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A Time and a Place for Immediate-Use Sterilization
Answers to 5 common questions about acceptable practices.
Rose Seavey
Publish Date: April 29, 2014   |  Tags:   Infection Prevention
Immediate-use sterilization QUICK TURNAROUND Immediate-use sterilization is effective and safe as long as it's limited to emergent cases.

The good: I've seen a lot more attention being paid to properly performing immediate-use steam sterilization. Facilities that understand its role in instrument reprocessing are doing it better and doing it less. The bad: There are still some facilities with questions that clearly indicate they don't understand how and why immediate-use sterilization should be used.

1. What's the true definition?
Flashing, as it used to be known, was originally intended for fast-tracking the reprocessing of select, one-of-a-kind instruments or needed items accidentally dropped on the floor during surgery. But surgery teams have applied a more liberal meaning to that strict definition over the years, opting to run full instrument trays and loaner instruments through IUSS cycles.

7 Key Points About Immediate-Use Sterilization

Immediate-use sterilization:

  • Should be kept to a minimum, and not used for implants.
  • May be associated with increased risk of infections to patients.
  • Should not cover for insufficient instrument inventory.
  • May put pressure on personnel to eliminate one or more steps in the cleaning process.
  • Should be exposed to the same multistep process (including decontamination, preparation and documentation) as packaged items.
  • Should utilize containers to transport instruments to the point of use.
  • Must follow the device manufacturer's instructions. Specialty instruments could require extended exposure time, and certain manufacturers of such devices do not recommend flash sterilization.

— Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSPDT

On the web:
Download Seavey Healthcare Consulting's handy immediate-use sterilization audit checklist to ensure your staff is following the proper protocols: outpatientsurgery.net/resources

Individual facilities need to determine what constitutes an emergent situation. In most cases, it should be matters of life and limb, and not because you don't have enough instruments to keep up with case volume. The surgical schedule should never dictate how instruments are reprocessed.

Problems surrounding flash sterilization are more common in ambulatory settings, where space is tight, instrument sets are limited and operating budgets are razor-thin. Eye centers have told me they don't have enough instruments, so they have to use IUSS. That's not acceptable.

Threats to life or limb are truly emergent situations, but you operate in the real world. If you're in the middle of a case, the patient is already anesthetized and a one-of-a-kind instrument is needed, perhaps that's a good enough reason to employ IUSS. But then look at the situation and decide what you can do to prevent it from happening again.

chemical indicators DOUBLE CHECK Immediate-use sterilization must include chemical indicators to ensure cycles reach the proper endpoint.

2. How should it be done?
Reprocess items the exact same way you would for terminal sterilization: The only difference between IUSS and terminal sterilization is little to no dry time.

AORN and the Association for the Advancement of Medical Instrumentation recommend the use of rigid containers to transport instruments for IUSS because they protect the items from environmental contamination. There are many rigid containers designed for conventional sterilization, others are validated for IUSS, and some can be used for both. Make sure whichever container you use for immediate use has been validated for it.

Reprocessing techs must properly clean instruments in the decontamination area — not in a scrub or hand sink — while wearing appropriate personal protective equipment and following the manufacturers' instructions for use. Instruments must be disassembled and reassembled for cleaning as they would be for terminal sterilization. Streamlining the reprocessing process does not mean corners can be cut.

Run immediate-use cycles according to instrument manufacturers' written instructions. Running 4- or 10-minute cycles in the OR as "flash" cycles may no longer be adequate to sterilize the more complex instrumentation in use today. Follow whatever exposure time manufacturers recommend — some suggest 8-,10- or 20-minute cycles, and some provide specific instructions for immediate-use sterilization. Still others, especially orthopedic suppliers, note that devices cannot be run through IUSS cycles.

Importantly, immediate use is defined as the shortest possible time between sterilization and aseptic transfer to the sterile field. There is no shelf life for these instruments; you can't hold them over for another case or store them for later use.

When Immediate-Use Should Not Be Used

stop sign
  • During the reprocessing of implants, except in a documented emergency when no other option is available.
  • During the post-procedure decontamination of instruments used on patients who may have Creutzfeldt—Jakob Disease (CJD) or similar disorders.
  • For devices or loads that have not been validated with the specific cycle employed.
  • For devices that are sold sterile and intended for single-use only.

Source: Multi-Society Immediate-Use Steam Sterilization Statement: tinyurl.com/lbdcb6z

3. How do you validate cycles?
Chemical indicators should be placed in the most challenging location of rigid containers or wrapped packages and checked at the end of cycles to ensure they've reached the proper endpoint. Also, check the physical indicators on sterilizer tapes to ensure cycles reach correct temperatures for the required amount of time.

Unless instrument manufacturers direct otherwise, avoid using gravity sterilization for immediate-use cycles. Some companies recommend against gravity cycles because they're not sufficient to achieve sterilization; they instead suggest the pulsing dynamic air-removal of pre-vacuum cycles, which are more efficient in removing air from lumens and complicated devices.

Document the same parameters you'd note during terminal sterilization cycles: specific sterilizers used, instrument lots and load numbers. AORN recommends you also define and document the reason for immediate-use sterilization when such cycles are run.

Common Causes of Immediate-Use Sterilization

immediate-use sterilization REPEAT OFFENDERS Some surgeons or nurses might be more inclined to send instruments for immediate-use sterilization.

Researchers have identified risk factors for immediate-use sterilization. The most commonly documented reasons for "flashing" during hip and knee arthroplasties were:

  • OR turnover;
  • unsterile instruments received in the OR;
  • instruments becoming contaminated during surgery; and
  • reprocessing of one-of-a-kind items.

The researchers noticed that smaller ORs had a higher incidence of immediate-use sterilization. They theorized that it was more likely for surgeons and staff to mishandle or drop instruments in smaller ORs. They also found that ORs closer to the autoclave were more likely to send instruments for immediate-use sterilization when it wasn't indicated.

Flashing was higher on Monday morning at the researchers' facility, a finding they found somewhat surprising, because instrumentation should be abundant at the start of the operating week. They acknowledged poor planning for a busy week of surgery could have been to blame.

Conversely, the study notes flashing rates were lower during morning procedures, which the authors say highlighted an important point: Flashing is more likely to occur as case volumes increase throughout the day and resources are stretched thin, highlighting the need to have enough instrumentation to handle the demands of a full operating schedule.

Notably, the researchers point out that only 10% of flashing cycles involved instruments that were contaminated intraoperatively — an acceptable reason to fast-track — which means most cycles were performed against recommended guidelines.

The 2012 study, "An evaluation of immediate-use steam sterilization practices in adult knee and hip arthroplasty procedures," was published in the American Journal of Infection Control (tinyurl.com/kkv4aw7).

— Daniel Cook

4. What about implants?
Implants should typically not be run through immediate-use cycles. But if you must, due to an emergent situation, include a biological indicator (BI) and a Class 5 chemical indicator, and quarantine the implant until the results of the BI come back. New BI indicators provide results within an hour, but if the patient is anesthetized, you might not be able to wait that long, which is where the Class 5 chemical indicator comes into play: It shows the same response as the BI, but in a fraction of the time. However, you still have to document that the BI was negative, and why you approved the early release of the implant before it was quarantined.

immediate-use sterilization ONLY AS NEEDED Benchmark against your own performance and take steps to limit immediate-use sterilization.

5. What's an acceptable rate?
There is no national benchmark for the number of IUSS cycles. AORN advises you to benchmark against your own performance. Determine a baseline figure, try to decrease that number, and document your progress over time.

But don't focus on specific rates. What's most important are the steps you're taking to limit immediate-use sterilization, which is why it's essential to document why your staff resorted to the fast-tracking option. Are the same service lines running the same instruments through immediate-use cycles during the same procedures? Is immediate use often used during a particular surgeon's cases or during a particular day of the week? Review those reasons routinely to identify trends that need correcting, and work on decreasing those factors during documented risk assessments.