In this space, I've covered many packaging issues. One that I haven't covered is sterilization containers. This has become a more important topic as they have gained market share. Despite this, many facilities don't have as much information as they should about sterilization containers, such as how and where they should be used and, most importantly, whether they are cost effective. Let's examine these topics.

Better protection than cloth wraps
Sterilization containers protect better than cloth wraps, but you must use them properly to get sterilant and air in and out. At several hundred dollars each, they're a big investment. But if they're compatible with your sterilization system, and you have large turnover of the same kinds of instrument sets, they can be cost effective.

Sterilization containers hold instruments during preparation and sterilization and, used properly, will protect them from contamination during storage and transport. The box-shaped containers, which also comprise a lid and an instrument tray, are re-usable and come in several sizes. Depending on the make and model, they can sometimes be used with gas and low-temperature sterilizers. Most commonly, sterilization containers are for use with steam sterilizers.

Surgical instruments are secured in an instrument tray (which has handles) by pegs or dividers and placed unwrapped in the sterilization container. Latches hold the lid and base together, some with locks and keys. Some containers have perforations in the lid; sometimes they are in both the lid and container bottom to permit entry and egress of the sterilant. Filters placed over the perforations plus a correctly seated gasket maintain the sterile integrity.

Some sterilization containers have baffles over the perforations to add protection to the filters. Others use specially designed valve systems that allow the entry and egress of the sterilant (Fig. 1). The method used to allow the sterilant to get in and out of the container is often the weak point in maintaining the sterile integrity of the system - which is why it's important your staff know how to test the filter system and change filters when necessary. Re-usable filters are made of fabric or ceramics; disposable bacterial filters are also available.

Trays are not storage systems, but they will maintain the sterile integrity of the contents until they are opened or until the filters/valves are somehow compromised.

All containers should have

• a way to show the container has been through sterilization
• a tamper-evident seal
• tags or labels to identify the contents; some have transparent lids for this purpose (Fig. 2).

Maintaining sterile integrity
Some will use a special table on which the circulating nurse places and opens the container. The scrub nurse then will retrieve the basket and place it on the sterile back table or Mayo stand. Others will have the scrub retrieve only the instruments as they are needed. Use whatever system works best in your facility, so long as instruments remain sterile throughout the procedure.

In 1986, as publisher of the Journal of Healthcare Material Management, I published an article by Peggy Ryan that explained how German hospitals were using their containers. They used specially designed transport carts that became the back table sterile field. They included in the container a cart-covering drape and wrapped the tray in either a disposable or reusable textile. The procedure had three steps:

• The circulator opens the containers needed for the procedure and places the lids in rails built into the carts.
• The scrub nurse unfolds the textile drape used to wrap the tray so that it forms a sterile edge to the cart.
• The cart-covering drape then is positioned to form a safe and sterile working area.

If your containers have solid bottoms and mesh-bottom baskets, dirty instruments could be placed back into the baskets and then into the container along with an enzymatic cleaner. The baskets could then be lifted out of the container and run through a washer without anyone's handling the contaminated sharp instruments. This is an important safety benefit.

Protecting instruments
Preparing surgical packs can be time-consuming and costly, and wrapped packs can develop tears and get wet, which requires rewrapping and resterilizing. Reusable wraps break down after repeated exposure to high temperatures and handling, and must be inspected and replaced regularly.

Rigid containers have been shown to be more durable and more resistant to contamination during storage and handling than conventional CSR wraps. They reduce trash volume if you are using disposable wraps, and they offer less preparation time and easier storage. They provide an aseptic system during the sterilization cycle and can be used to contain soiled instruments and supplies to be returned to the decontamination area.

Reported problems
Rigid container systems have been tested extensively and have a history of safe use, but like any equipment are not without problems. Normal handling can cause loosened rivets and worn gaskets (Fig. 4). Metal containers can become dented, scratched and otherwise deformed when dropped, thereby potentially ruining the integrity of the seal.

Some instrument sets can make the containers very heavy. Large containers, without their baskets, can weigh almost 10 pounds. Add the basket and enough instruments to fill a large container, and they could weigh more than the average supply person can safely handle. This added metal mass could also cause wet pack problems. The only solutions (assuming your steam quality is not at fault) would be to reduce the number of instruments in the set, add moisture-absorbent towels and/or increase the drying time. Towels laid out on the sterilizer rack would also help.

Plastic containers may retain EtO residue and can have the same condensate and weight problems found in metal ones.

Some container systems' latches and welds are easily broken. A good in-service by the manufacturer will often take care of this. Container systems are prone to being abused by poorly trained technicians.

Containers typically occupy more space than wrapped instruments, which can cause space problems in storage areas and decontamination.

Purchase considerations

• Try before you buy. Sample enough types of packs.
• Measure available space.
• Familiarize yourself with all the available options: dividers, pegs, clips, silicone racks, delivery and storage carts and interior basket types and sizes. Know if they require a major change in the way some of your sets are put together.
• Volume is the key to cost-effectiveness. A container used 15 times per month will pay for itself in a year; if used once or twice a month, it may take 15 years to recover the cost.
• Consider the time you'll save by using containers to improve your workflow and the efficacy of procedures that will be different.
• In addition to a quantifiable savings of time used to remove the instruments from returned trays, there is also the non-quantifiable cost of saving employees from sharps cuts.

Just-in-time, not just-in-case

Remember that preparation of sterile supplies using container systems should be just-in-time - not just-in-case - because they have to be used to be cost effective. Otherwise, sterilization containers are very expensive storage boxes.