrom the OR, SPD, infection surveillance and management, and our first step wasto follow a sterile instrument pack until it reached its destination: the OR. Aninstrument set must go through a rigid process during its stay in the SPD. Aftera set is used in the OR, it is sent to the decontamination area to be cleaned.The nurses bag the instruments to prevent cross contamination. In thedecontamination area the technicians disassemble and thoroughly clean theinstruments through manual or mechanical washing. After decontam, the sets aresent into the prep and pack area to be inspected, assembled, and packaged. Thepackage is then sterilized. The sterilization technician places a liner on thesterilizer-loading cart shelf to prevent the friction of the carrier metalagainst the shelf and therefore prevent holes on the wrapper. The instrument setload is logged in and pushed into the autoclave. Once the sterilizing cycle isfinished the load is removed from the autoclave and placed in the cooling area.The sterilization technician then transfers the sets to the designated transportcarts. The transported logs out the load and it is then that the instrument setbegins its journey into the OR.

The chances of surviving the journey might be 50-50. Why can't a set surviveits journey 100% of the time? Too many people, and too much handling of theinstruments! There is no heavy-duty, extra strong disposable wrapper that cansurvive that kind of journey beyond SPD. But what could be done in a 30-year-oldOR where there is no room for case carts and the volume of sterile instrumentssets delivered is more than 300 per day?

The best solution was to purchase rigid sterilization containers. However, wewanted to ensure that we selected the most efficient one. The immediate solutionwas to segregate instrument sets into transporting carts according to services.Once the instrument sets were delivered to the OR, they needed to be placed onthe shelves before the rush began. We needed an OR staff member to arrive anhour earlier to restock the sterile sets before the cases began. Meanwhile, theteam obtained information from rigid-container manufacturers, selecting a fewsystems to put them through the trial process. The team considered the followingfactors in selecting the proper rigid sterilization container:

• Can the container reach sterility?

• Can the container maintain sterility during transport and storage?¹

• Is the rigid container compatible with the departments' sterilization process?²

• Is the container easy to handle through the process, during packaging, and transportation?³

• Can using rigid containers help reduce labor hours in the department and improve the process?

• Can the container allow good aseptic presentation and reduce risk of contamination during presentation?⁴

• Is the container environmentally friendly or will it still generate garbage?

• Is the container cost effective?⁵

• How much out-of-pocket capital is required to begin the transition from wrappers to containers?

• Did the container manufacturer obtain a 510(k) from the FDA as a Class II device?

The team had the opportunity to work with the different container systems andcomplete an evaluation form. The product was evaluated at the sterile processingarea, the site of surgery, at the transportation, and handling area. Wecollected and compared the results of the data and we had two rigid containersystems with the highest scores. When the staff was asked to compare thecontainers with the current method of wrapping, 99.9% of the staff graded allcontainers superior and less time consuming. Sterile processing staff took lessthan a minute to wrap, and the OR nurses no longer had to bag the contaminatedinstruments. It was proven to be less labor intensive for both departments and away to improve the process. The only disadvantage to the container system wasthat they increased the volume of items to be washed in the decontaminationarea.

A usage report was generated to assess which instrument sets were going to betransferred to rigid containers. Our computerized instrument tracking system wasan essential tool in generating this report. We took into consideration thenumber of sets in the inventory vs the number of maximum daily uses. Wehad instrument sets that were immediate candidates for the conversion since weused them throughout the day. For other instrument sets the expense was notjustified since the number of uses did not exceed the inventory.

When considering the purchase of rigid containers the team kept in mind thatnot all instrument sets are good candidates for rigid containers. A thoroughevaluation of the usage data is necessary before deciding which sets should gointo sterilization containers. An assessment of the process using rigidcontainers is also necessary. Evaluate your capacity in areas such asdecontamination, sterilization, and storage:

• Decontamination area: Rigid containers must be decontaminated as well as an instrument set. They will double or triple the amount of items processed through the mechanical washer. Can your washer sterilizer/decontaminator handle the volume?

• Sterilization area: Is the sterilizer chamber large enough to accommodate the rigid container size? Is the sterilization capacity going to be decreased or improved?

• Storage area: Is the current storage space enough to accommodate the new rigid containers configuration? Neglecting to consider storage space might result in failure to comply with sterile storage guidelines. Do the containers fit in your case carts?

The success of a rigid sterilization container project can only be obtainedthrough teamwork. The OR staff's cooperation is essential in completing theconversion. Transfer sets one service at time, and it will be easier to trackyour progress and improve the process in phases. Rigid containers might not bean option for every hospital or every instrument set; the institution mustcarefully study the advantages and disadvantages of the purchase.

Mary Olivera, BA, MS, is the central service manager at NYU Medical Centerin NYC. She has been an active member of IAHCSMM and the local NYC chapter forCS Professionals.