Reducing immediate use steam sterilization (IUSS) can be challenging, but adhering to standards is essential not only for patient safety, but also for successful accreditation surveys.
“Accrediting organizations are hitting hard on all of sterilization, but especially IUSS,” says Rose Seavey, MBA, BA, RN, CNOR, CRCST, CSPDT, president and CEO of Seavey Healthcare Consulting, LLC, in Arvada, Colorado. “On surveys, CMS [Centers for Medicare & Medicaid Services] realized that many facilities were relying on IUSS too much and weren’t performing it adequately.”
Many OR leaders have taken a closer look at IUSS, including those at Cedars-Sinai in Los Angeles, where a task force was able to reduce instrument IUSS rates from 23% of total surgical cases in 2015 to less than 5% in 2016.
Dan Sabin, MSN, RN, CNOR, education program coordinator at Cedars-Sinai, recently shared how the task force was able to achieve these results. Nearly 40 OR suites are spread over six floors at the hospital, with each floor dedicated to a particular specialty.
“It all starts with creating a task force,” Sabin says. “People need to come together to collaborate.”
Members of the task force included representatives from performance improvement, infection prevention, sterile processing, and the OR.
“We had leaders, educators, and staff members who are in the trenches and know exactly how processes are happening,” Sabin says.
Initially the team met every week for about a year, and it still meets every 2 weeks to sustain improvements.
No national benchmark for IUSS exists, so most organizations divide the number of IUSS incidents by the number of cases over a month as a way to track trends. Organizations can then drill down to more detail by analyzing factors such as types of instruments, types of procedures, specific surgeons, and time of day.
One of the most important factors to analyze is the reason for IUSS. “We brainstormed and we looked at standards, the research, and our own data,” Sabin says (sidebar, below).
The team also assessed vendor compliance with maintenance and delivery of loaner and replacement instruments, investigated how surgeon requests were handled, examined how the sterile processing department (SPD) organized and returned trays to the OR, and got input from nurse supervisors.
The most common reasons for IUSS were:
• insufficient instrumentation
• inadequate prioritization
• increased rates of bioburden
• lack of gatekeeper approach
• inadequate surgeon requests
lack of vendor compliance.
The team took several steps to address these issues, many of which could be applied in other ORs.
Staff at Cedars-Sinai already had to complete a form each time IUSS occurred. Seavey recommends facilities include the following documentation on these forms: type of sterilizer, type of cycle used, lot control number, load contents, critical parameters for specific sterilization method used, the operator’s name, results of the sterilization process monitors, and the reason for IUSS sterilization.
At Cedars-Sinai, the team revised the form to include the following reason codes:
• not enough trays/single instrument (for the current case)
• unique/one of a kind instrument (the surgeon could not use a substitute instrument)
• contaminated in the OR (eg, instrument dropped on the floor)
• arrived contaminated from sterile processing (eg, no indicator, wet tray).
The team also added a gatekeeper—an OR nurse supervisor who reviews and signs the form to approve each IUSS. “That’s just to make sure all other avenues have been exhausted before IUSS and also to make sure that we’re gathering adequate data,” Sabin says.
Another documentation strategy was use of a color-coded instrument tagging system, which was designed to identify:
• quick turnover/same-day need (eg, eight ankle procedures are scheduled, but there are only six trays available for use)
• priority: needed the next day
• instrument missing
• item needs repair or is broken
• loaner item (vendors use this tag for the trays they provide).
A blank black tag is use for single instruments that are to be kept separate as a special peel pack.“The tags can go through the washing and sterilization process, and each team member knows exactly what is happening with that tray,” Sabin says. “This has really helped facilitate tray turnover.”
The nurse supervisor of each specialty floor worked with SPD to create a priority list of which trays would need to be returned on a regular basis because of frequent use.
For example, the orthopedic floor needs power tools and osteotomes to be available on a daily basis.
“Creating the lists helped sterile processing know which trays are used very frequently, so they could be bumped up in processing,” Sabin says.
A more detailed surgeon request form, submitted ideally 3 to 7 days before surgery, is a better way to identify instrument needs, so they can be obtained earlier in the process. The form is tailored to the specialty, so, for example, an orthopedic request form is different from a gynecologic surgery request form. The surgeon’s office staff completes the electronic form, which is sent to the OR, and from there to SPD.
To gain buy-in from the office staff, Sabin says, the hospital invited them to an onsite meeting to explain what was needed and why. “We gave them contact people if they had questions about a particular surgery, to encourage the flow of communication,” Sabin says. The contact information is also printed on each form.
Seavey adds that it’s important to consider instrument availability when scheduling cases.
“If you are going to schedule back-to-back cases, you need to be sure you have enough of those instruments to terminally sterilize, which could take up to 3 to 4 hours,” she says. OR leaders need to know when to purchase additional instruments to avoid IUSS.
“Vendor oversight was a big task,” Sabin says. “The bottom line is that vendors should have their instruments here between 24 and 48 hours prior to surgery.”
In the case of emergencies, SPD staff photograph the instruments and complete a form that includes what was delivered for which surgery and when it’s needed. The instruments then get pushed to the front of the line.
Each vendor received education about expectations and guidelines. For example, guidelines for loaner trays include the following:
• Vendors must provide an in-service for SPD staff on loaner trays not previously seen, before they are used in the OR.
• All vendors are required to supply a tray menu and sterilization parameters for each loaner tray provided to Cedars-Sinai. The vendor representative or designee and SPD staff reconcile each tray using the tray menu or SPD-provided photographs.
• All vendors must include the manufacturer’s recommended sterilization parameters for each tray.
• The vendor representative/courier is required to document delivery and pick up in the log form provided by SPD.
The team kept OR and SPD staff informed about any changes in processes and the reason behind each change. Orientation now includes increased emphasis on the care and handling of instruments at point of use, in the OR.
For example, surgical technologists know they must continually rinse instruments with sterile water, flush cannulated instruments, keep instruments organized, and, after the case, spray instruments with an enzymatic gel.
“That makes it much easier for staff in sterile processing to process the instruments and get them back in an orderly fashion, without bioburden that results in an IUSS,” Sabin says.
Seavey also recommends conducting regular audits to ensure proper procedures are followed (see Immediate Use Steam Sterilization Audit Checklist in the Toolbox at www.ormanager.com).
“A lot of reducing IUSS has to do with creating awareness throughout the organization and with team members,” Sabin says. “You need to build a strong relationship between the OR and SPD.” ✥
Cynthia Saver, MS, RN, is president of CLS Development, Inc, Columbia, Maryland, which provides editorial services to healthcare publications.
AORN. Guidelines for perioperative practice. Sterilization. Denver, CO: AORN, 2015; 665-692.
Centers for Medicare & Medicaid Services. Change in terminology and update of survey and certification (s&c) memorandum 09-55 regarding immediate use steam sterilization (IUSS) in surgical settings August 29, 2014. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-44.pdf.
Denholm B G. Calculating flash sterilization rates. AORN J. 2011;93(2):296-297.
Sabin D. Reducing immediate use steam sterilization (IUSS). Poster. AORN Surgical Congress & Expo, 2016.