Central Sterile


Upping the odds of
successful decontamination
Experts come clean on common shortcomings, best practices
by Julie Williamson

If professional prestige were based purely on job importance, those working in decontamination would be considered among the most elite in healthcare. After all, quality patient care hinges on the surgeon’s ability to wield properly working instruments that are free of blood and bioburden, and don’t pose an unnecessary infection risk.

Despite the undeniable importance of instrument decontamination, those in charge of the process would agree that the task is anything but glamorous. High temperature and humidity, and bloody instruments — coupled with many facilities’ challenges of insufficient workspace, inadequate workflow, outdated equipment and high staff turnover — create a less than desirable environment for central service professionals.

"If that weren’t enough, there’s also the challenge of having to increase [throughput] to meet the instrumentation demands of the operating room, and disassemble and clean more complex devices," explained consultant Charles Hancock, president, Charles O. Hancock Associates Inc., Fairport, NY. "Even though it’s an incredibly important job, it’s often a thankless one. When you put it all together, you can really see that the decontamination area is just not an easy, or particularly pleasant, place to be."

Easy, no. But it can be dramatically improved if CS managers and technicians are proactive and committed to making to a few key changes both in and outside the department, sources told Healthcare Purchasing News.

Quality trumps efficiency

There’s no doubt that time is of the essence in CS, and that’s never been more true than today. Case loads and surgical volume are multiplying in many facilities, and because many hospitals aren’t matching that growth with more instrument sets, that’s putting even more pressure on CS personnel to streamline efficiencies and meet sometimes unrealistic demands.

Not surprisingly, experts warn that rushing the process is the single greatest problem plaguing decontamination. "When you’re constantly working under a time crunch and are afraid of being yelled at for not having instruments ready fast enough, there can be a tendency to cut corners to speed up the process," noted Natalie Lind, CRCST, CHL, a sterile processing veteran who now operates Lind Consulting Services, Ada, MN.

Gregg Agoston, manager, Protection 1 Services, Karl Storz Endoscopy America, has seen those shortcomings firsthand. He has witnessed "significant breaches in technique" that can not only harm the instruments, but the patient as well. Some facilities, he said, are so afraid of breaking delicate instruments, such as scopes, that staff opts to simply wipe them down – or even just rinse them with water — rather than properly disinfect them. He’s also seen staff use saline, which can corrode instruments, and harsh chemicals not approved for use on surgical devices (such as floor cleaner). Such gaps in technique stem from inadequate education and mounting pressure to increase productivity – often with too few employees.

"I believe there’s too much focus on throughput and less on quality," Agoston noted. "I’ve seen people cut corners and I’ve seen processed instruments filled with dried blood. It just goes back to that same point: You can’t sterilize what isn’t clean."

The good news is there are ways to become more efficient without compromising quality. Even better news is that some of the most effective strategies are also the simplest and least costly. First and foremost, sources agreed that effective decontamination – and sterilization, for that matter – requires ongoing interdepartmental training, and a hands-on manager who is accessible to staff and keeps a finger on the pulse of the changes and challenges impacting the department.

Equally important is keeping instruments moist to prevent blood and body fluids from drying on them. "Instrument cleaning really needs to begin at the point of use," said Rose Seavey, R.N., MBA, CNOR, director of sterile processing at the Children’s Hospital in Denver. "We want the instruments to already be soaking before they enter the decontamination."

Rick Schultz, president and CEO of Stow, OH-based Spectrum Surgical Instruments Corp., stressed that moisturizers and enzymatics are highly effective, but added that even a simple moist towel can get the job done.

"Using a [suitable] spray-on product or a surgical towel with water on it in the O.R. is fundamental to helping the decontamination process. And it hardly takes any time at all," Schultz said, acknowledging that the barrier to adopting the practice is much less about time than lack of education on its importance.

The O.R. isn’t the only department needing the education, either. Instruments used in other areas, such Labor & Delivery, can prove particularly challenging because they often aren’t picked up and taken to decontam until many hours after the procedure, Schultz pointed out.

"These instruments are often loaded with blood and fluids. They should be treated just like surgical instruments." Spectrum Surgical’s Spectra-Moist is a detergent-based, spray-on moisturizer that keeps instruments moist for approximately four hours. One 32-ounce bottle costs $10 and can take care of an O.R. for up to two months, according to Schultz. "All it takes is a couple sprays per tray."

Clean designs

Poor set-up and flow in the decontamination area can also negatively impact outcomes. Many departments don’t have enough sinks or floor space, for example, which makes managing and maneuvering heavy instrument sets an almost impossible task.

"I can’t stress enough the importance of good flow and design in the decontamination area. How is a person supposed to handle a 30-pound instrument case if there’s no room to move around and not enough sinks or workspace available?" asked Lind. She added that good lighting is also critical for providing staff with a better view of the instruments being cleaned.

Of course, having good, up-to-date equipment can also go a long way in improving efficiencies in the decontamination area. Today’s washer-decontaminators, for example, have greater capacity, speedier processing times and multi-cycle programming features to increase productivity and improve outcomes. Still, even the most cutting-edge technology can’t replace the need for effective cleaning products and accessories. Lind said she’s seen some facilities using the same old brushes that came with the instruments when they were first purchased. Further compounding the problem is that many departments use the wrong size brushes. "If they’re too big, they can damage the instruments. If they’re too small, they won’t be able to properly clean," she explained.

Having systems and controls in place that can make employees more comfortable while in the decontamination area is also important. The Children’s Hospital is in the process of building a brand new facility that will allow the decontam area to control humidity and temperature – and keep the controls separate from the rest of the facility.

"We’ll have negative air flow with air piped in to make [the area] more comfortable," explained Seavey. Ergonomic issues have also been considered. The facility has a 20-pound weight limit on instrument sets.

New York-Presbyterian/Columbia University Medical Center is also undergoing a departmental redesign – a positive change that will allow the department to meet increasing surgical volume. The department processes between 52,000 and 59,000 pieces each quarter, and because the facility will be taking on approximately 1,600 more cases this year, that volume will jump even higher.

"I looked at the increasing volume and then our space and knew there had to be a better way," said Lorraine Gatti, R.N., director of O.R. Support Services for New York-Presbyterian/Columbia University Medical Center. "Being in Manhattan, though, space comes at a premium, so we have to make the most out of the square footage. Everything will be streamlined here." The redesign will feature seven washers and six workstations with custom sinks that are 30 inches wide and extra deep. Each station will have handheld compressed air and hot water in a nozzle, along with a restaurant-style gooseneck sprayer. The six workstations and seven washers will nearly double the facility’s current capacity.

Specialized training

In light of increasingly complex instrumentation, sources contend that it’s never been more important to build and maintain productive relationships with device manufacturers to determine the best method for managing devices.

"Not only are [these more complex devices] more difficult to clean, there is also the challenge of knowing how devices come apart – or even if they should come apart," Seavey said.

Having access to manufacturer instructions, and of course, following them to the letter, is the only way facilities can be certain that their policies and practices are up to par. Detailed inservicing on proper handling and care of instrumentation is vital to the process and, according to Agoston, should be offered at least several times per year. Aside from that, he believes training on care and handling should be part of every new O.R. and SPD employee’s orientation.

"If you have questions or concerns about how to handle a device, or about the instructions themselves, contact your vendor. I believe vendors also need to be actively involved with the end user to help support them in the process," Agoston said, adding that training should be multi-faceted. "Those in the O.R. need to be taught that the way they handle instruments can damage them and also impact efficiency down in processing. If instruments aren’t properly handled, everyone loses."

Prime examples of improper handling include unsafe packaging, stacking and transporting of instruments, and mixing of sets. "I’ve seen expensive instruments teetering on top of other sets, and I’ve seen them fall on the floor during transport. I have to explain that dropping a scope and camera is equivalent to driving a $20,000 car into a telephone pole," Agoston continued.

Some facilities are relying on specialized training to help make the most of staff resources and bring employees up to speed on the nuances of more sophisticated equipment. In some cases, that means designating staff to certain specialties and placing them more in an "instrument specialist" role. Seavey’s department does just that. The department has approximately 24 employees, ten of whom are considered "instrument technicians," which is at a higher level on the employee ladder. They are assigned to work in the instrument area and each one is a liaison for a different specialty, such as orthopedics or neurology.

"They work directly with the O.R. The nurse service leader of that service goes to that particular instrument tech with any changes or issues," Seavey said, adding that the instrument tech is responsible for making the change and communicating it to the rest of the department. "This works very well for us, and the O.R. staff like knowing who to go to — and that their changes will be made in a timely manner, as well as communicated to the rest." Still, Seavey was quick to point out that these liaisons’ instrument knowledge isn’t just limited to their designated specialty. "They still have to learn other roles of sterile processing, such as sterilization, decontam and case cart picking."

At New York-Presbyterian, the Central Sterile department is outfitted with a Minimally Invasive/Endoscopy specialty area whereby Karl Storz-trained and -certified staff members can carefully assess devices to ensure they’re in good working order. "I’ve set up a light source so we can thoroughly check instruments over before they are packaged and sterilized," Gatti noted. "That way, we can identify problems with instruments early on and avoid having devices that don’t work properly from making it into the O.R. and delaying cases."

Gatti acknowledges that her department’s hands-on, comprehensive approach to instrument management appears to go against the grain. While some facilities eagerly adopt processes to reduce the steps involved in the instrument management process, she believes her more detail-oriented approach is better for ensuring quality.

"I believe that the more steps and checkpoints there are in the process, the better the outcomes will be. If you have a good, streamlined system in place, it can be done without placing unnecessary burden on staff," she said.

Trading places

Because decontamination isn’t the most pleasant environment, sources agreed on the importance of rotating staff through the area, as opposed to having only certain people managing the process 100% of the time.

Gatti’s approach? At the beginning of each shift, every staff member goes into decontam to move instruments out more quickly. This way, she explained, no one feels penalized, and because "many hands make quick work," they can shorten the duration spent in the decontam area. To further maximize staff efficiency, Gatti advocates scheduling more employees during the evening and night shifts, and fewer during the day.

"A lot of Central Sterile departments are chock full of employees on the day shift, but then operate on a skeleton crew when they really need it, which is in the later shifts," she noted. "I do the opposite here. It’s about taking the time to identify and understand the needs of the department – thinking smart so you can work smart."

Gaining a better understanding of other departments’ roles and unique challenges is another way to work smarter. Seavey, a former O.R. nurse, knows that value firsthand and has stayed committed to maintaining positive relations between CS and the O.R. She has negotiated with the O.R. to send SPD staff into the O.R. to observe cases and also encourages the O.R. to send staff to her department for a week during orientation.