May 14, 2020

Is your SPD ready for a post-COVID world?

By: Derrick Bransby, MBA

While responding to demands of the COVID-19 pandemic, perioperative leaders are busy preparing staff and departments for life after the initial shock subsides. Chief among their preparations are strategies to address the glut of demand for surgery due to postponement of elective and nonessential surgical procedures. Naturally, many focus on creation of capacity in the OR—expanding hours, increasing utilization, redistributing blocks, and otherwise aligning demand with capacity. However, to realize the full potential within each plan, leaders must look beyond patient-facing elements of the system to those that lie in the background and often, quite literally, under their feet.

Sterile processing will play a critical role in addressing the elective surgery backlog. Its capacity, or lack thereof, to wash, disinfect, assemble, and/or sterilize surgical instruments and medical devices directly affects the ability to realize capacity in the OR. Without instruments, surgery cannot proceed, and even the best laid recovery plans will halt. Hence, sterile processing personnel will face enormous pressure to keep up with the pace of their colleagues in the OR. Perioperative leaders must take time to think critically about variables that govern the capacity of sterile processing to support strategies for recovery and take down barriers that prevent it from realizing its full potential.

Recognize and address resource constraints

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Addressing resource constraints in the sterile processing department (SPD) is no small task. Unfortunately, qualified technicians are in short supply, and adding equipment, at least in the short term, is impractical. Even facilities with unused or underutilized capabilities may find themselves stretched thin as they are required to process the personal protective equipment (PPE) necessary to treat COVID-19 patients in addition to instruments for the OR. Therefore, it is imperative to think critically about existing conditions, recognize constraints, and plan accordingly to make best use of limited resources. Consider an assessment that includes the following:

  • Take inventory. Identify the quantity, type, and condition of equipment and staff in sterile processing facilities. Consider resources in nontraditional locations such as those in the OR.
  • Locate bottlenecks. Determine the nature and location of probable bottlenecks. Brainstorm solutions that address the root cause(s)—resist the urge to treat the superficial wound!
  • Address constraints. Where possible, address constraints through improvements to facilities and processes. Where unaddressed, make plans for temporary storage of work in process.

 Like many of her colleagues, Nancy Doraiswami, BSN, RN, CGRN, CRCST, CFER, director of central processing operations at Beth Israel Deaconess Medical Center in Boston, has used downtime in the weeks since postponement to prepare for life after the pandemic. Aside from updating technician competencies, Doraiswami and her team have taken advantage of the lull in cases to catch up on projects, reorganize workspace, and even upgrade equipment.

First, the department focused on immediate needs related to disinfecting PPE and other devices used to treat COVID-19 patients. Early on, this meant clearing space and relocating hydrogen peroxide sterilizers to an area suitable for reprocessing N95 masks. In addition, the department created a section for disinfecting and repacking stethoscopes used in the hospital’s isolation units. Though PPE operations have shifted to large-scale disinfection systems brought in especially for that purpose, the department stands ready to assist if needed.

“We know we’ll need to move quickly when elective cases resume,” says Doraiswami. To that end, technicians have checked, wrapped, relabeled, and sterilized sets to ensure they are ready to support the OR when ramp-up begins. The department also took time to clean, organize, and relabel shelving within sterile storage and various locations in the OR. Finally, the leadership team took advantage of the lull to shut down one of three SPDs to install a new instrument washer/disinfector, replace a sterilizer door, and create a new high-level disinfection area. The team hopes investing in its staff and work environment will pay dividends when elective cases resume. Like Doraiswami, perioperative leaders must take a proactive stance toward preparations for the future.

Right size and redeploy instrument inventory

Considering capacity as a function of inventory feels unnatural to some, but it could be the difference between success and failure. Leaders must establish a clear understanding of inventory and consider it as a constraint as scheduling strategies are developed. Instrument inventory need not be a barrier; think creatively about solutions that expand capacity locked within the instrument fleet:

  • Repurpose sets that are underutilized and/or used for cases that are not a priority.
  • Use downtime to repair or otherwise complete sets that are out of circulation.
  • Modify sets to support a wide variety of cases, perhaps through the addition of a peel pack.
  • Relocate sets from facilities that have not fully reopened, perhaps a surgery center.
  • Work with surgeons to develop a list of suitable substitutes if needed in a pinch.

Purchasing additional instruments remains an option, but one that should be considered carefully. Purchase of instruments solely to increase capacity in the short term could very well constitute a waste of cash if demand returns to pre-pandemic levels shortly after recovery is achieved. Perhaps even more so than before the pandemic, planning with foresight and patience is essential.

Set expectations and coordinate resources

“When SPD is rushing to get things done, quality suffers, and risk of a sentinel event increases,” says Dwayne Taylor, PA-S, CST, CFA, CRCST, CHL, CIS, CFER, ACE, director of sterile processing and distribution at Cincinnati Children’s Hospital Medical Center in Cincinnati. “Realistic expectations as to what it takes to get instruments ready for use are key to keeping our patients safe and healthy,” says Taylor. In his opinion, using downtime to educate OR staff on sterile processing workflows and the effort required to produce a high-quality product will pay off when elective cases resume. Invite surgeons, nurses, scrub technologists, and administrators to the department. Explain the flow of instruments. Answer questions about equipment and cycle times.

“Explain the importance of pretreating and sorting soiled instruments, even little things like keeping instruments free of gross contamination during the case, that speed workflows in the SPD,” says Taylor. Keep lines of communication open, agree on expectations, and establish service level agreements prior to extending hours and increasing utilization in the OR.

How does this pandemic compare to recovery from Hurricane Harvey in 2017? “The length of COVID is unique. It’s hard to compare a recovery measured in weeks to something we expect to last for months,” says Travis Tingle, BSN, RN, CRCST, director of sterile processing at Houston Methodist Hospital in Houston. In his opinion, ramp-up will be slower than after Harvey given the limited access to common supplies like surgical gowns as well as the need to disinfect PPE for isolation units. However, Tingle believes that in this crisis, just as during Harvey, daily communication is key.

From the outset, leadership recognized that clear and repetitive communication was vital to a successful response in this crisis. Houston Methodist achieves such communication through daily web conferences, facilitated by an incident command, between sterile processing, supply chain, and all departments planning procedures. Such a forum provides stakeholders with a regular opportunity to voice concerns, address challenges, and share solutions.

Preparing for life after COVID-19

Sterile processing personnel will face enormous pressure in the coming weeks and months as facilities across the country increase utilization, extend business hours, and even shift to 7-day operations in an attempt to address the elective surgery backlog. To ensure such strategies are successful, perioperative leaders should consider the role of sterile processing and take action to bring down barriers that may prevent it from fully supporting the OR. Such actions include:

  • Determine the nature, location, and root cause of probable bottlenecks. If the SPD is understaffed, consider hiring qualified agency technicians. Time to train new employees will be limited.
  • Address constraints through improvements to facilities and processes. Where unaddressed, make plans for temporary storage of work in process and plan for inefficiency.
  • Consider capacity as a function of available inventory as scheduling strategies are developed. Repurpose and/or refine underutilized sets, and relocate sets from facilities with low volume.
  • Set clear expectations for how quickly sets can be turned over between cases. Educate the staff on best practices that speed workflows within the SPD.
  • Create a forum for clear and repetitive communication between sterile processing and its customers. Encourage stakeholders to voice concerns and collaborate on solutions.

For better or worse, future profitability—and even the very existence—of many hospitals will depend on actions taken by leaders in the days and weeks to come. How well we learn from our shared experience, and what we do today in preparation for the future, will no doubt affect our eventual success, or lack thereof. Use this time to challenge organizational, operational, and clinical services strategies that have left us susceptible to the effects this pandemic, think creatively about how to improve, and take action to address constraints that prevent your department from realizing its full potential.

Derrick Bransby, MBA, is senior manager of healthcare operations strategy and analytics at St Onge Company, York, Pennsylvania. He specializes in application of industrial and systems engineering to perioperative systems in areas such as flow, scheduling, and capacity planning.


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