June 22, 2021

No such thing as downtime: CSP renovation does not stop surgery

By: Barbara Underwood, MBA, BSN, RN, CNOR, CSSM

Many of today’s medical facilities have been modernized, but some still have areas of aging infrastructure. The central sterile processing (CSP) department at Cleveland Clinic Mercy Hospital in Canton, Ohio, is one such example. The original Terrazzo floor from when the facility was built in 1953 had become hazardous. The floor was hard to clean and slippery, and there were pits and ruts that caused carts and racks to get stuck and tip over, spilling contaminated instruments onto the floor.

The goal to replace the floor without shutting down surgical services was met largely because of excellent communication and collaboration between OR and CSP staff, as well as other stakeholders. Some of our challenges may be unique to our facility, but we identified some parameters that are common to any kind of renovation project.

The facility’s main OR has 15 surgical suites. The main OR volumes average 900 to 1,000 cases per month, with 45 to 55 cases daily; the case mix is spread across 15 specialty lines. Additional case volumes are generated from other surgical/procedural areas, including two open heart suites, two Caesarean section suites, two endoscopy rooms, two moderate sedation procedure rooms, and two minor outpatient rooms. The CSP department processes an average of 340 trays per week day and 94 trays per weekend day.

The decontamination area is where instruments and equipment from the main and satellite facilities are sorted, inspected, decontaminated, and cleaned. Items are manually cleaned before undergoing ultrasonic treatment and an automated washing process. The decontamination area at our facility also processes other items such as code carts, wound VAC systems, and ventilators.

We needed a durable, seamless, easy to clean, and non-slip floor surface. Evaluation of the floor surface, however, revealed no feasible method for the area to be operational during floor replacement or for the project to be completed as phased construction.

These images show the area around the sink before (left) and after new flooring was installed. Photos courtesy of Barbara Underwood, MBA, BSN, RN, CNOR, CSSM.


Crafting a plan

A multidisciplinary team effort and communication among all hospital departments and outlying facilities were essential for shutting down the CSP department for renovations. Key stakeholders included surgeons, anesthesia providers, CSP staff, OR staff, plant and engineering staff, and general contractors. A task force with representatives from each of these areas explored options for 3 months to determine how to maintain surgical volumes during the construction project.

We also assessed the facility’s physical requirements and limitations, equipment and instrument needs for the hospital and outlying facilities, workforce requirements, and effect on surgical instrument availability during construction. Extensive discussions with the flooring contractor clearly delineated access requirements and the amount of time needed to replace the floor.

Alternative decontamination sites within the facility were cost prohibitive.The processing area in the endoscopy department was identified as an alternative location to decontaminate instruments if needed in an emergency. Outside vendors, both onsite outsourced processing and offsite processing, were investigated.

After it became clear that onsite outsourced processing would be cost prohibitive, an offsite processing center located 2 hours by car from the hospital was selected to meet surgical volume needs for both individual items and surgical trays. To minimize expenditures, instruments would be returned clean, then assembled and wrapped by our own CSP staff. The inspection and assembly area of our current CSP area was reorganized to accommodate large loads of incoming clean instruments.

To minimize disruptions to the surgical schedule and other areas of the hospital, work was scheduled for a weekend. Extra staff would be scheduled on Thursday evening and night shifts, so that all instruments would be processed for the contractor’s start time of 6 am on Friday. The decontamination area would be unavailable for instrument processing from Friday morning until Monday evening.

These images show the air station before (left) and after new flooring was installed. Photos courtesy of Barbara Underwood, MBA, BSN, RN, CNOR, CSSM.


Implementing the plan

The floor contractor was onsite throughout the week before construction began, to have as much preparation work completed as possible.

Information regarding the construction plan and process was communicated to all stakeholders. To estimate surgical volume and prepare for down time, nurse team leaders reviewed the surgical schedule and assessed the needs of all service lines. Individual item and instrument tray counts were tabulated. Surgeons were notified of process changes for the project time frame, but no schedule adjustments were made.

Sales representatives were also notified that they needed to have all loaner trays onsite no later than Thursday morning prior to the start of the construction project.

During a site visit from the processing vendor, instrument flows were observed, tray and instrument volumes were reviewed, and staging areas and routes for carts with both clean and contaminated instruments were reviewed. A practice run was scheduled to allow truck drivers to become familiar with security procedures, parking, and cart routes for both clean cart delivery and contaminated cart pickup.

Daily pickup times were scheduled for mid-day and 6 pm, with a return run scheduled for 2 am. CSP staff flexed shifts to prepare instruments for the offsite facility and to wrap and sterilize instruments returned during off shifts.

Flexibility was key to success. Soon after the start of the surgical schedule, when instruments began to arrive in the staging area, it was evident that instruments could not be prepared for transport in a timely manner by the single staff member provided by the vendor. During times of high volume, multiple staff were needed to prepare instruments for transfer during scheduled runs.

Team members from both the CSP and OR departments flexed their schedules to accommodate instruments. OR service line team leaders and OR staff assisted CSP staff to ensure that all available instruments were ready to send for decontamination when the trucks arrived. Many adjustments were promptly implemented, such as the additional truck runs that quickly became needed as trays accumulated beyond scheduled run capacity.

CSP staff and nurse team leaders worked closely together to ensure that the necessary instruments were returned onsite and available for procedures. Many staff worked varying and extended shifts to efficiently prepare and/or process instruments and trays.

Additional improvements were made to walls, lighting, and sinks during the day Monday, and supplies were moved back into the area on Monday afternoon. Equipment was returned and stored for use with the first scheduled cases on Tuesday morning.

Staff were very excited about the elimination of floor hazards and smoothly rolling carts and racks. The new flooring also allowed for appropriate cleaning, which helped to improve infection control.


Key take-aways

The CSP decontamination area is vitally important, and it is challenging to perform surgical cases during a renovation. Lessons learned from this project will be applied when the rest of the CSP flooring is replaced.

In particular, our process could be improved with better record keeping of trays and instruments as they are bagged for removal and returned. Because of the quick turnaround time that was needed, multiple staff were involved in assisting, which reduced the accuracy of tracking. Our facility does not have the ability to scan instruments, which would have been beneficial in tracking instruments and trays.

One important step is conducting trial runs to identify potential problems and delays with planned interventions. When developing plans for renovation, success hinges on communication with stakeholders and continued flexibility. Through teamwork and the dedication of staff and leaders, our project was completed as scheduled, and no surgical cases were cancelled or delayed. ✥

Barbara Underwood, MBA, BSN, RN, CNOR, CSSM, is OR educator at Mercy Medical Center, Canton, Ohio.

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