Managing Flash Sterilization

We start by addressing instrument problems associated to the following criteria;

• operating budget
• preference card management
• room turnover delays
• flash sterilization
• consignment instrumentation
• surgeon named trays
• one of a kind instruments or sets

Section three – Practice IV, 2. 

Ø Flash sterilization may be associated with increased risk of infection "to patients" because of pressure on personnel to eliminate one or more steps in the cleaning and sterilization process.

It is essential that all steps in sterile processing be performed in a conscientious manner. 

An understanding of this is simple and easy to appreciate when looking at all the information available to us today.

The process in question are the steps associated to washing, cleaning or low-level disinfection of surgical instruments prior to flash sterilization.

Step #1:     First we established an general instrument operating budget line in all four services, Main OR, CV OR, Women’s Surgery, and Out-patient; also including CSSPD budget so that they could manage the ER and other support areas.

General use surgical instruments which make up the largest percent of an instrument inventory and are not capital expenses.  Granted, some instrument can cost over $1000.00 each but that is not a good reason to capitalize them.  There is no Medicare pass-through for general instruments. 

With the operating budget in place we can now build instruments sets over the course of the year addressing volume changes, new physicians, physician changes, and best practice. 

Step #2:   Room turnover instruments issues are directly related to three areas;

• turn-over of surgeon named trays
• turn-over of consignment ortho instrument systems
• turn-over of one-of-kind instruments or sets

We eliminated surgeon named trays which allowed us to increase the number of sets associated to general, ortho, CV, and cysto procedures.  A great example is our CV Open Heart program which has no surgeon named trays, only the following; - back-table – mayo - leg - and - delicate instrument trays.

As stated by Gary S. Graham, PhD, in the Aspen publication of “Sterilization Technology for the Health Care Facility” page 4, “no quantitative standards exist for cleaning procedures”. 

Furthermore the Spaulding Classification list surgical instruments in the “Critical” category requiring “Sterilant/disinfectant” under the “EPA product classification” prior to patient use.

There is no clear documented evidence based process identified to disinfect surgical instruments prior to flash sterilization nor is there any quantitative test completed to address microbial reduction related to manual hand washing. 

Step: #3:   By managing the preference card data base we were able to re-design the computer generated cards eliminating old information and matching the tray descriptions to the CSSPD count sheet system.

We also removed tray and instrument information from the free-text instruction section of the preference card and added them to the equipment section so that they were now on the pick ticket. 

With everything identified and built in the equipment files we then could see what the daily needs actually were based of utilization from the OR scheduling system. 

Accurate usage reports can now be generated from data in the OR scheduling system from the surgeon preference cards.

Step #4:   Flash sterilization took a little longer in that the CSSPD staff had to take over the responsibility for flash sterilization.  There was no history recorded on flash logs as to what was used; only the patients name.  By assuming the responsibility and record keeping we were able to identify all the problem related single instruments and sets. 

We have also seen a reduction in repairs previously caused by over use of flash sterilization and the effects on surgical instruments.

Manual hand washing in a sink with little if any proven ability to render the instrument disinfected does not meet the Spaulding Classification or standard of care from patient-to-patient. 

There is also numerous published articles regarding biofilm and the ability of prion’s too survive terminal sterilization. 

Knowing that there are no quantitative standards supporting microbial reductions by hand washing of instruments should send a clear message to everyone in the profession that this process needs to be stop.

Better yet it should only occur when and instrument is contaminated during a procedure and there is no replacement available for that same patient; "NOT" patient-to-patient.

There are steps that must be followed starting with soaking to manual removal of visual bio-burden in the OR to high-level disinfection utilizing an automated washer; that must be followed to address the shortcomings associated to the care and handling of surgical instruments.

These steps may not be addressed in the Spaulding Classifications but there are levels of disinfections that should be adapted by CSSPD and the OR staff.  (see tables below).