A Google news search of "dirty surgical instruments" will turn up several examples of surgeons allegedly operating on patients with soiled tools, including the highly publicized sterility issues that plagued Detroit (Mich.) Medical Center. How could that possibly happen? Gail Horvath, MSN, RN, CNOR, CRCST, senior patient safety analyst and consultant at ECRI Institute in Plymouth Meeting Pa., offers some insights. Her recent analysis of contaminated surgical instrument reports submitted to ECRI Institute by 123 hospitals identified several factors that can lead to reprocessing errors. How many need to be addressed in your facility?

Surgical instruments are becoming more functional and complex and, not surprisingly, more difficult to clean. The data bears this out. Ms. Horvath's research found that complex and cannulated or lumened instruments were identified in 75% of the reported dirty instrument events. She views this problem as the top contributing factor, especially in outpatient settings where orthopedic surgeries have significantly increased in volume and instruments get soiled by difficult-to-remove bone, debris and bioburden. Many newer surgical instruments have more parts, more pieces and more complex instructions for use (IFUs), points out Ms. Horvath. "When the instruments are under development by a device manufacturer, they're developed very well for their intended use and function," she says. "But often there's not significant recognition of how difficult they are to clean."

There's a big difference between cleaning instruments in a lab, where you're not dealing with large volumes and multiple other instruments at the same time, and actually doing it under the time and productivity pressures of a working facility. Ms. Horvath believes that in addition to bringing in physicians as advisors when developing new products, instrument manufacturers should consult sterile processing personnel to make sure instruments can be properly cleaned and sterilized.

In the meantime, your staff needs immediate access to reprocessing resources when questions arise about how to care for specific devices. "It's unrealistic to expect them to be experts on every device they encounter," says Mark Voigt, CRCST, CHL, director of sterile processing at CentraCare Health-St. Cloud (Minn.) Hospital. "Make sure appropriate educational materials are readily available to them."

More and more, your reprocessing techs are likely to encounter instruments that are unfamiliar to them and require special cleaning regimens that they don't know how to perform. Ms. Horvath provides an example: A surgeon adds a new procedure. A vendor rep comes in with the new instruments and trains the OR team on how to use them. Reprocessing techs receive a paper copy of the instruments' IFUs, but no in-service to learn how to clean and sterilize the tools. There's no opportunity for them to ask questions or have their concerns addressed before the instruments show up for sterilization. Does that make sense?

The availability of up-to-date and easy-to-understand IFUs is also a common issue, notes Ms. Horvath. Another problem, she says, is that the sterile processing department is often not involved in the purchasing decisions of new instruments, so techs might not have the knowledge or equipment needed to reprocess devices that you purchase.

Competency-based orientation and ongoing education is vital for sterile processing staff. When onboarding reprocessing staff, make sure they clearly understand device-specific IFUs for cleaning and sterilizing, suggests Mr. Voigt. And don't stop there. "Training on IFUs needs to be continuous, with meaningful and detailed competencies given on a regular basis," he says.

There's another factor to consider, if you haven't already. "Sterile processing is often considered a non-revenue producing department," says Ms. Horvath. "But we need to recognize that it's essential. Reprocessing techs should no longer be considered "glorified dishwashers.' Their pay needs to be commensurate with the high expectations we have for them and the knowledge they need to have. We also need to reward certification."

"Reprocessing techs aren't glorified dishwashers."
— Gail Horvath, MSN, RN, CNOR, CRCST

Mr. Voigt says it's important for reprocessing techs to seek certification through the International Association of Healthcare Central Service Materiel Management (iahcsmm.org/certification.html). "States are beginning to recognize how important education is for reprocessing techs, and the value of understanding the basic principles of sterile processing," he adds. "We're starting to see this in mandatory certification laws" in states like New Jersey, Tennessee, Connecticut and New York.

Every member of your staff should be aware of the challenges reprocessing techs face when sterilizing instruments and appreciate the immense pressure of working in the OR. "Hold in-services for staff from both areas, so everyone understands not only how instruments are cleaned and sterilized, but also how they're used," says Mr. Voigt.

Take it one step further and have your sterile processing staff observe surgery and members of the surgical team watch reprocessing techs in action. That helps build a rapport between the departments and gives them insight on the role they play in the entire team effort, says Mr. Voigt.

Ms. Horvath agrees that it's important to create a shared purpose and goal between staff in the OR and the sterile processing department. "They should walk a mile in each other's shoes, so they're aware of the responsibilities the other group handles and so they develop a mutual respect," she adds. "They need to work as a team, because they're on the same team."

Even the most technically advanced decontamination and sterilization equipment will fail if there's a breakdown in the process, says Mr. Voigt. For example, he says the cavitation and impingement actions of an ultrasonic and washer-disinfector are only effective if you can appropriately disassemble instruments and choose the appropriate cleaning method. Chemicals and disinfectants are only effective if you're familiar with contact times, efficacy claims and appropriate applications. Enzymatic soaps are designed to catalyze specific biochemical reactions, but in order for them to work, you must know the temperature and concentration needed to effectively break down carbohydrates, lipids and proteins.

Ms. Horvath says point-of-use care and cleaning of lumened instruments or devices with working channels is especially important. Members of the OR team should flush and rinse instruments as soon as cases end and, before transporting them to sterile processing, make sure they're sprayed with enzymatic cleaner and covered with a wet cloth in accordance with manufacturers' IFUs. After they clean lumened or cannulated instruments in sterile processing, techs could use a borescope to examine the scope's channels to ensure bioburden has been removed so effective sterilization can occur.

Instrument reprocessing has become more difficult and more fraught with risk as the pressure mounts for facilities to perform as many procedures as possible and as more complex instrumentation has emerged. Ms. Horvath maintains the dirty instrument problem is not a function of reprocessing techs being bad at their jobs. "It's not people who are failing," she explains. "Instrument reprocessing is a multifactorial process that has multiple potential failure points in it."

Ms. Horvath says there's heightened awareness about the importance of proper instrument care, but there's also a heightened chance for things to go wrong, despite everyone's best intentions. Reducing the risk of contaminated instruments being sent back to the OR demands addressing the issue from several angles and many layers. It's a daunting task, but one that can no longer be ignored.

Start by encouraging the reprocessing staff to speak up if proper instrument care is lacking, says Mr. Voigt. "They understand better than anyone the barriers that exist and what issues their department faces," he adds. "Empower them to make decisions on process improvement initiatives that will ultimately improve patient safety." OSM