A Model Policy

August 1, 2002

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

By Michelle Gardner

Withouta doubt, the physical environment of central sterile (CS) helps preservesterility of the instruments before, during and after they are processed andwrapped. Slipshod housekeeping can recontaminate instruments and induce peril inthe operating room. On the other hand, diligent cleaning in the work arearetains trust in the department. Overall, it is uncommon for infections to comefrom central sterile.

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

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

"The floors in decontam, processing and sterile storage are cleanedevery night," shares Sandridge. "We do not flood them, but they arewet mopped by the housekeeping staff, which is trained by a housekeepingsupervisor who follows written policies and procedures for cleaning thisdepartment."

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

During processing, dust particles in an instrument set being sterilized canstill have an infection from a foreign body reaction, says Sandridge. "Alldust, foreign flakes or a hair from under your cap has to be cleaned up on adaily basis. You can have infections from sterile foreign bodies. I don't knowof any documentation, but if your hospital has a very low infection andcross-contamination rate, it would be because you have a spic-and-span sterileprocessing 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 andshelves are done by our own people (and) floors, walls, ceilings and air ventsare supposed to be done by the Environmental Management Service (EMS),"says Kurt Browne, chief of the sterile processing department. "I am the onewho complains, but I am not the one who can make sure it gets done. I buddy upwith the infection control people and they help a lot. The relationship iscritical because they will go to the industrial hygienist to (get thingsdone)."

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 isnot changing filters on a timely basis, we get dirty air."

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

Brownehas 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 dishwashingdepartment vs. a department that supports surgery. They have a difficult timeseeing the relationship between the instruments that get processed here and thepatient on the table in the operating room." He finds that proper trainingstresses the importance of CS and helps his staff understand its relationshipwith the OR.

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

Pat Pratt, central service lead hand for Renfrew Victoria Hospital inOntario, Canada, agrees that to keep an area clean, the staff doesn't traversefrom a dirty area to the clean area. "It is a constant challenge to keepeverything 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 gointo that area, we put on protective clothing, gloves and aprons and when weleave, they are removed," says Pratt. "Handwashing helps ensure wedon't spread anything. We have a pass-through from the dirty area to the cleanarea. Everything that is washed is passed through to the clean area and it ispackaged 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 physicaland staffing considerations that prevent them from meeting the guidelinesprecisely. "I have worked here about 20 years and we never had an infectiontraced back to our department," says Pratt. "Housekeeping cleans thefloors and our bathroom. The counters and shelves we do ourselves weekly or asneeded. 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 sameones. Now our Central Services Association puts out an all-encompassing coursethat our employees have to take, which trains them in the proper way to dothings. We try very hard to improve as best we can. If you don't have the properenvironment, you can't guarantee what you are putting out."

A Model Policy

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

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