ON THE MOVE Author Mark Voigt delivers sterilized instrument sets to the expansive storage area in St. Cloud Hospital.

Our sterile processing department handles more than 150,000 instrument trays and 80,000 single-pack items a year. That's a lot of devices to clean, disinfect and sterilize — and a lot of chances for things to go wrong. Here's how we ensure that we properly sterilize every instrument.

It starts with decontamination
It's the oft-repeated mantra of sterile processing because it's true: Dirty instruments can't be sterilized. Proper decontamination begins in the OR when techs pre-treat instruments in an enzymatic solution to keep them moist and prevent the drying of bioburden. Case carts come down from the ORs in a dedicated elevator that empties into a soiled decontamination area. All instruments undergo thorough manual cleaning according to manufacturers' instructions for use (IFU), even though our 4 automated washers are validated to clean items that haven't undergone hand scrubbing. We consider manual cleaning an added safeguard.

Lumened and complex instruments are challenging. We open scissors and take apart devices with multiple parts. We flush, brush and inspect all the cracks and crevices to ensure visible tissue and blood are removed. We invested in a handful of different-sized brushes to fit instruments with various-sized lumens. We soak and manually wash all items in warm water and detergent, and rinse them with distilled water before running them through the automated washers. We reserve ultrasonic cleaning for heavily soiled instruments or items that must undergo the cycle per manufacturers' directives.

We're planning to install computers at each decontamination workstation so staff can access instrument tracking software that displays instructions and video tutorials for cleaning every item in our inventory. Certified techs are permanently assigned to each area in our reprocessing department. These specialists are responsible for implementing new policies and procedures, ensuring instruments are cleaned and processed properly, and answering questions the staff might have about caring for specific items. The techs also runs staff in-services whenever new instrumentation is added or new methods of cleaning are instituted.

COMMON GROUND
Bridging the Gap Between the OR and Sterile Processing

UNSUNG HEROES Does your OR team appreciate what the reprocessing staff does to get instruments ready for use?

Improving the communication between sterile processing departments and surgical teams is critical. Often the sides don't fully appreciate the pressures each is working under. We've taken steps to break down those communication barriers. Our hospital assigns lead nurses to each surgical specialty, and leadership here in sterile processing has many meetings with them to keep the lines of communication open. The nurse leaders consult with us when purchasing new equipment and communicate reprocessing-related issues that we might be able to address and solve.

We view the surgical department as our customer, and our job is to understand their needs. At the same time, the surgical teams have to appreciate what it takes to properly reprocess instruments, and can't put unrealistic expectations on our abilities to turn around a high volume of instruments in a short amount of time.

Specialty instruments and trays present a unique challenge. Many of our surgeons, especially in our joint replacement program, require specialized tools to perform procedures. Specialists in our sterile processing department dedicate their time to coordinating with vendors to ensure instrument sets are in-house when needed and reprocessed in time for cases.

When setting our department's polices and procedures, we follow regulations established by the state department of health, OSHA, IAHCSMM, the Joint Commission, AORN and AAMI. We also work closely with an infection preventionist who's assigned to the surgical and sterile processing departments. Our infection control policies are generally more stringent than national policies and practices.

We also work closely with leaders from other departments throughout the hospital to self-audit our performance. The team of leaders rounds through the department, looking for areas where we can improve. They often catch the little things that can get overlooked when you walk by them every day. It's a valuable exercise for our department, and also provides opportunity to pull back the curtain on what we do and to develop a rapport with leaders from other departments throughout the hospital.

— Mark Voigt

BY THE BOOK Each instrument must be reprocessed according to its manufacturer's instructions for use.

Set reassembly
After instruments emerge from the automated cleaners, assembly specialists reassemble instruments trays. All trays are barcoded, so the specialists can access electronic pick sheets and pictures of every instrument that belongs in the set. (Our tracking software lets us check where instrument sets are along the reprocessing pathway once they're scanned in at decontamination, assembly, sterilization and storage.) At this point, staff recheck and rebrush lumened instruments and demagnetize needle holders. They also inspect all instruments, checking for sharpness quality, visual debris, and damage or imperfections that could jeopardize effective use.

We're trying to convert to the full-time use of rigid sterilization containers — some instrument manufacturers have yet to validate their items for reprocessing in containers, so that's been a limiting factor — because they increase the likelihood of maintaining an instrument set's integrity throughout the sterilization process; issues related to blue wrap getting wet, ripped, rubbed or damaged are eliminated. Rigid containers also allow for minimal handling of sterilized instruments.

Converting to rigid containers is an expensive option, but fiscally beneficial and environmentally responsible in the long run, because we're not using as much blue wrap and not having to reprocess instruments again when the integrity of wrapped package is jeopardized.

Using our barcode tracking system, the assembly specialists scan instrument sets that have been prepared for sterilization. The system prints a barcode label that contains the time the set was reassembled, the tech who worked on it, the required sterilization cycle (steam or low-temp, for example) and the name of the set that's in the container or wrapped pack. The sets are then loaded into the sterilizer, which electronically monitors every cycle to ensure specified parameters have been met.

Whether blue wrap or rigid containers are used, we place sterilization indicators in the most challenging spots for steam to reach — under instruments and in corners. For example, we place 2 indicators on each level of multilevel trays in rigid containers. The containers are also locked with disposable plastic clips that contain a sterilization indicator dot, so we can quickly see that they passed through cycles properly before sending them to the ORs. When lids are popped in the OR, staff there can confirm that steam reached all of the instruments with a quick check of the indicators we placed before sterilization.

We also run a biological indicator with every load. That's only required with implants, but it's an additional step we take to ensure all instruments and devices have been properly sterilized. Reassembling instrument sets and properly preparing them for sterilization are incredibly important, but time-consuming steps. They're also the marks of quality sterile processing departments. Forgetting to include sterilization indicators in an instrument load is a common error in some facilities, and it takes just a single misstep to have the surgical team questioning the overall performance of your department — even if the 300 previous sets arrived on time and ready to go. I tell my team to constantly focus on the task at hand, because improperly prepared trays will end up back in the department for decontamination, reassembly and sterilization, which will double their workload.

Full circle
At the end of sterilization cycles, staff members in the instrument storage area scan barcodes on blue wrap bundles and rigid containers to record where the instruments are kept, including specific locations along shelves in assigned rows. When the surgical team needs to pick sets and individual instruments for case carts headed back to the ORs, they know exactly where the items are located. It's an efficient start to a process that's about to be repeated yet again. OSM