October 29, 2020

Trim waste in instrument reprocessing with these simple steps.

If you're looking for low-hanging fruit for cost savings at your surgical facility, look no further than your sterile processing department (SPD). "Your certified sterile processing techs are the gatekeepers for the instruments that end up in your ORs," says Alicia Apostoles, RN, BSN, MSN, MBA, director of ambulatory surgery development for OrthoNY Surgical Suites in Albany, N.Y.

"There's perhaps no one in your facility who's more dialed into which tools are needed, and which aren't, for every case your surgeons perform," she adds. "Tapping into their in-the-trenches insights will help you find cost-saving opportunities and improve your facility's bottom line."

Ms. Apostoles offers these three suggestions for finding savings in your SPD:

• Rightsize your trays. Have your SPD techs receiving case carts analyze the items surgeons did and didn't use, as it might be possible to create smaller trays. Ms. Apostoles proudly points to her own facility as an example. Her SPD techs worked with an instrument vendor to consolidate total knee instruments from six trays to two, eliminating about 100 instruments to save $320 per case in reprocessing costs. This single step enabled the facility, for each total knee case, to decrease sterilization cycle times by 30 minutes, run one sterilizer instead of two, reduce time to apply blue wrap to sterilized instruments from 45 minutes to 15 minutes, and save money on blue wrap, tray liners and chemical integrators. "Because of the techs' problem-solving, we're able to schedule back-to-back cases and keep the surgical schedule on track without having to purchase thousands of dollars in additional instruments," explains Ms. Apostoles.
• Improve management of loaners. Have your SPD techs create and manage a sign-in policy for vendors bringing in loaner instrument sets that requires all trays and instruments be on site and signed in at least 48 hours before the start of the case in which they'll be used. This enables SPD to make sure all needed items are present and reprocessed before the scheduled case, as well as spot waste-reduction opportunities by pulling unneeded instruments, says Ms. Apostoles. This policy holds instrument vendors accountable for the accuracy of their sets and can help consolidate instruments.
• Tap into your techs. When you add new procedures, include SPD techs in related surgical staff training and in-services. Allow them to see the instruments that will be used and how the table is set up. "That exercise gives techs a much better understanding of the inventory they can expect to arrive for reprocessing when the case concludes," says Ms. Apostoles. "It's also a great opportunity for them to let you know if they'll realistically be able to turn around the sets used during the case in a reasonable amount of time."

As you can see, the benefits of streamlined instrument care aren't limited to the SPD. "Consolidating instrument sets decreases overall reprocessing cycle times, which impacts your bottom line from an instrument and consumable perspective, and with respect to total case volumes," says Ms. Apostoles. "The ability to reprocess instruments in a more efficient manner can translate into adding revenue-producing procedures and the opportunity to provide more patients with high-quality care."

Promote communication and teamwork among two groups that don't always see eye-to-eye.

Do your perioperative staff and your sterile processing department (SPD) get along? Do they even know each other that well, or at all? Even worse, is there an epidemic of mistrust, blame or even hostility between the two departments? If these questions result in less-than-ideal answers, it's important to forge a culture of respect and understanding between OR and SPD staff.

We recently spoke with two experts about how exactly you can execute this challenging culture change. Cheryl Barratt, RN, BS, MHA, founder and president of Perioptimal Performance Partners, a consulting firm based in Evanston, Ill., and David Jagrosse, CRCST, CHL, president of David Jagrosse Consulting and past president of the International Association of Healthcare Central Service Materiel Management (IAHCSMM), say a "buddy system" between the OR and SPD can promote the communication and teamwork necessary to make it happen. They offer these four steps on establishing one:

• Recruit natural leaders. Identify the OR and SPD staffers who have shown the ability and enthusiasm to mentor others in their own departments. Then ask those staffers if they'd like to extend their sphere of influence by serving as the first set of OR-SPD buddies. The size of your facility will determine how many buddy-to-buddy connections are needed. Even just one set at a small ASC, for example, could do the trick.
• Set the tone. The buddy system gives staff in one department the opportunity for a clearer, firsthand view into the everyday world of the other. As you move forward, encode the buddy system in your center's DNA. Pair every new surgical tech and RN you hire with an SPD buddy during their orientation so they can officially visit the department, learn about your decontamination and sterilization processes, and gain an appreciation for SPD staff's role in safe patient care. Likewise, pair new hires in SPD with an OR buddy, so they can observe surgical procedures up close and better understand how and why the instruments they clean and sterilize are used.
• Consistently communicate. The buddy system shouldn't be a one-time thing. It should be a relationship that builds over time. Buddies should develop a rapport by meeting monthly or quarterly and, as needs arise in either direction, communicate accordingly. Is a delicate, expensive laparoscope showing up in SPD buried and possibly damaged under other instruments on the tray? Is an instrument missing for an upcoming surgery? A simple call from one buddy to another can solve the problem quickly. As they build their rapport, they can also address long-term operational issues between the departments.
• Encourage cross-networking. Now that they have a better understanding of what the opposite department really does, have your buddies attend each other's staff meetings. For example, maybe block 15 minutes of an OR staff meeting for an SPD buddy to answer questions and address problems.

These types of peer-to-peer conversations typically don't take place. With a buddy system, the results are much more collegial than they might be with a top-down, manager-to-the-employee communication structure. Your goal should be to eliminate barriers to good relations between the OR and SPD and replace them with a non-confrontational partnership based on mutual understanding and appreciation. All it takes is opening lines of communication, and keeping them open permanently.

Are Today's Sterilization Processes Up to the Task to Ensure Patient Safety?

Patient safety in the ambulatory surgical setting is a top priority. Heathcare providers need to keep in mind that complications and risk factors can arise at any time, even before the patient arrives.

"The patient safety journey tries to address preventable risks by viewing the experience holistically, but we cannot overlook those factors that don't involve the patient directly and often happen before they enter the facility," explains William Leiva, MPH, Global Care Setting Scientific Affairs Manager at 3M.

Depending on the specific surgical procedure, many of the multi-use instruments and devices used are cleaned, decontaminated, packaged, and sterilized prior to the surgery. The proper sterilization of instruments is critical to infection prevention and, ultimately, patient safety. The sterilization process is so important because it can break the chain of infection by preventing transmission of pathogens between patients. No one claims this process is easy, especially with today's COVID-19 challenges.

"Despite the existence of multiple evidence-based standards and guidelines, sterilization departments are challenged: staff turnover, limited resources, aging equipment, evolving recommendations, and, in 2020, add a global pandemic into the mix!," said Leiva.

One way to help ensure instrument sterilization remains a successful patient safety strategy – despite resource limitations – is to streamline and standardize monitoring processes.

In the United States, the American National Standards Institute (ANSI)/Association for the Advancement of Medical Instrumentation (AAMI) ST79:2017 Comprehensive guide to steam sterilization and sterility assurance in health care facilities (Association for the Advancement of Medical Instrumentation, 2017) standard provides clear guidance to address the most important aspects of the steam sterilization process.

Why steam? First, it is cost efficient, highly effective, and fast. Second, steam was the first technology used for sterilization of medical devices and currently it is still the most heavily used process today. This high temperature sterilization method relies on saturated steam which condenses on surfaces, releases energy, and kills any microorganisms on the surface of a device.

But what constitutes best practices?

"In order to help deliver sterile and safe instruments to every patient, and save time when resources are limited, 3M took best practices from the AAMI ST79 standard and streamlined them into four steps for steam sterilization monitoring standardization," said Leiva.

These steps include the following:

1. Practice equipment monitoring to find out whether your sterilizer is doing its job properly.
To monitor vacuum-assisted steam sterilizers, begin each day with a Bowie-Dick test to detect air leaks, inadequate air removal, inadequate steam penetration, and the presence of non-condensable gases - any of these can compromise sterility.

2. Use exposure monitoring products (external chemical indicators) to know quickly whether packs have been exposed to steam during the sterilization process.
This step assures surgery staff handling the items that the pack has been exposed to steam without the need to open the pack or check load monitoring records.

3. Use pack monitoring to help verify specific exposure conditions have been met.
The use of chemical indicators for internal monitoring of packs, trays, containers, and peel pouches verifies that the sterilant has penetrated to the point of placement of the chemical indicator in the pack – and it also confirms that specific exposure conditions have been met.

4. Monitor every load with a biological indicator.
Load monitoring is the process by which a load is monitored and released based on the result of a biological indicator (BI) in a process challenge device (PCD). Only a BI can detect the actual killing of microbial spores inside the sterilizer. If all spores inside the BI die, you have the assurance that other infectious organisms have also likely died inside the sterilizer.

"Sterilization is a complex process, however there are plenty of tools that can be used to tackle the challenges sterilization professionals face," said Leiva.

3M's four steps for steam sterilization assurance are available in this handout. More resources and education are in the 3M℠ Health Care Academy.

Objective outsiders identify issues you may not have noticed.

At Winchester (Va.) Medical Center, the sterile processing department (SPD) reprocesses instrument trays from 15 ORs. Unsurprisingly, workflow issues emerged in the busy department. "We needed help streamlining the way we worked," says Susan Riley, RN, the facility's operating room business manager. "It's very hard to break habits and routines. It's even more difficult to make repeated attempts at making change happen." She decided an outside expert with new ideas and a fresh voice could help, so she hired a consulting team.

Ms. Riley says good consultants spend time learning what makes your specific SPD tick, rather than trying to impose a generic set of process-improvement goals and a boilerplate punch list of tasks. "They should spend weeks watching the flow of instruments during the busiest of times and lulls in the action, and observe how your team interacts," she says. "They need to look at the whole process before making suggested changes, which shouldn't disrupt your current workflow." Trust is a key aspect here. "You need to know they have your best interest in mind," adds Ms. Riley. "Once you do, let them do their thing."

Through observation and communicating with staff, consultants can understand how trays move through the OR-SPD circuit and identify where opportunities for improvement lie. "They look for repetitive or unnecessary steps, and ways to make it more effective and efficient," says Ms. Riley. The consultant she worked with suggested members of the OR team roll individual carts full of soiled instruments to SPD as soon as they're ready, rather than wait to move several at a time, which can create bottlenecks that reprocessing techs have to manage.

Ms. Riley's consultant also assigned designated runners to the SPD, allowing reprocessing techs to remain at their decontamination stations. "The runners feed the techs work based on need," says Ms. Riley. "That was a brilliant suggestion."

The consultant also suggested reworking shelving configurations and adjusting shelf heights based on the size of instrument pans, which reduced wasted space and maximized storage capacity.

All told, the experience was positive and transformative for Ms. Riley and her facility. "The full consulting team was here for several months before they slowly dwindled in numbers as we learned how to implement the process improvements they suggested," she says. "We had direct and indirect contact with them for at least a year. They took ownership in our success."

Standardized supplies enhance patient safety and save precious minutes.

Preparing and mixing drugs in the OR is a time-honored cost-saving approach for many surgery centers. The danger, however, is that high-pressure, on-the-spot compounding can lead to errors and sterility issues, as well as negatively impact case efficiencies.

Despite this, it's difficult for many facilities to quit compounding in the OR. Outsourcing everything you mix in-house to a compounding pharmacy is an option, but if your facility has safety or cost concerns, or doesn't have time or resources to properly vet outside compounders, it's too radical of a step.

Sanford Medical Center Fargo (N.D.) found another way. The facility's variety of irrigation solutions were often compounded or mixed by a circulator in its ORs, but the Joint Commission raised concerns about the safety of that approach. Sanford therefore undertook a detailed analysis of 50 surgeon preference cards that eliminated certain solutions in the interest of standardization.

"Find out what your surgeons are willing to part with, and then go from there," says Laci R. Soper, BSN, RN, the facility's operating room educator. Ultimately, the medical center reduced its broad list of irrigation solutions to three options: a commercially available low-concentration 0.05% CHG jet lavage system, a saline solution and a pharmacy-produced antibiotic solution created in compliance with USP 797.

When the standardized irrigation protocol went into effect, all OR staff received comprehensive training on the change. This focused, strategic process improvement worked so well that Sanford used the same plan to reduce mixing of local anesthetics.

Reduction of potential medication errors aside, the change has also saved time for OR staff. Now that the circulator and other OR staffers don't need to gather sterile supplies and dilute, mix, dispense and label each of the irrigation agents, the facility saves approximately seven minutes per case.

"Safety drove the change, and the time-savings helped push it through," says Ms. Soper.