Our same day surgery unit has 10 ORs and three flash autoclaves in substerile rooms between sets of ORs. One flash autoclave is for rooms 1 through 4, another for rooms 5 through 8, and the third for rooms 9 and 10. When the unit opened in 1982, this configuration worked. Most of the cases were lumps-and-bumps and other minor procedures, and the instrument inventory matched the unit's needs quite well.

But anesthesia now lets us do longer and more complex procedures, such as orthopedics, greatly increasing the demand for flashing. We took the usual tacks of increasing instrument inventory and updating the flash autoclaves themselves, but the unit's needs were still straining the machines - up to five or six cycles per day. When an autoclave goes out of service, we use flash packs to flash and transport instruments, but when two flash sterilizers recently went down, one after the other, we saw that what we really needed was to update our flash sterilization policies and our OR staff's training for them. We focused on three areas.

1 Use and care of the flash autoclaves
First and foremost, we reviewed the appropriate times and pressure for flash sterilization. While there are several models of manual and digital autoclaves located in our surgical suites, all operate on the same principles, and therefore are set according to the needs of the item being sterilized: five or 10 minutes, depending on whether the item has a lumen or tape. Some manufacturers require 55-minute cycles on their devices. Posting a list of devices that fall outside the usual parameters and their flashing requirements at your machines can help minimize any confusion that may arise. We posted on a bulletin board key points from our policy statement on use and care of the flash autoclaves:

• Complete daily biological testing and document it on the flash log.
• Central processing cleans the autoclaves weekly.
• The SDSU has digital read-out autoclaves. Staff collect the previous day's read-outs when the daily biological is done at the start of the day and file the read-outs with central sterile.
• For all flash autoclaved loads, record on a log the patient's name, medical record number, load contents, exposure time and whether the post-cycle parameter was met.
• Record per policy medical implants that are flash autoclaved. (More on that very important and specialized policy in a bit.)
• If there are problems with the autoclaves, we have a designated route of action. Our clinical engineering department is the first place we call for repair and follow-up.
• If the flash autoclave has been repaired or adjusted, it must complete two sequential cycles with negative biological indicator results before you return it to routine use.

Some staff didn't know that the sterilizer needed to undergo this validation after servicing. Thanks to our bulletin board, nurses and techs responsible for operating the flash autoclaves got a briefing on the information needed on the log for each load, with a sample of an acceptable indicator and a completed log, a picture of how instruments should look when properly placed in the flash sterilizer and a sample of the autoclave printout.

2 Daily biological run
You must know whether flash cycles are working. For quality assurance purposes, staff must complete and document daily biological testing of all autoclaves. We reviewed proper use of biological indicators (regular and rapid reader) and the procedure to undertake if the quality assurance rapid biological indicator has a positive readout after one hour. Some things that have worked for our SDSU:

• To ensure proper function of each autoclave and to be able to identify a possible malfunctioning specific autoclave, every workday we run a rapid reader biological, marked with the date and flash sterilizer number, for all autoclaves in the SDSU.
• A biological indicator is placed in a perforated instrument tray on the bottom shelf of the autoclave. Put the tray directly above the drain hole in the front of the autoclave to simulate a flash cycle in the coolest part of the autoclave.
• Run the cycle at 270' for five minutes at 30psi. Our flash autoclaves kill spores in five minutes at 270'.
• After the cycle is complete, remove the biological indicator from the sterilizer and let it cool for 10 minutes to allow for gradual temperature variation.
• Place the biological indicator in a towel to prevent it's being exposed to cold metal surfaces, which may alter the results, and immediately take it for incubation to the instrument room, the central location for incubation of all biological indictors.
• Instrument room personnel contact the OR team leader or charge nurse if, after one hour, the biological is problematic. If this occurs, run a second biological indicator and take the autoclave out of service until you obtain the results. If a second positive result is obtained, the team leader or charge nurse is responsible for shutting down the autoclave and contacting the biomedical engineering department so that extensive checking of the machine may be done.
• As recommended by AAMI, instrument room personnel document in a log the results of the tests for each autoclave.

3 Flash sterilization of medical implants
The systems our very active hand surgery department uses come with the implants in the same box as the equipment, which sometimes means that the same systems are required in back-to-back cases. So we developed a policy regarding the flash sterilization of medical implants - a practice that should be kept to a minimum - for those rare occasions when it's necessary to flash sterilize them. Principles behind this policy include:

• Properly and thoroughly decontaminate implants or instrument kits with implants according to manufacturer guidelines and the instrument room's policies and procedures.
• Flash implants for 10 minutes. Place a biological indicator with the implant. Never flash a medical implant with other kits. Follow protocol for biological indicator follow-up (let instrument room staff know that you need results as soon as possible, because the BI is from an implant).
• Once the cycle is done, remove the implant and isolate it on a separate sterile field until the result of the biological indicator is known.
• Instrument room staff should call the OR with the results at one hour and document the patient's name, MRN, surgeon, date, time and item flashed. Instrument room staff document the test results in a log in the instrument room.
• If the surgeon elects to use the implant before the results of the biological indicator read out are available, inform him that protocol calls for isolating the item until the results are read. If he still wants to continue, document on the perioperative record, "Implant used before reading of one-hour biological indicator."
• If the biological indicator results are positive at one hour, sterilize the implant again. If it was implanted, however, the circulator must complete an incident report. If the 24-hour biological indicator results are positive, the instrument room personnel should inform the appropriate team leader, who will inform the surgeon by phone and in writing, then complete an incident report.

Keep it safe
Done properly, flash sterilization is a safe and convenient way to reprocess in an emergency or when you need an item immediately. Remember, though, that flashing should be used only when there is insufficient time to sterilize an item by another acceptable method; should be performed under strict supervision, in compliance with your protocols and accrediting bodies' recommendations; and should be painstakingly documented.