SPD weathers hustle,
bustle with OR tussling
Nadeau Della Vecchia
reduce instrument turnover time and repair frequency, OR personnel
should spend time understanding what goes on in the Sterile
Processing Department — and vice versa.
While it seems like it should be
a pretty straightforward relationship, interactions between the sterile
processing department (SPD) and operating room (OR) are plagued by friction,
strife and even animosity in many healthcare facilities.
To understand some of the hot
button issues between these two departments, I posted discussions in "PeriOperative
Department Professionals" and "Sterile Processing Department Professionals"
groups on the social networking website, LinkedIn, asking OR and SPD staff
to share the challenges they face in working together. While the
PeriOperative group was silent on the issue, those in the SPD group were
quick to respond with comments such as:
"The OR needs to understand that
SPD services more than just the OR. ER and L&D are just as demanding and
"The OR needs to understand what
"Turn-around" time is for a tray. It is definitely not the 15 to 20 minutes
given for a room to be turned around. Depending on the hospital, and tray,
this can be 4 to 6 hours."
"The OR techs do not put the
instruments back in the pans they came out of. Board more cases than we have
instruments for. Expect us to turn around a set in 30 minutes."
"When the OR calls us in SPD
asking for a sterilized surgical set, it is wonderful when they speak
clearly. What a difference it makes when I can understand them!"
In this article, Healthcare
Purchasing News explores some of the top friction points between the
OR and SPD, as reported by professionals in these departments and industry
experts, and present their suggestions for overcoming these challenges in
ways that benefit both parties — and the patients they serve.
"The relationship between the two
departments ultimately will impact patients. The better the relationship,
the better the patient outcomes and physician satisfaction. Like it or not,
we are each customers to each other, not just for the doctors or patients,
just like any business," said sterilization expert Michele DeMeo, CRCST,
CSPDT. "The subtle nuances naturally built within the confines of the
structure or foundation of each department are no different than the tiny
fractures or cracks that occur in a concrete building foundation. It is how
they are addressed that seems to dictate whether or not they remain simply
cosmetic differences or true danger spots."
Both sides agree that a basic
lack of understanding about each other’s profession fuels much of the
friction between the SPD and OR. We asked those with experience in the SPD,
OR and in some cases both departments their opinion on what the SPD and OR
should know about each other’s work environment and responsibilities to
improve workflow and relations between the two.
times and unrealistic expectations
Multiple SPD professionals stated
that OR staff do not understand how long it takes to properly clean,
disinfect, sterilize, assemble, package and deliver a tray. Most noted that
the OR dramatically underestimates turnaround times, placing unrealistic
expectations on the SPD.
"OR staff typically doesn’t
understand that it takes three to four hours to sterilize a tray properly
because most don’t have insight into or experience with what actually
happens in the SPD," said Heather Margiotta, CSS Work Leader,
Virtua Memorial Hospital. "Many think if they send down a tray it will
be fully sterile within an hour."
On the flipside, Jean Sargent,
Director, Advisory Solutions,
how SPD professionals often don’t understand the pressures placed on OR
staff to quickly turn around the OR for the next case and how errors in
instrument preparation impact patient care and case flow.
"The SPD needs to understand the
pressure OR staff is under in terms of turnaround times, keeping the
physicians happy and maintaining a sterile field, and how all of this is
impacted when they receive a set from the SPD with a missing instrument,"
said Sargent. "Incomplete sets are a troublesome issue for both sides and
cause a great deal of friction between the two. Often, the SPD and OR get
into a back and forth around how and when the instrument got lost with each
party pointing to the other as the culprit."
As someone who has worked in both
the OR and SPD, Richard Schule, MBA, BS, FAST, CST, FCS, CRCST, CHMMC, CIS,
CHL, AGTS, Director of Clinical Education for
Steris Corp., agrees
there can often be complacency within the ranks, due to poor communication,
education, and structure, both OR and SPD professionals do not understand
nor appreciate the important role and contributions the other makes
impacting patient care.
"There can be little room or time
for improvisation when it comes to missing, incorrect or improperly cleaned
instruments at the bedside during a procedure," said Schule. "In most cases,
the patient is placed in various states of analgesia, hence the urgency for
completing the procedure as quickly as possible. When SPD is unable to
provide dependable, reliable product to the clinician at the bedside, then
the patient may suffer."
It’s a two-way
While the OR expects the SPD to
deliver complete sets that are organized appropriately and ready for use,
SPD professionals point out that the sets returned to them from the OR are
often "a mess," containing instruments soiled with blood and tissue and
haphazardly placed in case carts.
"When case carts get to the
decontamination area with the instrument sets scrambled and mixed up, it is
extremely difficult and time-consuming to process the instruments," said
Tracey Rapp, Clinical Operations Director,
Integrated Medical Systems
International Inc. (IMS). "This can result in missing instruments and
incomplete trays. Many times, delicate instruments and specialty equipment
are damaged when placed under a heavy item or misplaced for transport.
Instruments can also be damaged when heavy bioburden is left on them for
long periods of time."
Carmen Ferriero III, Associate
Director of Sterile Processing Operations at
Albany Medical Center,
points out how most failures in instrument processing are not SPD or OR
issues but global issues that both parties must work collaboratively to
"While instrument issues tend to
fall on SPD, we are the last people to touch them. Just think about how many
hands these instruments go through. You have the scrub techs and nurses
counting them, sorting them, putting them back together, and handing them
off. Surgeons have them in their hands and in some cases the vendors too.
Because there are so many parties involved, instrument management must be
thought of as a global process and not just an SPD-related issue," said
Because ORs are dealing with
living, breathing patients, nothing is ever set in stone and priorities
frequently shift due to a variety of factors — from an unexpected emergency
case to a patient arriving late for his/her surgery. SPD professionals
stress the importance of OR staff keeping them abreast of changes so they
can prepare the needed instruments accordingly.
"If SPD knew a doctor was running
late or a case was ‘bumped’ or even ‘jumped to first’ this would prevent
re-work and/or at least enable them to shift priorities," said DeMeo. "SPD
will only work on the instruments that are deemed most important in the
moment. Well ‘the most important’ or needed ones sometimes change and we
need to know that. Screaming at SPD because a tray that was sent down at 10
a.m. and is not done by 2 p.m. when on the surgical schedule it appeared it
was not going to be needed and yet a case was added in the morning… that is
not necessarily SPD’s fault."
On the other hand, DeMeo points
out that SPD staff must be flexible to accommodate true emergencies when
"I would imagine OR would like
SPD to keep in mind that they are faced with a collage of shifting needs,
too," added DeMeo. "Demanding physicians and patients needing the best care
immediately is imperative and statements like ‘sorry we don’t have that to
send to you’ are not going to be received well and shouldn’t be, either."
"In my 20 years as a surgical
technologist I have had the privilege of working with a number of excellent
surgical teams working on trauma cases or elective procedures with the rare
intra-operative complication, dictating an immediate need for instruments,"
adds Schule. "You don’t have time to improvise sometimes. It can be very
critical. Unless you have the training and experience necessary to perform
and/or support procedures in the clinical setting, it can be difficult to
convey to the SPD an appreciation for the urgency sometimes needed in
Both SPD and OR professionals
expressed frustration with regards to instrumentation terminology and
knowledge. It makes the SPD’s job more difficult when OR staff members
request instruments using their own terminology for the devices rather than
using the proper names. On the other hand, OR staff become frustrated when
they ask for instruments and SPD staff members do not have in-depth
knowledge about the devices and their use in patient care.
"There have been times when a
nurse or OR tech has called down to SPD asking for a specific device and if
it is unavailable they will ask the SPD professional to recommend an
alternative," said Margiotta. "What OR staff don’t understand is that while
SPD staff are trained to understand the instruments themselves and how to
care for them, most do not have in-depth knowledge around what those devices
are used for in the OR so they can’t simply suggest a substitute. OR staff
get frustrated with this but they must take into consideration the role of
the SPD and the extent of training these professionals receive in regards to
challenges via communication, collaboration
We asked professionals from the
SPD and OR and other industry experts for their recommendations on how these
departments can overcome these and other challenges, removing hurdles and
making everyone’s work lives easier, more efficient and more effective. They
provided the following suggestions.
For an SPD or OR staff member who
would like to improve interactions between the two departments, experts
recommend that he or she should identify an ally within the other group.
Schule suggests seeking out an individual who is confident, knowledgeable,
vocal in his/her department, a visionary and someone whom others listen to
"Good communication and
interpersonal skills are critical to fostering better relations between the
OR and SPD," said Schule. "Efforts such as this must be led by strong
individuals who serve as cheerleaders for their respective departments. Once
you’ve identified a potential ally, sit down with them over coffee to
discuss challenges and expectations then collaborate on whatever is
necessary to move forward."
At Ferriero’s facility, both the
SPD and OR report to the same person, creating "shared initiatives and
facilitating an effective problem solving process by making issues team
issues rather than compartmentalizing them down to departmental issues,"
explains Ferriero. As in many facilities, the SPD previously reported to
materials management. Ferriero comments:
"Even though SPD is not clinical
in the traditional sense of the word, everything we touch touches the
patient so it makes sense for the SPD and OR to report together," said
Ferriero. "This reporting structure enables the right people to be at the
table when brainstorming ideas and making decisions around instrument
handling and processing. Someone in materials management likely knows that
the hospital purchased $1500 forceps but they typically don’t understand
what they are used for and why they keep getting broken. These are the kinds
of issues the OR and SPD are best suited to address. When you bring the
right people to the table that’s how you can make the best decisions not
just for the patients but also for the whole team."
Open the lines
The experts agree that the SPD
and OR must open lines of communication between the departments paving the
way for better understanding of each other’s expectations, needs and
challenges. Sargent suggests a member of the SPD department attend the daily
OR morning meeting to hear about the latest case schedule and room
assignments. That way, the SPD can be prepared to address last minute
changes and challenges that arise.
"By being there in the OR meeting
the SPD liaison has first hand knowledge of what’s occurring that day and
issues that are likely to impact his or her department," said Sargent. "For
instance, the OR may have nine cases scheduled that all require the same
instrument set while the hospital only has eight of these sets. The OR
doesn’t necessarily know there are only eight sets so having that SPD
professional in the room enables both sides to identify this issue up front
and set in motion steps to address it, such as collaborating to get one set
back to the SPD as soon as possible so it can be ready for that last case of
To better understand the
challenges each are facing with regards to surgical instruments and
equipment, DeMeo recommends SPD and OR staff conduct rounds in each other’s
departments, hold joint department meetings, have collaborative educational
sessions and share both the wins and areas for improvement together.
"The SPD and OR need to see
themselves as a team, not just when they want to be included, but always,
through the good and tough times. That’s how a team is built," said DeMeo.
Walk in each
Many facilities have implemented
programs where SPD and OR professionals spend time in each other’s
departments to understand one another’s processes and challenges. Matt
Ofenloch, Staffing and Development Manager, IMS, explains how this not only
fosters better understanding of each other’s responsibilities, but can also
help a facility better maintain its surgical assets.
"Having SPD staff spend time in
the OR and observe a surgery from start to finish would allow the SPD staff
to understand all important aspects of the surgery," said Ofenloch. "They
would gain understanding of how each instrument is used and why it is
important to that procedure and patient."
"In return, having OR staff
members each spend a day or two in SPD would allow them to understand the
decontamination, assembly and sterilization processes," added Ofenloch. "OR
staff would better understand why it is important for them to keep
instruments organized in the original trays and use an instrument pre-soak
spray. By understanding the complete cycle of use and reprocessing, these
two teams can work together to reduce instrument turnover time and repair
Ferriero explains, at his
facility, every new OR technician must spend four days in the SPD to learn
about the department’s process and issues and see them first hand. In
addition, Ferriero has hired two OR technicians as case cart coordinators to
help bridge the gap between the SPD and OR. He notes how these individuals
have brought with them inside knowledge from the OR that has helped the SPD
make informed decisions about how they prepare and deliver sterile supplies.
"These individuals now serve as
our main service lifeline to the OR," said Ferriero. "When the OR calls down
to SPD they get somebody on the other end of the line who speaks their
language and can easily decipher nicknames for products and can also
troubleshoot and provide effective alternatives in certain situations where
the desired product may not be available. It has been eye opening for these
techs to be on the other end of the process and live the challenges we face
each day when communicating with the OR."
DeMeo notes how it is equally
important for SPD staff to experience the OR and the challenges its staff
faces in patient care.
"The SPD staff is a little
sheltered in the fact that they don’t see the tension that happens in the OR
and often do not have to face an angry physician when there is an instrument
issue," said DeMeo. "When a problem surfaces OR staff cannot simply walk
away. They must deal with it immediately and safely for the patient’s sake.
This is another reason I have always advocated SPD rounding for each case in
the core of the OR."
According to Schule, another key
to successful SPD/OR interactions is for facilities to implement quality
management systems around the handling and preparation of instruments and
equipment both in the SPD and OR. Schule is currently co-chairing AAMI/ST/WG86
Quality Systems for Device Reprocessing, a new document the Association of
Medical Instrumentation (AAMI) is tasked with developing on implementing
quality systems for reprocessing medical devices.
"Once we remove the emotion
surrounding an event and can focus on the elements and requirements of the
process we can begin to improve the working relationship," said Schule.
"More specifically, stakeholders must begin to embrace and appreciate
opportunities gained by implementing quality management systems as a
fundamental foundation in developing a structure of support to include
regular communication and scheduled education around a system of documents
and reoccurring process audits.
"We cannot simply state we expect
instruments to be delivered to SPD at the end of a clinical procedure in the
same manner received by the OR without educating the end user on the
rationale," he added. "This is no different than the OR expecting
instruments to be present and functional within a trauma tray without
educating on the importance and rationale behind the clinical implications
and the impact on patient safety."
plan and stick to it
Most relationships require
constant attention and work to remain successful and mutually beneficial,
and the alliance between the SPD and OR is no exception. Those interviewed
stressed the need for the two departments to establish a solid plan by which
to improve communication and collaboration, hold their staff and each
other’s accountable, and stick to it.
"They need to have a full game
plan — here’s what the problems are, here are the solutions and here’s how
we will achieve them," said Sargent. "I recommend starting with a defined
plan of action, encompassing the next six months, that includes specifics on
how the two departments will work together on a daily, weekly, monthly
All agreed that SPD and OR staff
must be proactive in their efforts to reduce friction and foster better
relations between the departments. Ferriero encourages SPD staff members to
seek out OR staff, speak with them and ask questions.
"As a department leader I try to
encourage my staff to get out there. When they have some downtime I
encourage them to talk with the OR nurses during the different shifts," said
Ferriero. "I also get our staff in to see surgeries when they can so they
can watch how instruments are used and ask questions."
Margiotta too stresses the need
for SPD professionals to be proactive in their interactions with the OR,
"SPD techs should take the initiative to go
to the OR, observe and ask questions. Actions such as this go a long way in
overcoming the frustration that occurs on both sides as a result of
miscommunication and lack of knowledge."