Accelerating set turnaround; Establising a case cart system
with Ray Taurasi

Question: I am an OR nurse manager and have instituted procedures to curtail the routine flashing of surgical sets. I have been working with our CPD manager to implement a method to accelerate turn around times especially when OR scheduling requires a fast turn around of certain sets for back-to-back procedures. My preference is to have all instrument sets go to CPD for reprocessing and terminal sterilization. I am not asking for any short cuts or steps to be rushed or skipped in the cleaning, inspection, assembly or sterilization process. I just would like CPD to prioritize designated sets and when requested or needed to expedite their processing. There are many times we have called for sets to be sent back to us following a fast turn around request and the CPD manager has stated the sets can not be released for use until they are totally cooled down. If I insist upon the sets being returned he will open the sterilized sets and tell us they will need to be flashed. The sets in question are in sealed sterilization containers and I see no reason why they cannot be released prior to "total" cooling for immediate use. He maintains that the release of hot instrumentation would be a breach in technique, as condensate would create excessive moisture inside the container and cause contamination. We are at an impasse here and I would appreciate your thoughts and any information you may be able to offer that may help resolve this issue.

Answer: Certainly best practice would be to allow all sterilized goods to be thoroughly cooled prior to handling, or releasing for distribution or use. Goods wrapped in woven textiles or non woven disposable packaging materials should never be handled or released for use until they have thoroughly cooled and must be considered contaminated if any moisture is present on the inside or outside of the package. If your sealed sterilization container has offset perforations between the filter retention plates in containers lid and base which creates a torturous path, minimizing the risk of microbial strike through, under the circumstances you described the sets may possibly be released prior to complete cooling for your immediate use. Since there are great variations in container design and technology I would suggest that you consult with your specific container manufacturer for advice and documentation. To ensure sterile integrity and sterility maintenance protocols should be implemented which will minimize the degree of handling and detail the care, movement and logistics of sterile packages. There are rigid metallic sealed sterilization containers now available which have FDA 510k clearance for use in Flash Sterilization and Express abbreviated cycles which can be processed in remote locations i.e. CPD and safely transported to the OR prior to total cooling without the risk of contamination.

Question: We are doing some major renovations in our OR and CPD areas and are considering a case cart system. There are three issues we are debating and would appreciate any assistance you might offer.

1. How many case carts are required?

2. How much space is required for a case cart system?

3. Are open or closed case carts better?

Answer: 1.Number of carts required

There is no one set answer that will work for all institutions. The answer will vary among organizations depending on procedures, processes, type of hospital, procedure case load, physical design, logistics and the services and specialties offered. The goal is to have enough carts to run at peak capacity. Some sources recommend you have 3 carts per OR – 1 in use, a 2nd ready for the next case and a 3rd in processing. Some hospitals plan for a case cart for each surgical procedure ( #cases per OR per day x #ORs = # case carts required ) plus 2 C section carts and 1 case cart per specialty e.g. emergency, cardiac, ortho, neuro, trauma etc…

2. Determining space requirements –

Approximately 10 NSF is commonly allocated for each cart in the assembly and holding areas i.e. OR, Decontamination, staging etc. ( you will need to project the maximum number of carts likely to be in these areas at one specific time period)

Here again there is no fast formula – more or less space may be needed based on uniqueness of each individual hospital and types of carts selected e.g. tall, short ,wide narrow and the like. Measurements of carts can be taken (include all appenditures such as bumpers, handles, door swings etc.) project the anticipated maximum number of carts to be in given area at one time allow for a 10% variance and a clearance of at least 1 – 1.5’ around cart and adjust specifications accordingly.

3. Open vs. Closed Case Carts – From a practice perspective both designs are acceptable and both have advantages and disadvantages. The decision basically gets down to user and facility preference based on needs and uniqueness of their facility’s design, policies and procedures. Some advantages and disadvantages to consider in the selection process include the following:

• Lighter in weight

• Lower in cost

• Provides visibility

• Easier to clean; facilitates better drying

• Requires covering in transit

• Increased potential for compromising technique and sterile integrity

• More difficult to contain contents

• Maximum security and protection of contents

• Minimizes the risk of environmental contamination

• May need larger size as there’s no give for expansion

• Heavier weight

• Higher cost

• More challenging to clean and dry

• Doors require more space for opening

• Working mechanisms and doors prone to damage; greater maintenance may be required. HPN