When done correctly, flash sterilization is a safe and effective process for emergency or unusual situations. But it shouldn't take the place of standard wrapped sterilization or serve as justification for keeping fewer instruments on hand. And as the following incident illustrates, it shouldn't be performed by staff who don't know the fundamentals of flash sterilization.

The printout clearly said "abort"
A hand surgeon came to our hospital and brought his own specialized instruments for a skin flap procedure. He asked the nurse to sterilize them. The nurse put the instruments in the flash pan and put it in the sterilizer on a 4-minute, pre-vacuum cycle.

About 10 minutes after the cycle was finished, the nurse took the flash pan to the OR, where the scrub technician put the instruments in the sterile field for use during the procedure. Meanwhile, the nurse wrote the names of the instruments, the surgeon's name, room number, case number and her name on the sterilizer printout.

The surgery ended uneventfully and the patient went to the PACU. However, the next day we had to tell the surgeon that the cycle used to sterilize the instruments for his patient had been aborted because it didn't meet all the parameters ensuring that the instruments were sterile.

The surgeon came to me wanting to know what this all meant. Like many surgeons, his only experience with flash sterilization had been giving the circulating nurse surgical instruments that needed to be sterilized right before a case or when an instrument was dropped on the floor during a procedure and another one was not immediately available.

Not knowing the particulars of the incident, I told him that I would look into it and get back with him immediately. I reviewed the sterilizer printout for the case and noticed that the nurse who did the flashing was one of our most experienced, knowledgeable and conscientious staff members. I talked to her about the case, and we reviewed the printout together. It clearly said "abort" on it. The nurse was very upset for having put flashed items on the tray without reviewing the printout. Usually, the nurse said, she reviewed the printout before putting items on the sterile field. This time she didn't.

During our conversation, I asked her a few other questions about flashing and using the sterilizers, such as when do you use the different sterilization cycles and what is the minimum amount of documentation required. To my surprise, she wasn't sure what the difference was between the cycles or when to use them. She said she usually used one cycle for everything she flash sterilized. This got me thinking. I decided to ask other OR nurses how they flash-sterilize instruments to see how much of the process they understood.

Tell me about it
I talked to seven nurses, about 20 percent of our OR nursing staff. Their experience ranged from less than one year to more than 10 years in the OR. I asked the same basic questions (see "Give Your Staff This Pop Quiz" on page 43).

The results were consistent, regardless of experience. The nurses understood the mechanics of flashing, including cleaning and decontaminating, placing instruments in the flash container, correct placement of indicators and proper transport of the sterilized items to the rooms. But they had gaps in knowledge regarding how to operate the sterilizers, when to use the various cycles, how to read the printout and what information needed to be documented on the printout.

Besides the informal survey, I reviewed the sterilization logbook to see if there were any trends. I found a handful of cycles run on test mode and a lack of documentation on printouts. After follow-up interviews, I learned why items were flashed on a test cycle. Each night, the sterilizers are run on test cycles for quality control. When the test cycles were completed, the sterilizers were left set on the test cycle. The next day when nurses used the sterilizers, some of them were unaware that the flash sterilizer was still set on test cycle. I also found strips with no nurse's name on them and instances of no documentation saying whether an instrument was used after the strip indicated that the machine had aborted a cycle.

All this made me realize that there was a tremendous need to educate our staff about flash sterilization. The education and training nurse manager and I developed plans for a training program that addressed the basics of flash sterilization, the difference between cycles on our machines, the guidelines that spell out when different cycles should be used and what should be documented on each sterilization printout.

First, we looked at how we educated our nurses. We found that the only training nurses received on flash sterilizers was during their orientation phase. Another nurse would sign off once the new nurse had been shown once or twice how to use the sterilizer. After that, there was no annual training.

Next, we looked at the sterilizers. They had too many pre-programmed cycles from which to choose. It was easy to see why a lot of the nurses were confused. We considered having the sterilizers reprogrammed to delete all the cycles we didn't use. But biomedical services staff said that wasn't feasible. Lastly, we realized that nurses had different ideas about what should be documented on the printout because there was no list for the nurses to consult.

Make a day of it
On our next training day, we devoted time to flash sterilization. We discussed the concept of flash sterilization and reviewed AORN and Association for the Advancement of Medical Instrumentation recommendations and practice guidelines. We created a reference sheet that hangs near each sterilizer and explains which cycle should be used for which instruments and what data should be documented on each printout. To wrap up the day, each nurse demonstrated how to operate the sterilizer, explained which cycles are appropriate for specific instruments and listed the data that must be on each printout.

Afterward, as part of our quality improvement initiative, we assigned a nurse to review all the sterilizer printouts at the end of each day to make sure that nurses were correctly documenting the cycles they ran. If the strips were missing any information, the nurse reviewing the strip would find the nurse who ran the cycle and have her complete the documentation.

New machines
Since that training day, we've installed new sterilizers that have been programmed with only the pre-vacuum cycles that we use. We've dedicated another training day to orient the nurses to the new sterilizers and to review the updated reference sheet that reflects the pre-programmed cycles. We continue to check the daily flash logs at day's end to ensure compliance. The new sterilizers are easier to use because they have fewer available cycles. As a result of this and our QI initiative, we've had fewer printouts missing required documentation.

Since we've made an effort to keep everyone properly trained, the nurses have done a better job with the sterilization process. But because we have a 20 percent to 30 percent annual turnover rate and many nurses rotate out of our facility for long periods of time, maintaining proper competency in sterilization among all our nurses has been an ongoing, never-ending job. In the end, I'm glad I asked the nurse what she knew about flash sterilizing. If you don't ask, you'll never know what your staff is missing.