REPROCESSING CHALLENGE Narrow-lumened instruments and endoscopes have the highest risk of being improperly reprocessed.

There's no margin for error in your central sterile processing department, and that's a lot of pressure to contend with every day. Add in the challenges associated with flexible endoscopes, narrow-channeled phaco handpieces and other notoriously tough-to-clean lumened instruments, and it's no surprise that burnout and turnover are so common among reprocessing techs. These 6 "secrets" to cleaning lumened instruments may help to ease the pressure and eliminate some of the situations contributing to reprocessing failures.

1. Start the reprocessing sequence in the OR. In reprocessing, every minute matters, and epidemiologist Cori L. Ofstead, president and CEO of Ofstead & Associates in St. Paul, Minn., says the clock starts ticking in the OR, not central sterile.

"When an instrument sits up in the OR for a while, or if it's used early in the case and hangs around until the case ends, the residue will harden and create a situation that will require additional soaking and brushing," she says. Also, the amount of bacteria on an endoscope doubles every 20 to 30 minutes after use. That's why she endorses established guidelines that recommend OR staff pre-clean instruments right away; disposable bedside kits can help to prevent bioburden from drying and solidifying in endoscope channels.

"If there is any delay in getting the device to reprocessing, OR staff should have a mechanism to let the reprocessing department know so they can plan accordingly," she says. "Unfortunately, most ORs rarely communicate with central sterile about those kinds of things."

2. Use only water-based substances. Clinicians often resort to using lubricants, de-foaming agents and other substances — cooking sprays, for example — to facilitate certain GI procedures. These substances go against manufacturers' instructions for use and may be contributing to some reprocessing failures, in part because central sterile might not be aware that such substances are being used.

The most universally used products that interfere with reprocessing include infant gas-relief drops that contain the anti-foaming agent simethicone, says Ms. Ofstead. These products aren't sterile and contain sweeteners and thickeners, along with silicone (osmag.net/BJtUs2), while cooking sprays have oils — silicone, too — that can be quite difficult to remove from the channel of a scope even with a thorough cleaning.

"A nurse or doctor might be using something like infant gas-relief drops to reduce foam and bubbles that impede their ability to see clearly during procedures, or cooking sprays that help lubricate guidewires before they're passed through the channel," she says. "These consumer products may be inexpensive options, but they're not intended for those medical uses and may create a lot of problems for reprocessing."

3. Use techs as "another set of eyes." A good sterile tech can be an invaluable resource in preventing a reprocessing challenge from turning into an infection risk (see "Taking Initiative in Central Sterile"). Like every OR staff member, each sterile tech needs to be well trained and empowered to speak up, says Laura E. Staubitz, MEd, BSN, RN, CIC, an infection prevention practitioner with Providence St. Peter Hospital in Olympia, Wash. Adopting a culture in which techs feel as if they have the tools, training and support they need may help to prevent stress and burnout.

"Make yourself available to your techs, and observe the complex process of cleaning," says Ms. Staubitz. "Empower them to speak up and rely on them as a resource. There are thousands of surgical instruments, so there could always be issues down the road that they can help you identify."

Have each sterile tech trained at least twice a year. Refreshers may help to prevent "little pieces of information from getting lost," she adds, be it knowing which brush by diameter and bristle type to use on a particular instrument, or any limitations on heat-sensitive scopes processed in a low-temperature sterilization system.

FRONTLINE FAITH
Taking Initiative in Central Sterile

ENGAGED Dedicated sterile techs may help to identify instruments whose design may pose unanticipated reprocessing challenges.

Although central sterile techs have their hands full turning around flexible endoscopes and cannulated drill bits for speedy re-use, the challenges extend far beyond lumened instruments. Even seemingly straightforward surgical instruments may pose an infection risk, says Laura E. Staubitz, MEd, BSN, RN, CIC.

Ms. Staubitz, an infection prevention practitioner with Providence St. Peter Hospital in Olympia, Wash., is a firm proponent of following instructions for use when it comes to reprocessing each manufacturer's instruments. But she also recalls one instance in which "going against the grain" was an acceptable course of action.

It was 2014, when she was with CHI Franciscan Health, and a surgical tech was having trouble cleaning a particular rongeur, so he went against the manufacturer's IFUs by opening up the rongeur to make sure it was free of bioburden. Long story short: It wasn't.

"Inside there was a lot of bioburden," she says. "It was pretty shocking."

The facility responded by pulling the particular rongeur from use, and it also filed a MAUDE (Manufacturer and User Facility Device Experience) report with the FDA, which feeds a public database of adverse events involving medical devices. In the process, the facility learned that at least one other facility had issued a report on a similar instrument years before.

"The tech was brave in what he did," says Ms. Staubitz. "He was told by the vendor not to open the rongeur, but he felt something wasn't quite right. It was a hard thing to do, but his actions made a difference. That's why your frontline staff are so important. They're another set of eyes. They can help you identify surgical instruments that, because of the nature of their design, may be impossible, or nearly impossible, to clean, disinfect and sterilize."

— Bill Donahue

4. Automate. Automated endoscope reprocessors may help to enhance critical steps in the manual cleaning process, or even eliminate them altogether, while automated irrigation systems flush bioburden from narrow channels at the push of a button. They also remove the human temptation to skip vital steps — say, manually pushing only 1 syringe of water through the channel when the manufacturer's instructions for use clearly call for 3.

"Some sites just use a syringe full of fluid from the sink, but it's hard to effectively do this with some lumened instruments," says Ms. Ofstead. "If you're not using the right mix of water and enzymatic detergent, rinsing may not be effective enough to remove all of the detergent, which is bad because it contains protein that can foster the growth of bacteria."

5. Consider every "touch" during the cleaning process. Carefully audit the cleanliness of the area where your techs are cleaning instruments, including the area used to verify the effectiveness of cleaning, by using adenosine triphosphate (ATP) testing to indicate the presence of living cells. Is the workflow designed so sterile techs start in one place and don't have to backtrack? Are the brushes and other cleaning tools being stored where they can't be contaminated? Is this area being terminally cleaned on a regular basis?

"You could be doing a great job of cleaning a scope, but then a tech might lay a brush on a non-sterile towel," says Ms. Staubitz. "Or you could be putting the brushes in containers that aren't being cleaned, or are stored in places where traffic patterns can spread dust. That defeats the whole purpose of everything you've done up until that point."

6. Aim for quality over efficiency. What word best describes a well-run central sterile department? If you're tempted to say "efficient," Ms. Ofstead would like you to reconsider.

"When institutions prize efficiency above all else, central sterile techs do what makes sense, which is to skip steps and move fast," says Ms. Ofstead. "And when that happens, we lose sight of what our goals should be: protecting patients by making equipment safe for re-use; and protecting staff from exposure to hazardous chemicals and infectious diseases."

Sure, your techs need to clean, high-level disinfect and sterilize those flexible endoscopes so they can get back into the lineup as quickly as possible, but never at the expense of safety and quality. How? Start by making sure you have an ample inventory of scopes, which would resolve the constant "do it yesterday" pressure most sterile processing departments face. Ms. Staubitz admits, however, that budget constraints may make this "easier said than done" for some facilities.

Also, make sure sterile techs have the tools they need to do the job right, including a broad selection of brush styles and sizes to accommodate the different ports and channels for cleaning different lumened instruments. And, of course, never skimp on the proper PPE — namely, hair covers, face shields, surgical masks, extended-cuff gloves, impermeable gowns and shoe covers — because a dedicated, capable sterile tech deserves protection from exposure just as much as every one of your patients. OSM