Question: I was always taught that you must re-sterilize or dispose of (if it is a single-use item) any sterile package that falls on the floor. I've been hearing about some facilities that don't follow this policy. Can you pick a sterile pack up off the floor and put it back on the cart or shelf?

Answer: Infection control specialists are finally re-evaluating this sacred cow. The short answer is that you should stop the practice of discarding or recycling sterile items that fall on the floor. The problem with this practice is that it doesn't take into account the wide variety of circumstances that "falls on the floor" encompasses.

I believe it started with double 140TC muslin-wrapped trays and packs. The theory was that the force of the impact with the floor would implode air (and contamination) through the fabric onto the sterile item. There are several problems with the theory.

• First, it doesn't really happen. I debunked that theory 30 years ago by dropping various sized packs from various heights after first dusting the outside surfaces with a fine powder. We never could get the powder to "implode" into the pack. It's time we put it to bed.
• Second, very few, if any, facilities still use 140TC muslin. It has been proven to be in inadequate barrier even when new, let alone after many, many launderings. Most facilities use either a higher thread-count fabric or disposable wraps, either of which is far superior to 140TC muslin as a barrier material.
• Third, the theory doesn't take into effect the differences in the items being packaged. It treats cotton balls in a plastic bag the same as a 20-pound orthopedic tray in a cloth wrap.
• Fourth, it doesn't differentiate between sterilizable and single-use/disposable items. Under the old policy, if a sterilizable item fell on the floor, you simply picked it up and sent it back through the system. But what happens when a single-use product hits the floor?

'See if anyone is watching'
I used to ask my audiences, "What is the first thing you do when a single-use/disposable sterile item falls on the floor?" After getting many varied answers, all of which I would shake off, I finally told them, "The first thing you do is look around to see if anyone is watching."

This always got a laugh because in many instances it was true. The person who dropped the package (for example, a catheter in an all-plastic bag) knew it was not damaged and certainly not contaminated as long as there was no hole in the bag. Common sense said to put it back on the shelf. But uncertainty persisted, as this was clearly a violation of the "dropped-on-the-floor" policy. A double standard then developed between hospital and industry packages.

The policy was so pervasive that hospitals would set aside a barrel or carton to collect single-use items that fell on the floor so that they could send them to third-world nations! Several doctors initiated these so-called relief expeditions of perfectly good items being carted off overseas simply because they fell on the floor. It drove me crazy that these well-meaning professionals had so little common sense and blindly followed an arcane policy without challenging it. Our lectures and writings gradually got people to thinking about what they were doing and the policy has been, by and large, moderated.

What should your policy be?
There is certainly a difference between the cotton ball package and the ortho tray. These decisions are easy. The cotton balls are still sterile, so why not put them back on the shelf? Should you wipe off the package with an antiseptic wipe before placing it back on the shelf? Well, it depends. Did it fall on a floor right after the floor had been cleaned (Fig. 1) or did it fall on a highly contaminated floor (Fig. 2)? Decide each case on its merits and be sure the person(s) making the decisions is trained to make the right ones.

The ortho tray is also an easy solution. It should be picked up and examined for damage to the wrap, the tray and the instruments and devices in the tray. Finding damage, of course, warrants a complete re-doing of the tray.

There are an infinite number of items that fall between these two extremes. All staff that handle sterile items should be trained to make a judgment in each case. If they can't do it, institute a policy where all dropped items are brought to someone who can make informed decisions. No more double standard. In either case, stop following this mindless practice of discarding or recycling sterile items that fall on the floor.