Sterile Processing Unscripted: Know When to Innovate

The US health care system was caught off guard when COVID-19 was declared a worldwide pandemic in March 2020.¹ Infection preventionists and other health care professionals had to innovate in a hurry, the most obvious example being how to deal with the lack of N95 masks.²
Among the frontline workers who had to make do with what they had were sterile processing professionals. IAHCSMM held its annual conference virtually last month. One of the presenters was Berg, who was president of IAHCSMM’s board of directors in 2018 and 2019 and is now the organization’s vice president for strategic initiatives. The presentation by Berg and Amanda
Benedict, vice president for standards for the Association for the Advancement of Medical Instrumentation (AAMI), was titled “Sterile Processing Unscripted.” Berg spoke to Infection Control Today^® before his presentation about the innovations that sterile processing professionals had to come up with to function during COVID-19’s first wave.

Infection Control Today^®:“Sterile Processing Unscripted.” What’s that all about?

Damien Berg, IAHCSMM Vice President for Strategic Initiatives: It’s great. I do want to give a shout-out to my copresenter, Amanda Benedict, the vice president for standards at AAMI. She and I had this conversation a long time ago….during the first COVID-19 wave. There were several things going on, like reprocessing of N95 masks. They asked sterile processing departments to process 3D-printed items that I have never used and there are no standards that cover this stuff. There were a lot of things that happened during the COVID-19 time during the [FDA’s Emergency Use Authorization (EAU) act] that were confronting sterile processing professionals like myself. I manage a department for a large health care system and when I tried to reference standards—I have been part of the [American National Standards Institute and the AAMI] standards committee for 16, 17 years—I couldn’t find anything. And on the AAMI side, Ms Benedict, she was getting calls, emails, and questions from [individuals] like me asking: “What do we do when, basically, the standards don’t match the reality of what the world’s going through right now? How do I do it?” We said it’s sterile processing unscripted because we’re dealing with something that doesn’t have a script. We’re doing something that doesn’t have a [standard attached to it]. How do we do that? How can we create a pathway moving forward, so that whatever hits us next, it’s not this panic scenario on our part?

ICT^®: Can you give an example of how this might work on the ground?

Berg: A good example is recently in Louisiana when we had the hurricane and there was immense flooding, power outages, and water outages. What people don’t realize is that in hospitals when the city water goes out, how are you getting your steam? How are you getting your water to wash things? How are you handling that? There is no blueprint or anything to cover that. So, we wanted to say, when the water turns back on, how do you boil the water when you’re drinking water from the boiler? Water that you sterilize or wash your instruments with? We wanted to create blueprints for [individuals] to pick up and go so they don’t have to think on the fly. We want to give the leaders of either AAMI or IAHCSMM a tool to move forward with. That’s our presentation. We’ve got different areas we’re talking about: on the regulatory side, how standards are made and the rigor behind them. Then I’m going to talk about how that impacts the end users and my members and how they use those devices. Then, what are some examples when nothing matches either the education and/or the regulatory side? What do we get?

ICT^®: You mentioned hurricanes and the electricity going out. I imagine that AAMI and IAHCSMM already had protocols about what to do in emergencies. Was COVID-19 just something so unusual that they didn’t apply?

Berg: Most facilities have emergency operation plans. But it’s tough to write a standard or metric. You can be educated on certain points. Honestly, with COVID-19 and Emergency Use Authorization, that changed the dynamic. Never in modern history can I remember being allowed to do things that we would never have been allowed to do before. Again, I use that idea of reprocessing the N95s or reprocessing [personal protective equipment]. We were [previously] just told, “No, you can’t do that.” Once that was allowed, then other things happened. We were approached by the end users about all kinds of [methods]. “Well, hey, what about using this now, but you can’t do this.” You open the door for it. Now you can do this. The industry people love it. This is where I think back to the Industrial Revolution and those times when America was creative, creating stuff nobody ever saw or thought of. People in the industry were really being creative with 3D printing and/or coming up with new devices to substitute shortages in the supply market, that we’ve never seen before. There literally were no standards to develop around that or education around it. They basically kept saying, “Why can we do it with the N95 mask and not with this?” We wanted to talk about that and say, “This is the way we need to address this moving forward.” And industry…it is awesome that people are thinking outside the box to solve [problems] in the real world. But we also want to make sure we’re doing it safe for the patients and the providers using these devices that we reprocess. Also, it’s reproducible. I can almost guarantee that I can sterilize and clean anything once. Can I do it multiple times with the same efficacy? That’s the rigor you need to put behind this. It’s like giving your kids permission to do something, and then you say, “Sorry, never mind. You can’t do that now.” And they’re like, “Wait a second. You can’t tell me I can do it, then tell me I can’t. You can’t say it was safe for me, and now it’s not safe. What’s the difference now?”

ICT^®: It sounds like you’re talking from painful experience here.

Berg: Yes, sir. Also, one thing I didn’t tell you, and it’s something about me. I also spent 21 years in the military as a combat medic and [found myself in] multiple adverse conditions where I didn’t have things I needed. Sometimes you just improvise. We make it happen. I’m used to doing that. I came from that same thought process and mindset. The difference is I was—with reaching out to industry experts and standards and my background—able to show that we put some rigor behind doing it. We just didn’t listen to the noise out there. We didn’t listen to everybody saying, “Just do this” and run around like Chicken Littles shouting that the sky is falling. We did testing on N95 masks. We did documentation. I was able to track every mask to every reprocessing cycle to every end user and the number of times….The steps are so if there ever was an adverse event or outcome later, I was able to trace it back. But I also said at a certain point, we need to stop doing this because the supply chain will be back to normal, which it is in certain spots. It’s still wavy. But it has created that pull/push from the end users saying, “Well, I got this pin and I’m going to go and sterilize like we did with the N95s.” We have to say, “Well, that’s just not how we do things. Right now, we’re following policy, because there are no emergencies.”

ICT^®:You mentioned that you were a medic and I want to thank you for your service. You have to be a special kind of person to be a medic.

Berg: During the presentation…I’ll be using some of those real-world examples. There were things you just had to do, because you didn’t have an option and you had to go through with it. It was about explaining the “why.” So, the N95 masks—we literally knew our burn rate for them. And if we did not move—and we use UV light reprocessing at my health care facility—if we did not do that, the “why” would be that we would run out of masks in 5 days. That was our approach—thinking outside the box, using research from other institutions that are well renowned and had some stuff done to say, “OK, this is how we’re going to do it.” We got a multidisciplinary team together to come up with a process and the “why” behind it. “Why” wasn’t because we just wanted to do it, but because if we didn’t do it our care providers and our patients and we wouldn’t have N95 masks when we were treating the first wave of COVID-19. We really had to say: “This is the call to action.” On the military side, I’ll give a graphic example. I was in the field for a unit and I did not have surgical gloves or sterile instruments. I had to go inside someone’s inner body cavity with my bare hands and instruments that I sterilized on my own to stop the bleeding. The “why” was if I didn’t do that, that person would die. What would impact a patient greater: Me not having sterile gloves and me getting exposed to their blood, or me just saying I don’t have them so I’m not going to do anything? You must make choices. Those are 2 extreme examples. When I have to do things in this world now, I always use the old method. I check my pulse, and if I have a pulse, then I can calm down and move on. I don’t get too excited about things anymore. I just think through them differently. That’s unscripted, because you’re going to have those unscripted moments where you can’t wait for the regulatory folks to say, “Do this.” You’ve got to use some common sense but also your science and background and then do what we call in the military an action review. You look backward and say, “OK. What did we do? Why did we do it? How do we do it? And do we need to change anything on why we did it?” I think the same thing really applied to this road map. I had some [individuals] do some soul searching and ask: “Do I really want to do this profession anymore?”...The level of stress that they went through, they probably never experienced in their lifetime. There are different levels of stress and [individuals] handle it differently. They’re just kind of soul searching, saying “Is this really what I want to do? Am I close to retirement? Should I just retire? Or do I switch career paths and do something different?” That’s fine for everybody. I look back and think, “Boy, we did some innovative stuff.” I’ll give you some good examples. Where sterile processing really was—and it’s still holding true; it’s a byproduct of COVID-19—we were looked at, because we’re the cleaning disinfection and sterilization experts in the facilities….People didn’t really know that. COVID-19 put a light on sterile processing professionals in a positive way. We became a force multiplier in the hospital by the things we did. And we got known. We got asked more questions about: Is this contact time right? What’s the dwell time? What’s the chemical ratio? They didn’t know what dwell time was prior to COVID-19. Not the masses. They didn’t know what contact time was. They just did their thing. But now they rely on us as subject matter experts. To me, that is a longer-lasting thing to keep me in the profession vs the small lap or the stressful intense time of the first wave…. Now we’re dealing with multiple smaller waves that are hitting, but we’re using those lessons learned. That passion for what we do is to keep moving forward.

ICT^®: Is there something that I neglected to ask that you think is pertinent and you want fellow health care professionals to know?

Berg: Great question….Years ago, I joined the military at 17, and wanted to be a combat medic, and I did surgical tech and flight medical. I did sterile processing in the military, but I never thought that was my calling. When I transitioned to the civilian side—I’m still in the National Guard—I found sterile processing to be an honorable profession that does impact patient care, and you are appreciated. You need to know that. To the sterile processing people out there: Know that you do make a difference. Everything you do touches a patient’s life, and thus the families and thus the surgeons and thus the hospital community. We do make a difference. You are appreciated. You’ve got to know that. You’ve got to soul search that, and be proud of it by getting certification, by knowing your standards, and by being engaged in your community. That’s by far what I want to leave you with.

This interview has been edited for clarity and length.

References:

1. Kavanagh K. Viewpoint: US woefully unprepared for COVID-19 pandemic. Infection Control Today®. March 11, 2020. Accessed September 30, 2021. https://www.infectioncontroltoday.com/view/viewpoint-us-woefully-unprepared-covid-19-pandemic
2. Diamond F. Survey: many hospitals have only 10-day’s-worth of N95 masks left. Infection Control Today®. March 26, 2020. Accessed September 30, 2021. https://www.infectioncontroltoday.com/view/survey-many-hospitals-have-only-10-days-worth-n95-masks-left