Q On the blueprints for the ASC physicians I work with are building, the architects have positioned the autoclaves to open into the main hallway where everything - patients, dirty instruments - is transported. The OR suites are across the hall, as are the scrub sinks. The consultant says I'm the first person to ever be concerned about this. I looked into closed flash sterilization pans, but I still think the architects should re-work the plans to include sterile corridors. Your thoughts?

A I have several recommendations. First, I hope they're not planning to use only flash sterilizers in this facility. Flash sterilizers are designed for emergency use only, in the event an instrument becomes contaminated and there is no handy replacement, and should never be used for routine sterilization. Flash sterilization is gravity sterilization without the protection of packaging. You accomplish nothing if you attain sterility but don't maintain it to the point of use. It would be a shame to build a state-of-the-art facility with Dark Ages sterilization and infection prevention.

The second is to enlist the help of a major sterilizer manufacturer. Such companies have consultants at their disposal who have stock facility designs as well as the ability to custom-design a sterilization facility to fit your doctor's needs.

The third would be to contact the Association for the Advancement of Medical Instrumentation (www.aami.org) and ask for copies of its ANSI/AAMI ST42 standard, "Steam Sterilization in Ambulatory Care Facilities." Section 3.2.2 deals with design criteria and 3.2.3 with functional workflow patterns. Page 27 even has an example of a recommended layout of an ambulatory facility showing proper consideration for keeping clean separated from dirty. You'll note there are no flash sterilizers in this plan.

I would also get ST46, "Good Hospital Practice: Steam Sterilization and Sterility Assurance." It is full of the common sense rules you should follow when designing any medical facility that will be doing sterilization.

Q I was told by a colleague that you could handle the reprocessing of a cystoscope the same as an endoscope. But it seems to me you would use the same sterile technique with a cystoscope as with, for example, a catheter. Can you settle this?

A When it comes to reprocessing endoscopes, some people have fallen into the high-level-disinfection trap: They're not as concerned about sterility as you might be with a urinary catheter, to use your example. High-level disinfection is good for endoscopes - as long as they're thoroughly cleaned, then sterilized or disinfected just before use. The longer they're left hanging around after disinfection, the more likely it is they'll be contaminated by the environment.

But a cystoscope is relatively easy to clean, package and sterilize compared to endoscopes, which have multiple, extremely narrow channels. So why wouldn't you sterilize it?

As an observation, most urinary tract infections are caused by indwelling catheters, and that is where the infection-prevention attention should be primarily focused. Careful, intelligent insertion and handling of catheters and cystoscopes is, of course, also important.

Q We currently soak our flexible cystoscopes in glutaraldehyde. To decrease the amount of glutaraldehyde we use, I'm considering a wall-mounted unit that has tubes you put the scopes in for soaking and tubes for rinsing. Each tube is long enough to soak the scope up to the control section. If we were to wipe down the angulation section and the eyepiece section with a disinfectant/decontaminant, would that meet standards of care?

A What you are suggesting makes me very nervous. Cystoscopes can become contaminated along the entirety of their bodies, inside and out - and wiping down the eyepiece and angulation sections may not render those portions safe to use, depending on the scopes' previous uses.

I would check with your cystoscopes' manufacturer(s) for advice. Before you adopt this process, think about this: You are trying to save a little money on glutaraldehyde and instead spending time on the extra wipe down.

If you decide to go ahead, I'd recommend extra care in the cleaning procedure before the glutaraldehyde soak and terminal sterilization of the scopes overnight/at the end of the day, so that, at the very least, you'll be starting each day with a sterile scope. Contrary to popular belief, this doesn't violate the equal-standard-of-care principle and is highly recommended by JCAHO and others.

Q I recently transferred to a rural hospital that hasn't changed infection control practices in 30 years. For example, we terminally clean our OR suites before and after a total joint, we mop the whole floor between cases and we outdate all our wrapped packs for 30 days. Our OR turnover time is long, but ideas for change haven't been well-met. Can you recommend some literature regarding OR turnovers and sterilization techniques?

A I sympathize with your situation. Changing old, idiosyncratic traditions is a frustrating - and time-consuming - job. First, you need to find a champion/sponsor with clout in your organization to help you overcome some of these outdated practices.

Here are several places to find information:

• First, you can research back issues at writeOutLink("www.outpatientsurgery.net/search",1) for articles on each problem you encounter. Our first annual infection control survey (writeOutLink("www.outpatientsurgery.net/2003/09/infection_control_survey.php",1)) covers many of the issues you're dealing with.
• The gospel of good hospital practices regarding sterilization issues is the AAMI "Standards and Recommended Practices, Sterilization Part 1, Sterilization in Healthcare Facilities." This is available at writeOutLink("www.aami.org",1).
• Go to writeOutLink("www.apic.org",1) for information on how to get on the Association for Professionals in Infection Control's APIClist, a question-and-answer, round-table forum for asking your peers questions and getting their feedback.
• Last, but not least, the Association of periOperative Registered Nurses (writeOutLink("www.aorn.org",1)) has written recommended practices on most of the situations you will encounter. I find their information particularly thorough and professional when dealing with OR practices, but a little suspect when dealing with infection control and sterilization problems.