BEHIND CLOSED DOORS There's no shame in flashing, so long as you decontaminate thoroughly and follow protocols to the letter.

It's easy to say you want to eliminate rapid-cycle steam sterilization — better known as flashing. But the reality, particularly in an outpatient surgical facility, is that finances and time are limited and, at the same time, we're all under pressure to get as many cases done as efficiently as possible.

And that means, sometimes, flashing will be inevitable. There won't be enough sets to accommodate back-to-back-to-back cases. Something will get dropped. Someone from sterile reprocessing will be out sick.

Should everything be flashed? Absolutely not. But the Association for the Advancement of Medical Instrumentation (AAMI) and the Association of periOperative Registered Nurses (AORN) standards allow for the practice — and, done correctly, it poses no additional risk to patients. Here's a look at some of the cornerstones of a good flashing policy, and how your choice of rigid flash containers can enhance those principles.

1. Proper decontamination
Everything in sterile reprocessing — regular steam cycles, high-level disinfection, low-temperature sterilization and flashing — begins with thorough decontamination. If an instrument has been decontaminated properly, you can proceed with meeting the rest of the processing parameters with confidence. I can't stress enough that proper decontamination is the most important step in any kind of processing.

QUICK QUIZ

Would You Flash in This Situation?

You're setting up for an orthopedic case, and you drop 2 of the implantable screws. The screws are specific to the procedure and can't be replaced. The patient is minutes away from entering the OR. Which of the following steps should you take?

1. flash sterilize the screws as near to the point of use as possible
2. flash sterilize with an extended exposure time
3. flash sterilize using a rigid, specially designed container
4. all of these
5. do not flash sterilize and reschedule the procedure

Answer: d. all of these
Although wrapped, conventional steam sterilization at the usual times and temperatures is preferred, correctly performed flash sterilization is effective and acceptable in instances such as the described scenario. But flash sterilization is not to be used routinely because 1) biological indicators don't provide results quickly enough; 2) the lack of packaging opens the flashed item to contamination during OR transport; or 3) the sterilization cycle time, temperature and pressure meet only minimum recommended requirements.¹

To address these concerns, you can use a biological indicator with a 1-hour turnaround; flash in a rigid container designed to allow steam penetration, as near to the OR as possible; and extend the exposure time "to ensure lethality comparable to sterilized wrapped items (for example, 4 minutes at 132 ?C)."¹

It's important to remember that, once a flashed item is exposed to air, it will eventually become contaminated — so you should remove the screws in this scenario as near to the time of use as possible. However, clinical burns are possible with items that haven't cooled properly.1 Air-cooling is acceptable, but you can use immersion in a sterile liquid such as saline to cool the flashed items and minimize air-exposure contamination.

— Linda R. Greene, RN, MPS, CIC

Reference
1. Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, 2008. Available from www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf.

Ms. Greene ([email protected]) is the director of infection prevention for Rochester (N.Y.) General Health System.

2. Sterilization parameters
There are 2 flash steam sterilization guidelines, depending on your autoclave type:

• Gravity displacement. Three minutes for metal, non-porous items without lumens. Ten minutes is the standard if an item has a lumen or is porous. Temperature should be 270 ? to 275 ?F, with 0 or 1 minute of drying time.

• Dynamic air removal/pre-vac sterilization. Three minutes for metal or nonporous items at 270 ?F to 275 ?F. Metal items with lumens and porous items are processed at 270 ?F for 4 minutes or 275 ?F for 3 minutes, with no drying time.

It's important that your vendor be able to provide validation for your flash containers' sterilization parameters. Ask about it; nurses need to combine science and care in their roles as patient advocates.

3. Rigid closed containers
Both the AAMI and AORN standards specify that you must use rigid closed containers "designed and intended for flash cycles." You must purchase containers designed for flash sterilization and the manufacturer must provide independent clinical validation studies that verify the product meets AAMI and AORN standards of practice.

When the facility I work with recently bought a new group of flash containers, we looked for ease of use, and we wanted a variety of sizes, to give us the flexibility to flash everything from small ophthalmology instruments to entire ortho/spine sets. We also didn't want moving parts that required frequent maintenance or extra steps. The point of flashing is rapid turnaround, and our nurses and techs didn't want extra manual steps to slow the process.

Sterile reprocessing staff want to perform decontamination, put the instruments in the container, put the container in the autoclave, then close the lid before transport to the OR. Fewer steps equal better compliance with protocols, particularly in pressure-packed situations.

4. Chemical indicators
A Class 5 chemical integrator should be used in each container because it provides an instant readout to verify a successful cycle. Some people like to use more than one in different parts of the container, and that's fine, too. Our flash containers have a port on the front that allows for the displacement of air during the sterilization cycle. An "accept" on the integrator identifies that the sterilization parameters were attained and provides additional assurance that the autoclave performed properly.

5. Transport and cooldown
Transportation is crucial. The flashed item must arrive at the OR in a completely closed container. The surgical tech shouldn't be leaving the room to retrieve instruments, as happened years ago. When the circulating nurse opens the container lid in the OR, the surgical tech is charged with making sure by touch that the item or items are cool enough to use. If not, the items are cooled in sterile water before use.

Flashing done right
The purchase of new flash containers is a major investment and one that demands careful research based on expected usage and container longevity. We all try to limit usage, but flashing is a reality for most surgical facilities in an emergent situation. When performed correctly, flash sterilization is a safe and effective process for the sterilization of medical devices.