ON THE FRONTLINES Are your sterile reprocessing techs doing all they can to prevent healthcare-associated infections?

Pathogens, along with being invisible to the naked eye, can jump from person to person in any number of ways. That makes the battle against infections both complex and daunting. Still, out of sight can't be an excuse for out of mind. Just the opposite, in fact. An invisible enemy demands keen awareness and extreme diligence. The experts we talked to recommend these often overlooked practices to boost your sterilization efforts.

1. Train and certify
It starts with making sure people are properly trained, says Frank Myers, M.A., CIC, a third-level infection preventionist in the UC San Diego Health System and a member of the Association for Professionals in Infection Control and Epidemiology (APIC) Practice Guidance Council. Facilities often hire nurses and medical assistants who have no experience with sterilization, he says.

"I've seen a tabletop sterilizer literally being crammed full of instruments well beyond its capacity," he says. "The staff at this facility didn't understand that that was not the way to run a sterilizer. They didn't have a person there who was really competent."

The added danger is that a lack of competence can be baked into facility culture and passed down to future hires, says Mark Duro, CRCST, FCS, director of sterile processing operations at New England Baptist Hospital in Boston.

"Most sterile processing departments get their staff through environmental services, patient transport, or somebody just randomly walking in without any real background or knowledge," says Mr. Duro, who consults with numerous hospitals. "Their training might be, Well, this is how we do it here. That mindset needs to change."

One answer, he says, is to require certification of sterile processing staff, something currently mandated by only a handful of states. "Every hospital does things differently," he says. "But everything is based on instructions for use (IFUs). If staff can't understand or interpret an IFU, they may improperly process a device, and that can lead to infections."

EDUCATION MATTERS If sterile processing staff aren't properly trained and certified, a lack of competence can be passed down to future hires.

It's easy to throw instruments into a sterilizer, push a button and hope for the best, as casually as one might while loading a dishwasher at home, but competent high-level disinfection requires in-depth training and understanding. "When you press the button on a sterilizer, it's important to know what's going on and to be able to interpret the printout," says Mr. Duro. "Some facilities just print them, sign them off and file them. They don't even read them.

"An uncertified staff member in sterile processing can be very dangerous," he adds. "We can't make decisions based on opinions." Certification, he says, provides the needed foundation: "(It's) how to put instruments in a washer, how to pack a kit, how to lay out instruments when you build a set, what you're looking for when you inspect an instrument, and so on. Take a basic instrument like a needle holder. You don't just put it on the stringer and wrap it and sterilize it. You have to look at it, make sure the tips are right, make sure it's functioning properly and make sure it's clean."

Of course, not all smaller facilities have sterile processing departments. They may have just one person who's trained and competent. "But what happens when that person goes on vacation and the clinic stays open?" asks Mr. Myers. "It's a battle for us (at APIC). You want people who do the task to do it a lot, because the more they do it, the more likely they are to be competent." But the flip side is that when that person is out, the task falls to somebody who does the job rarely and is bound to be rusty.

A facility may have recently added a new type of endoscope with a different design and different channels, and the backup may not have been trained on it yet. If the lead person calls in sick one day, the backup suddenly has nothing to go on other than trying to read and understand the IFU, "which is a pretty scary situation," says Mr. Myers. How can you make sure your backup maintains an adequate level of competency in a one-person department? APIC recommends having the understudy do the job at least biweekly, under the supervision of the primary person.

DRIED ON Instruments that aren't pre-cleaned in the OR become much harder to sterilize.

2. Give sterile processors a hand
No matter how well-trained sterile processing staff are, they still need help they're not consistently getting. Decontamination should start in the OR. "But the problem is everyone's in a hurry," says Mr. Duro. "It's, 'Let's get this stuff out of here and get ready for the next case.'"

Too often, he says, instruments aren't pre-cleaned and thereby become much harder to clean, because blood, bioburden and bone dry and harden. "It's like trying to clean a lasagna pan that sat out overnight," says Mr. Duro.

Instruments might need just a quick wipe down. They might need to be hit with a cloth and some sterile water. Or they may require some enzyme spray or foam. "OR staff know which instruments have been used and what needs to be done," says Mr. Duro. "It takes a little time, but it shouldn't be a deal-breaker."

Leftover surgical residue also damages equipment, causing pitting and ultimately making instruments impossible to sterilize, says Mr. Myers. "You can't clean it if it's pitted, because there's no way to get in and make sure all the organic material is gone. You can put it in the sterilizer as many times as you want. It's still not going to be sterile."

3. Use AERs that also clean
The sterilization challenges associated with some instruments may simply be too demanding to perform manually. Mr. Myers recommends using not just automatic endoscope reprocessors (AERs), but also using those with "cleaning claims," which most don't have.

"The literature shows that when endoscope cleaning is done manually, there's only about a 1% chance you're going to do all the steps, in the right order, and do them correctly," he says. "And when people use the regular AER, it's still done correctly only about 80% of the time, because of problems with manual cleaning." For example, guidelines say to use a brush and then examine the brush for physical debris. "When I was 20, my eyesight might have allowed for that," says Mr. Myers. "But now, what I see is very different."

Also important: AERs don't succumb to peer pressure. "I've seen people trying to (manually) go through the cleaning process, and then suddenly 2 or 3 more endoscopes land, and they're told that these need to be cleaned now," says Mr. Myers. "Whether we want to admit it or not, you're psychologically pressuring that person to move faster, even if you say take your time. AERs don't feel that pressure. They clean the same way, whether there are 10 scopes backed up or just one."

4. Use rapid-read biologicals and more of them
Can you be sure your instruments are sterile after undergoing high-level disinfection? Not if you're not using a biological on every load.

"Some facilities only run biologicals with implants, or only once a week. That's bad," says Mr. Duro. "Why? Say on a Monday you put a biological in, incubate it and it's fine. You go on sterilizing kits all week and then on Thursday, you have an implant. So you run a biological, incubate it and it comes up positive. You now have to recall everything since the last negative biological, which was Monday."

The best rapid-read biologicals can be read in an hour, although those that can be read in 3 hours might be reasonable for some facilities. "(But) if you have to wait longer — like 12 or 24 hours — you're putting yourself in some trouble," says Mr. Duro, who argues that readouts on loads that don't include implants are just as important as readouts on those that do. "In my opinion, the screwdriver being used to put the implant in is very important too," he says. "There are 3 things I need to know about every load: Did the chemical indicator change, do the mechanical readouts meet expectations, and did the biological pass? I need to feel comfortable about those things before releasing the load."

Yes, there's a cost, maybe $10 to $15 per load. "But what's more important, patient safety or costs? Best-in-class hospitals should be doing this," he says. And smaller facilities aren't likely to be running more than a few loads a day. "At a hospital, it's pricey, but for an ASC that's doing 4 loads a day, cost shouldn't be an issue."

5. Keep good records
In addition to being a hot spot for the Joint Commission and others, subpar recordkeeping can be a ticking time bomb for infections.

"It's one of the problems I see almost routinely," says Mr. Duro. "If instruments are put on the shelf or go up to the OR, and then there's a problem — and you don't have accurate records — you won't be able to recall the instruments you just sterilized." You always need to be able to identify every patient a device has been used on.

6. Use safe-injection practices
When practitioners compound drugs, they're violating U.S. Pharmacopeial Convention standards, and it's happening far too often, says Mr. Myers. "We don't see it in hospital outpatient centers where they have pharmacies that oversee the entire process. But in smaller outpatient settings, where consultant pharmacists aren't there on a daily basis, it's still happening."

Mr. Myers says he recently had a class in which about 20% of the participants acknowledged that drugs were being combined — for example, with vancomycin — at their facilities. "These were highly motivated people from highly motivated organizations, people taking the time and trouble to learn. Many facilities don't ever send infection preventionists to national training courses. So it raises concerns about what's happening overall."

There is, he says, a prevalent lack of understanding about how easily multi-dose vials can be contaminated and expose patients to bloodborne pathogens. His advice: Insist on using single-dose vials to minimize that risk.

7. Continue to push hand hygiene
Poor hand hygiene happens for two reasons: People either forget, or they find it very difficult to practice, depending on the circumstances. One study (osmag.net/yRXZ8d) found that for anesthesiologists, compliance with recommended guidelines simply wasn't feasible.

Anything you can do to make compliance easier is a plus, whether it's taking advantage of technology that monitors the number of times each dispenser has been used, posting signs that remind people to wash for as long as it takes to sing "Happy Birthday," or sponsoring hand-hygiene fairs and passing out containers of hand sanitizer and having people compare culture plates taken from hands that have been washed with those that haven't been.

"We need to take hand hygiene more seriously in all settings," says Mr. Myers. Some forethought and planning helps: If staff members dry their hands with paper towels in the bathroom, are they throwing those towels out before they touch the door handle (and get their hands dirty again)? Having a wastebasket next to the door, so users can use the paper towel to open the door, then toss it, is a simple, but effective, solution.

SURE THING The only way to be sure high-level disinfection is always achieved is to use a biological on every load.

8. Clearly delineate
cleaning responsibilities
It's easy to assume that everyone knows where his cleaning responsibility begins and ends. It's also dangerous. "I'll walk into an ASC sometimes and say, 'Who cleans this IV pump?'" says Mr. Myers. "And a nurse will say, our medical assistant does that. Then I'll ask the medical assistant the same question, and he'll say, the nurse does that."

Point made. You may not have to single out every item, but you should at least make categories of responsibility clear — for example, all electronics are the responsibility of this person or this group.

9. Promote common sense
"I've seen medical people in hospitals get into an elevator with gloves on and press a button," says Mr. Duro. "Things like that freak me out. Who knows where that person has been and what those gloves have come into contact with?"

Could a faux pas like that lead to infections in your facility? Common sense isn't always as common as you'd like. When you're fighting an invisible enemy, it's best not to take anything for granted.