Contaminated surgical instruments pose a danger to patients and to an organization’s bottom line. In Part 1 of this two-part series, we discussed prevention strategies (OR Manager, April 2019, 14-15, 19). In Part 2, the focus is on investigating potential contamination, along with design considerations.
Despite best efforts, contamination of surgical instruments does occur. Investigations can be triggered by staff seeing visible bioburden on an instrument or by an uptick in rates of patient infections, says Scott Lucas, PhD, PE, director of accident and forensic investigation at ECRI Institute, Plymouth Meeting, Pennsylvania. “OR and sterile processing staff often blame each other, but a multi-departmental investigative team stops the blame game and focuses efforts on finding the source of the problem,” Lucas says.
The team typically includes representatives from administration, the OR, the sterile processing department (SPD), infection prevention, risk management, engineering, and facilities management. Team members examine six areas.
Policies and procedures. Policies and procedures should be specific, sufficient, and congruent with current guidelines, Lucas says. If they aren’t, they should be revised. Lucas adds that it’s best to have separate policies for instruments and endoscopes because each category has unique needs. He advises reviewing and updating policies on a regular basis and whenever any new equipment is added.
Compliance. Sometimes the best policies and procedures aren’t followed because of pressures such as time constraints. To assess for compliance, the team can review reprocessing logs for completeness, check biological indicator and test procedures and results, and conduct audits.
“It’s good to use peers to conduct some of the audits,” Lucas says. For example, staff can check a percentage of trays for proper processing. Supervisors can conduct random audits at various points in the processing cycle. Some instrument tracking systems may make it possible to link trays to the specific patients on whom they were used.
Staffing. Lucas says the team should ask, “Where are the bottlenecks?” because staff may cut corners in these situations. Bottlenecks may occur during a specific shift or in a specific point in the reprocessing cycle, such as the manual cleaning station.
It’s also important to assess staffing levels, what percentage of staff are from agencies, whether staff have had sufficient training, and how long it takes for staff to clean an instrument. (If cleaning takes a long time, it may be necessary to change the technique so that the instrument is still clean, but the time is reduced.) Lucas recommends that organizations commit to having an SPD supervisor on each shift to support staff and manage problems that arise.
Equipment. Lack of proper cleaning equipment can lead to inadequate cleaning of instruments. For example, enzymatic solutions need to be readily available in the OR for point-of-care cleaning. SPD staff need adequate sinks, sprayers, brushes, and other equipment for correct reprocessing of instruments. The equipment also needs to be cared for. “Be sure someone is cleaning equipment such as washers and sterilizers on a daily basis,” Lucas says. Regular inspection and preventive maintenance of equipment is also vital.
Technique. Team members should assess whether OR and SPD staff are performing manual cleaning correctly. “Staff need to strictly follow manufacturer recommendations for cleaning, disinfecting, and reprocessing, including using the proper cleaning tools,” says Lucas. OR staff may need to be reminded not to use saline for instrument cleaning, he notes.
To reduce the potential for contamination, SPD staff should wear long sleeves and not have beards. Staff also may benefit from access to videos and photographs showing proper technique. Sometimes the nature of the problem provides a clue to the solution. For example, wet packs are typically the result of a process issue such as insufficient drying time, which can vary by geographic elevation.
Systems issues. Examples of systems issues are insufficient inventory, poor communication, and managing vendors. Additional factors the team might want to examine are the use of multiple complex devices and failure to update physician-specific trays or devices.
Lucas says the team needs to determine what the debris is by sending it for analysis by techniques such as scanning electron microscopy and stereomicroscopy. The team should send the potential source of the contamination along with the debris to see if there is a match.
The physical work environment of the SPD plays a large role in effective instrument processing and, therefore, plays a critical role in preventing contaminated instruments. The three main areas are decontamination, clean setup (where staff assemble and wrap cleaned instruments to ready them for sterilization), and sterile storage.
SPD leaders who are fortunate enough to be involved in designing a new SPD should follow guidelines from national organizations, says Robert Maliff, director of strategic growth and business development at ECRI Institute (sidebar at right). Organizations should consider the number of ORs that will need support and the project numbers for each of the following: transport carts, daily instrument sets reprocessed, daily carts/container racks reprocessed, and daily surgical procedures. If using a case cart system, plan for a minimum of eight standard storage units per OR.
“It’s important to design for flexibility and adaptability to accommodate future expansion,” Maliff says. “Don’t try to squeeze sterilization into a closet.” Organizations should provide space and utilities for one additional instrument washer-decontaminator and one additional steam sterilizer. “Using stainless steel modular wall panels will help facilitate installation of future equipment,” Maliff notes. Security, such as controlled access points and video monitoring in strategic locations, should be incorporated into planning early in the process.
Given the high cost of major SPD equipment, SPD leaders need to take special care in choosing a brand. For example, Maliff says that the useful life of a cart washer is 15 years, with life cycle costs ranging between $250,000 and $375,000. Selection criteria include estimating the throughput demand for the cart, how well it disinfects surgical instruments, and whether water can be recycled. The useful life of a steam sterilizer is 15 years, with life cycle cost averaging about $200,000. In this case, selection criteria include internal or external steam sources, air removal (gravity/vacuum/steam flush/pressure pulse), throughput demand, and how much water is used.
Healthcare systems increasingly are centralizing services, which can make inter-facility transport challenging because of potential contamination from temperature and humidity changes.
“There aren’t any universal guidelines that specify an appropriate temperature range or humidity level for transport vehicles,” Maliff says. Organizations must be vigilant in testing for contamination and making modifications as needed. One option is to use climate-controlled trucks and log the temperature and humidity at each stop. Regular and thorough cleaning of the trucks to protect instruments from dust, dirt, and other contaminants is also important.
The most distressing result of “dirty” instruments is the effect on patients’ health. Ensuring proper processes are in place, providing staff training, investigating contamination, and designing SPD space to optimize workflow can all help promote optimal patient outcomes. For a best practices checklist, visit www.ormanager.com and click on Free Toolbox under the Resources tab. ✥
Cynthia Saver, MS, RN, is president of CLS Development, Inc, Columbia, Maryland, which provides editorial services to healthcare publications.
Chobin N. Dissecting the dirty instruments issue in healthcare facilities. Infection Control Today. 2012. https://www.infectioncontroltoday.com/sterile-processing/dissecting-dirty-instruments-issue-healthcare-facilities.
ECRI Institute PSO. Sterile processing department’s role in patient safety. PSO Navigator™. 2012;4(3):1-9. https://www.ecri.org/components/PSOCore/Pages/PSONav0812.aspx?tab=2.