Talking about flash sterilization

When it comes to preventing infection, perioperative professionals are at a crossroads. From one direction, regulatory agencies including the federal Centers for Medicare and Medicaid Services are instituting more stringent rules holding healthcare facilities responsible for surgical-site infections. From another direction, facilities face limited supplies and increasing pressures to handle more cases and reduce OR turnover time.

"Flash sterilization is the Band-Aid facilities sometimes use, but flash sterilization may be associated with increased risk of infection to patients because of pressure on personnel to eliminate one or more steps in the cleaning and sterilization process. In the end, resorting to flash sterilization may cause the facility more cost and put patients at risk," said Sheila Mitchell, RN, BSN, MS, CNOR, perioperative nursing specialist in AORN's Center for Nursing Practice and clinical editor of the 2008 Recommended Practices for Sterilization in the Perioperative Practice Setting.

"If facilities are using fl ash sterilization as a substitute for suffi cient instrument inventory, they may be putting patients at risk for increased surgical-site infection and may face a citation by The Joint Commission or other accreditation organizations," she advised.

Recognizing the challenges perioperative professionals face, AORN is working closely with The Joint Commission, the Association for the Advancement of Medical Instrumentation (AAMI), the Centers for Disease Control and Prevention, the Association for Professionals in Infection Control and Epidemiology (APIC) and others to ensure AORN's recommended practices and other guidelines are in line with accreditation and infection-control requirements from partner organizations. AORN is also working with partner organizations to better understand and measure the prevalence and practice of flash sterilization.

Advocating for safe flash sterilization practices
Because AORN's evidence-based standards and recommended practices are used by facilities to develop the infection prevention and control policies that are reviewed by accrediting bodies such as The Joint Commission, it is important for AORN to keep open communication with our partner organizations, said Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, a perioperative nursing specialist in AORN's Center for Nursing practice.

Giarrizzo-Wilson says heightened attention to preventing surgical-site and healthcare-associated infections has led to a focus on sterilization practices by healthcare facilities, AORN, The Joint Commission and APIC. According to members of APIC's Practice Guidance Council, "the issue of flash sterilization has become routine in most invasive-procedure areas . . . due primarily to the lack of systematic fiscal revenue management based on supply and demand. This flash sterilization approach to daily OR cases has become a contributor to several surgical-site infections, and has been noted by outbreak investigations published in the literature and from personal consulting experiences," the council told AORN Connections.

AORN recommends that "use of fl ash sterilization be kept to a minimum. Flash sterilization should be used only in selected clinical situations and in a controlled manner," according to Recommended Practice IV of AORN's 2008 Recommended Practices for Sterilization in the Perioperative Practice Setting, which are included in AORN's 2008 Perioperative Standards and Recommended Practices.

This recommended practice is in agreement with the recommendations included in the American National Standards Institute (ANSI)/AAMI ST79:2006 Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities. "We work to make the recommendations from organizations consistent so people get the same information no matter which document they refer to. However, AORN's recommendations are written specifi cally for the needs of the perioperative nurse," explained Ramona Conner, RN, MSN, CNOR, manager of standards and recommended practices in AORN's Center for Nursing Practice. Conner is co-chair of the AAMI workgroup that developed ANSI/AAMI ST79:2006.

Understanding the survey process
Last year AORN's Giarrizzo-Wilson submitted questions to The Joint Commission Standards group, which has resulted in ongoing dialogue between AORN and The Joint Commission regarding surveying flash sterilization practices.

Currently The Joint Commission offers ongoing surveyor training in infection control and sterilization methods, including flash sterilization, through a regular column in the organization's internal biweekly newspaper. This is in addition to the detailed and specific education in infection control and sterilization that all Joint Commission surveyors obtain, explained Louise Kuhny, RN, MPH, MBA, CIC, senior associate director-standards interpretation for The Joint Commission.

"We work with a variety of government agencies and professional organizations, including AORN, to understand what the latest guidelines are. By all working together in terms of recommending policy, our common goal is to reduce the risk for infections and increase patient safety," Kuhny said.

While The Joint Commission standards do not specifically address fl ash sterilization, this practice is included within the Surveillance, Prevention and Control of Infection Standard of the accreditation organization's Comprehensive Accreditation Manual for Hospitals. It is listed within standards IC.2.10, IC.3.10, IC.4.10 and IC.5.10., which are grouped into four basic categories: risk assessment, goals and objectives, intervention and evaluation. Kuhny added that "interventions need to be based on relevant scientifi c guidelines for infection prevention and control activities, including those offered by AORN."

Evaluation is a critical step in this compliance program, she emphasized. "Facilities need to have a data-driven process to make sure what they do is working."

Focusing on measurement
The emphasis on evaluation to measure the prevalence of fl ash sterilization is also a current focus for AORN and researchers at The Joint Commission, according to Nancy Kupka, DNSc, MPH, RN, project director in The Joint Commission's department of health services research, division of quality measurement and research.

"Flash sterilization is interesting because it has been around for so long. People just assume there isn't a problem with this sterilization method, but our surveyors say fl ash sterilization continues to be a problem, due to breaks in sterile process ranging from inconsistent use of fl ash sterilization to improper cleaning of instruments before sterilization and improper use of biological indicators," Kupka said.

Surveyors are expected to evaluate areas where anesthesia is administered, so fl ash sterilizers in operating room areas are often included in a survey, Kupka noted. "When surveyors talk to OR staff about fl ash sterilization, they are likely going to note any inconsistencies between what staff say and what an OR flash sterilization log shows."

All facilities need to be keeping an accurate, detailed record of fl ash sterilization activity. This is particularly important for ambulatory surgery centers because "the frequency of fl ash sterilization goes up in smaller facilities with tighter budgets," stressed AORN's Giarrizzo-Wilson.

While there are currently no national benchmarking data established for fl ash sterilization, AORN recommends that facilities should be benchmarking internally within their facilities because they need to know why they are flashing, particularly if they are flashing on a routine basis.

At a minimum, Giarrizzo-Wilson recommends that facilities need to document the following:
• Patient's name
• Surgery or procedure performed
• Item(s) and number fl ashed
• Exposure time and temperature

"Keeping accurate records for fl ash sterilization helps to build internal benchmarks needed to evaluate how frequently the process is used and determine the need to change existing practices," she stressed.

Giarrizzo-Wilson also encouraged members to enter their flash cycle data into AORN's Perioperative Nursing Dataset (PNDS) Dashboard by visiting, aorn.org/ PracticeResources/PNDS/PNDSDashboard/.

"Providing this information can help AORN contribute to a national benchmark for flash sterilization, which can provide all perioperative professionals with an evidencebased understanding for how often fl ash sterilization is being used in the perioperative environment," Giarrizzo-Wilson noted.

Tracking prevalence
In addition to focusing on benchmarking, AORN is also working with The Joint Commission's Kupka and Marguerite Jackson, PhD, RN, FAAN, chair of the APIC Scientific Research Council, to propose a study on the prevalence of flash sterilization in hospitals.

"We are all involved in infection prevention and interested in developing strategies that will help decrease surgical-site infection and promote infection prevention and control," acknowledged Joan Blanchard, RN, MSS, CNOR, CIC, perioperative specialist in AORN's Center for Nursing Practice.

The proposed survey, which is still in development, will query hospital staff about a number of issues related to fl ash sterilization, including when and why this sterilization method is being used, who is training for and practicing flash sterilization and what instruments are being flashed, said Kupka.

"Is flash sterilization being done for legitimate reasons, such as dropping an instrument? Or is it being used because a facility does not have enough instruments in their inventory?" she wondered. "Nobody really understands to what extent this is a problem. We suspect the reasons why, but this proposed study will give us the first opportunity to quantify what is going on."

As AORN continues to work with APIC, The Joint Commission and other partner organizations to help facilities increase awareness and gain a better understanding for flash sterilization practices, Blanchard hopes perioperative professionals will be encouraged to interact more with infection control professionals in their own facilities.

"Infection control professionals have the latest information on infection control guidelines and measurement, which perioperative professionals can use to establish best practices for flash sterilization and other infection control practices," Blanchard advised.

"As perioperative professionals face increased challenges to prevent and control infection, it is more important than ever to establish open dialogue with infection control professionals. These partnerships can help each us to provide positive outcomes for safer patient care."
  
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