Pretreating is prerequisite

Jan. 21, 2022
No more excuses not to clean at point-of-use

Pretreating instruments and devices in the operating room (OR) and other procedural areas following their use and before they are sent to the Central Service/Sterile Processing & Distribution (CS/SPD) department is not only specified in manufacturers’ instructions for use (IFU) but also provides significant benefits to all stakeholders.

Effective pretreatment post-procedure helps prevent bioburden from hardening on surfaces, which can improve decontamination/cleaning effectiveness, speed reprocessing times and protect instruments from damage. It is a win/win for OR and CS/SPD teams – streamlining workflows and improving patient safety.

So why are pretreatment compliance rates so low in some healthcare organizations and what can stakeholders do to increase compliance?  

Barriers to pretreatment

While clinicians, CS/SPD professionals and other stakeholders (e.g., infection control/prevention) should be aligned in their goal to deliver effective and safe patient care, misconceptions, miscommunication and individual job pressures can derail their efforts.

That’s not my job

When working with OR leaders and staff members, Mary K. Lane, MHA, CSPDM, CSPDS, CSPDT, MK Lane SPD Consulting, has come up against the belief that point of use (POU) pretreatment is not their responsibility.

“It’s almost as if it’s beneath them to engage in any type of activity that they believe is related to the cleaning of surgical instruments,” she said.

Lack of understanding for the importance of POU pretreatment among OR staff members is a prime reason why the practice is not done routinely, explains Seth Hendee, CRCST, CIS, CHL, CER, CSPDT, CFER, HSPA Approved Instructor, Clinical Education Coordinator, SPD, Healthmark Industries.

“Lack of understanding is the tough challenge because it has two factors of its own,” said Hendee. “First is that ‘precleaning’ is not an OR staff member’s job, though IFUs say different. Second is underestimating how difficult biofilms formation makes the rest of the process and how ineffective it can make disinfection and sterilization processes.”

When healthcare organizations attempt to implement POU pretreatment policies, Key Surgical Clinical Educator Michelle Lemmons, RN, BSN, PHN, CNOR, CCSVP, says they often come up against resistance to change from the OR team, stating:

“Often, new workflows are ‘communicated’ by a general order such as an email stating, ‘This is what you have to do now.’ OR professionals are not given context or adequate information about the motivation for the changes. Compliance to the adding, deleting or changing the workflow of a large group of people requires more than an email or a 15-minute meeting. It requires education, conversation, time for questions and follow-up conversations.”

With regards to the pretreatment of ultrasound probes at the POU, Ken Shaw, President of the Americas, Nanosonics, says the expanded use of ultrasound throughout clinical departments, such as emergency and burns units, presents challenges to compliance. The healthcare organization must reach all the various staff members preparing and using probes to educate them on why they need to perform pretreatment.

“Ensuring the probe is properly cleaned before sterilization or disinfection is essential, since the presence of gross soil may interfere with subsequent reprocessing steps. Most probes can be cleaned at the POU with a detergent wipe (do check probe IFUs),” commented Shaw.

I don’t have the time

Leaders and staff in the OR face the same challenges as those in the CS/SPD, including labor shortages, pressures to work more efficiently and increasingly complex instrumentation, explains Sharon Hadley, Principal Consultant, STERIS. Therefore, lack of time is often cited as a reason for not performing POU pretreatment in the OR.

“Until recently, POU cleaning hasn’t been a focus for OR staff. OR staff training (or lack thereof), coupled with the demand to decrease turnover times in the OR has led to instruments being delivered to SPD in less than acceptable conditions,” said Hadley. “Excuses for non-compliance (‘I don’t have time’) have been accepted. Even though both AORN [The Association of periOperative Nurses] and AAMI [The Association for the Advancement of Medical Instrumentation] has set a standard for how to care for instruments at the POU, accountability for compliance has been neglected.”

Products are hard to find/use

Mike Rischmiller, Lead Chemist, Ecolab, says another barrier cited by OR staff members for low pretreatment compliance is inability to find products to perform the job.

“They can’t always find the prespray because it’s not in their OR or available, and they won’t spend time looking for a bottle if it’s not right there,” Rischmiller commented. “Having the prespray available all over the place makes it easier to follow the protocol and it’s not an issue once staff gets in the habit of doing it.”

Ali Shrader, Product Manager for Belimed’s Protect line of consumables, commonly hears OR staff members complain that hand fatigue from the repeated spray trigger motion and weight of the pretreat bottles leads to poor or incomplete pretreatment practices. 

“After getting feedback from many customers around common objections to consistent pretreat application, we saw the need for a better application method,” said Shrader. “We recently launched the Belimed Protect Pretreatment Foamer, which ergonomically applies the product with triple the coverage in the same application time. We also completed an aerosolization study that shows product applied with the foamer does not aerosolize, making it safe to use in the OR.”

Tips to improve compliance

Pretreatment products should be implemented within the context of staff education and training, leadership support and policies and practices to promote accountability.

Call it what it is

With pushback from OR teams that instrument “cleaning” is not their job, change in terminology is one way the industry is fighting the battle for improved POU compliance.

“As an industry we have done a couple of things,” explains Hendee. “The first has been to shift to using the term ‘pretreatment’ instead of ‘precleaning’. The thought being that removing the ‘cleaning’ portion of the term will make those who feel precleaning is not a POU responsibility and should be done where the rest of the cleaning is done think differently.”

Mary Ann Drosnock, MS, CIC, CFER, RM (NRCM), AAMIF, FAPIC, Director, Clinical Affairs, Healthmark Industries, is the former co-chair of AAMI ST/WG 84, the working group responsible for endoscope processing. The group recently published an updated version of ANSI/AAMI ST91, which takes the issue of terminology straight on.

“We have re-termed what was traditionally on the endoscopy side called ‘precleaning’ to ‘point of use treatment’ for a couple of reasons,” said Drosnock. “To take out the connotation of cleaning because cleaning suggests using a cleaning brush and having to do all of the cleaning steps in the procedure room. We wanted to remove that connotation that the device is fully cleaned before it goes to processing.”

Drosnock says the other reason for the change in terminology is standardization. ANSI/AAMI ST79: 2017 uses the term “point of use treatment” so use of this same term in ANSI/AAMI ST91 brings them both in alignment.

Start at the top

Hadley says compliance for performing POU tasks must come from OR leadership, stating:

“I don’t think the advantages of having positive, collaborative meetings between OR and SPD staffs can be overstated. When the two departments understand their unique roles in instrument processing and work together to identify (and find solutions to) problems, accountability and compliance becomes a focus.”

According to Lane, long-term POU treatment compliance requires OR leadership to continuously champion the practice beyond the initial push, and ongoing communication between OR and CS/SPD teams.

“It is imperative for the OR staff and SPD to have a great working relationship with open communication and support from leadership,” said Lane. “Without these, we typically see the process being successful out the gate but waning when staff notices that leadership is not following through.”

Enlist champions

To bridge the gap between the CS/SPD and clinical teams when it comes to POU pretreatment responsibilities and expectations, Shaw says a collaborative champion is key.

“It takes one person who understands the needs and is driven to improve patient and staff safety,” he commented. “Whether you’re from CS/SPD or other department, collaborating with your Infection Prevention department is a good place to start to understand the landscape of ultrasound use at your facility. Secondly, adopting products and processes designed for POU can help each department own their probe cleaning and disinfection practices, while meeting the compliance requirements of your organization.”

As Hendee points out, CS/SPD staff have been trained to follow IFUs and understand that compliance to these documents is key to processing effectiveness. OR staff, on the other hand, typically do not receive this same level of direction and training on IFUs .

“In order for them (OR staff) to take the message to heart, it must come from a respected messenger who has received similar training and experience,” said Hendee. “Infection Preventionists (IPs) would be able to bridge the gap between SPD and the OR to raise compliance.”

In the case when an IFU is not readily available in the OR, such as when the surgical team uses a loaner tray, Leslie Kronstedt, CRCST, CHL, CIS, President Elect of the Western Wisconsin Chapter of the Healthcare Sterile Processing Association (HSPA), says the instrumentation manufacturer’s surgical rep can help ensure OR staff perform the correct POU pretreatment post-procedure.

“The surgical rep’s intimate knowledge of their loaner instrumentation becomes a lifeline to surgical techs and a safety net in preventing sentinel events,” she says. “The loaner rep is interested in maintaining their sets in the best shape and prolonging their life span on behalf of their company. In return, this keeps the customers happy and patients safe.”

In the surgical suite, Kronstedt suggests that the OR teams asks the rep to advise them on instrument disassembly, such as “lumens to be flushed and parts to be unhoused from one another,” which helps speed faster cleaning and quicker turnover of trays in the CS/SPD.

“This builds critical relationships between the staff in the surgical suite, sterile processing and the reps working together to streamline the cleaning process,” said Kronstedt.

Provide education and training

Hendee said successful POU pretreatment compliance comes down to the OR team understanding why it is necessary. He recommends that healthcare organizations spread education on biofilms and their detrimental effects on the rest of the process.

“Studies have shown that biofilms make cleaning harder, hinder the effectiveness of disinfection and sterilization, and can proliferate when they become mature. If all of these can be stopped with a few simple steps, I believe compliance will rise.”

Lemmons recommends cross-training between CS/SPD and OR teams so they can understand the impact of their actions on one another, stating:

“Having OR/ SPD champions and cross-training staff in both departments and using a checklist or training tool to ensure that they gain exposure to the ‘real’ workflow can be very effective. More research is coming out about the effectiveness of accountability and transparent workflows in motivating a change in practice.”

Rischmiller has seen several facilities achieve good success by having the OR staff spend a day in the CS/SPD to shadow staff and see what it takes for them to process instruments effectively and safely for re-use.

“Once the doctors and nurses see the cleaning process, they have a whole new respect for the work that goes into preparing the instruments they need,” he said. “Likewise, have CSD staff spend a day observing in the OR to understand the impact when an instrument needs to be sent back to CSD or the right instrument wasn’t included. They get yelled at by OR when the carts aren’t done right but seeing what that does to the OR schedule and patient helps them understand the importance of their work.”

With ultrasound probe usage expanding into different departments and disciplines, Shaw says organizations should start by determining where ultrasound is routinely used in a facility. Scoping initiatives at the organizational level and collaboration with department heads and staff can help guide POU pretreatment training initiatives.

“Once the probe models being used are identified, cleaning practices can be surveyed and compared to federal guidelines, standards and the probe IFUs,” said Shaw. “In some cases, a complex cleaning process requiring a centralized workflow could be replaced with a simpler detergent wipe cleaning at POU if clinically appropriate and the probe IFUs permit.”

“For semi-critical and critical probes, coupling this with automated HLD and traceability technologies designed for POU in each department can also help meet compliance needs and streamline clinical workflows,” he added.

Record and report it

In their IFUs, endoscope manufacturers state that if a scope sits for more than one hour after pretreatment before it is manually cleaned, the CS/SPD staff must perform delayed reprocessing procedures. Surgical scopes require an extended soak up to one hour, while GI scopes require up to 10 hours, as Drosnock explains.

The newly updated ANSI/AAMI ST91 features a recommendation intended to minimize this time and labor-intensive step, which can shorten a scope’s lifespan. It recommends that OR staff document the time they perform POU pretreatment and convey this information to the CS/SPD team.

“It is really about having an objective measure of that time instead of guessing if they are within the one hour,” said Drosnock. “This will help CS/SPD teams prioritize processing of incoming devices.

“There are a variety of ways OR teams can record and communicate time of pretreatment to the CS/SPD, such as a label on the container, tag on the scope, or an indicator with a chemical reaction that occurs at the one-hour mark,” she added. “It is up to the facility to decide on the method that works best for them.”

Hold staff accountable

As with any practice, maintaining POU pretreatment compliance in the OR requires consistent monitoring, ongoing measurement and leadership-backed intervention when compliance wanes.

“Both teams (CS/SPD and OR) must take ownership of the tasks for which they are responsible, and leadership must ensure there is a system for accountability put into place,” said Shrader. “If the OR is called out for each tray that isn’t pretreated, CS/SPD for incomplete sets and a tracking mechanism is established for each, this drastically improves compliance.”

Rischmiller says simple practices, such as placing a checklist or repair list on the CS/SPD door for OR staff to record missing or broken instruments, can help boost pretreatment compliance, stating:

“One example I’ve heard is a checklist when the carts are dropped off at CSD so someone has to acknowledge that all the right steps were done, such as pretreatment and tagging broken instruments.”

According to Lane, many of the organizations with which she has worked have implemented an audit tool to track compliance. Staff at the POU must also initial the audit tool prior to sending the soiled surgical instruments to the CS/SPD. She describes what happened next:

“Lack of compliance by POU staff or inadequate precleaning by POU staff resulted in OR leadership or infection prevention being notified and the staff involved were sent to SPD to clean their surgical instruments. Further the infraction was documented and if it continued it resulted in employee counseling.”

Christy M. Newland, Director of Professional Services and Processing Standards, STERIS, points out how some healthcare systems have begun measuring POU pretreatment compliance and reporting it as part of their internal quality initiatives.

“To be successful, this must be a collaborative effort between the OR and CS/SPD,” Newland said. “The roles and responsibilities must be clearly defined from all parties involved. Audits for sustainability once the POU process has been educated/trained to staff is necessary. Unless someone is focused on sustainment, staff will fall back to old habits and momentum will be lost.”

Lemmons explains how positive reinforcement is another way facilities can boost pretreatment compliance:

“Accountability and transparency can be very effective in the department setting. For example, highlighting ORs or individuals who consistently pretreat instruments at a joint OR/SPD meeting, providing feedback about which rooms are pretreating instruments and which aren’t to gain insight into what barriers may be in place to performing this step without reprimand and embarrassment.”

One system’s success story

When POU pretreatment of instruments became an industry standard, NYU Langone Hospital—Long Island, “jumped on board immediately,” said Robert B. Dybec, BSN, RN, MS, CNOR and Ruhof Clinical Specialist.

“When we started POU pretreatment maybe three or four years ago, it was with an enzymatic foam spray,” he explained. “We have an extremely busy OR and central supply and we noticed that trays that were less of a priority could potentially be sitting for longer than 72 hours, particularly on weekends.”

The OR team converted to Ruhof Prepclean Forever Wet, a neutral pH, non-aerosol humectant spray, which Dybec explains has a 72-hour life span. They also installed Ruhof ForeverPrep Pretreatment Sprayers, an automated application system for the Forever Wet spray, in every one of their ORs, including labor and delivery and ambulatory surgery centers.

They coupled the product introduction with a hospital-wide policy that OR staff perform pretreatment on every instrument tray, and education around why this practice was important to patient care and safety.

“We had to educate the OR team on why they were spraying,” explained Dybec. “They needed to understand how it benefits Central Sterile, the OR and the patient. It has really become a success story for us so much to the point that the other hospitals in the NYU Langone Health, system started adopting the policy and products as well.”

Central to the health system’s success is the great collaboration between the Central Sterile and OR teams. They regularly perform audits of instrument trays to ensure they have been pretreated following procedures in compliance with the policy. Anytime Central Sterile staff find a tray that was not sprayed, they immediately notify the OR team. They use a tracking system to identify the case in which that tray was used and the staff who performed that case are held accountable.

“On the other end if we have issues in the OR and we open a tray and notice Central Sterile didn’t do a good job cleaning we go back to them,” explained Dybec. “It isn’t a tit for tat, it is really all about making it the best for everybody. We want clean instruments, they want pretreatment.” 

Original photo courtesy Bayhealth SPD, HPN's 2021 SPD of the Year, with affects added by generative AI.
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