manager SPD

[Guest]

My hospital is trying to reduce their high flash rate which is primarily caused by loaner trays that need to be turned over for later cases. There is usually more than one tray that needs to be cleaned and resterilized. Sometimes the later case is the very next case. Keeping this in mind, plus the fact that wrapped instruments should not be touched until they have had an opportunity to cool at room temperature, I have taken the initiative to require sterile gloves be used to move the tray off of the hot autoclave cart, placed on a surface covered with a sterile cover and then covered with another sterile cover. These instruments need to travel in an unrestricted, public hallway to the OR to the point of use. My boss says this is unnecessary expense. In good conscience, I cannot discontinue this practice if they need the instruments in the OR before they have had a chance to cool to room temperature. Am I taking this too far? We use Kimberly Clark heavy wraps for these trays. The situation is getting tense here over this issue and I would appreciate some feed back as soon as possible. Thanks.
Jackie

[stevep]

Jackie,

We practice this same procedure. Always remember what "our" responsibilites are no matter how upset the OR gets. My way of dealing with the OR staff is if they struggle with our processes, they have autoclaves in the OR if they would rather flash them. Once I take that approach the responsibility falls on them. The good thing is that when it becomes "their" responibility they usually will let us do things the right way.

[Uprooted Scrub]

Jackie:

What about placing the instruments inside a closed case cart on several layers of towels (to separate them from the cold metal). The closed cart will protect your freshly sterilized instruments during their ride through non-restricted areas, and the towels should prevent condensation.

[Guest]

We always tell them if they want trays before they are cool, we unwrap them and they have to flash them. they used to complain, but I told them it is policy.

[jyoung]

We do the same thing, it is our responsibility to get the product to the patient bedside unharmed. The cost of an infection is a lot more for the patient and the orgainzation.

[Tim Brooks]

Jackie,
I know this is a little late but here it goes. We started by educating the surgeons, OR staff, and schedulers as to the potential risk associated to not following consistent processes. Then we completed a power point presentation showing a study that was completed by a hospital regarding the handling of consignment instrumentation and the lack of studies that support flash sterilization to the department of surgery.

We also addressed the handling of loaner trays form hospital to hospital referring to a study completed by Walter Reed Hospital. We also addressed the fact that there are no evidence based studies to support hand washing of complex loaner/consignment instrument sets prior to flash sterilization. Add in the AORN standards which also do not support routine flash sterilization and clearly address the shorts cuts that may take place during the rush to flash instruments.

This along with the legal aspects of an infection caused by the lack of a consistent process that does not support a standard of care between patients. Remember, if you are scheduling multiple cases on the same day and utilizing flash to meet the schedule then you are not providing a standard of care and you are supporting flash as a routine method. The legal system will one day address this, its only a matter of time

Additionally, the vendors have been instructed that if they do not get the instruments to sterilization 24 hours before the scheduled case then it will be canceled and re-scheduled, surgeons supported this. The vendors also know that they must maintain a sufficient inventory to support scheduled cases, for which most if not all are.

Educating the surgeons has been key to getting this all accomplished. We went from flashing over 3000 cycles in 2002 to under 400 annually eliminating six flash sterilizers from the building. If you would like, I will share the power point that I presented to the department of surgery. Hope this helps.

[chipmoore]

Flash sterilization can/could be a good practice if done correctly. There is no excuse for short cutting the cleaning step (one standard of care) and as long as a method for safe transport is employed to the point of use, the sterilization cycle does its lethal job. I’m also an advocate of using a vac cycle for Flashing, either for unwrapped porous/non porous instruments or in containers. There are many ORs with double door, pass through sterilizers for unloading flashed trays into the OR, thus eliminating the need for wrapping or containerizing.
If the OR has vacuum cycle capabilities, one method to provide a quicker turn around would be to clean the instruments (i.e. loaners) in CS, prepare the set into a container and send it to the OR for the sterilization cycle (again, vacuum is recommended especially for containers). No need for the dry cycle because the expectation for flash is wet anyway.
Flash sterilization can save not only time but money. Doing it right is the key.

Chip Moore
Somewhere in Western MN

[Harvey Johnson]

The key to your argument for flash is absolute control over cleaning and process before, during and post flash.
That's creating a big margin for the human error that could occur with one unforgiving misstep.
More so I believe than with the standard sterilization process.
A good way to test your theory, if you are agreeable Chip, is to direct all instruments be flashed the next time you are on the table for a procedure.....all in the interest of science, of course....:D

[Tim Brooks]

Jackie,
A few more thoughts. Flash sterilizers add on-going cost over the life of the sterilizer that can better be spent in increasing the instrument inventory. Additionally, if sterilization has no ability in the management of flash they also lose their ability to track instrument set usage; which if done correctly allows sterilization to adjust to inventory demands. The key to it all is instrument inventory management both hospital and consignment.

One very important aspect for us is that we have partnered with one primary ortho vendor who provides us with a number of total knee and hip systems to allow us to flip-flop room’s without flash, thus decreasing turnover and improving surgeon satisfaction.

We also have instrument technicians/coordinators that manage all flash sterilization including system-1. They work directly with sterilization insuring that the daily schedule is supported and that flash is only used when truly needed. Which is becoming even more rare now that the surgeons and surgical staff understand what it takes to manage instrumentation correctly. “Education, Education, Education”

Flash sterilizers also require floor drains in whatever location they are in which results in moisture that can lead to growth of mold and other potential bugs. The older the hospital the worse it gets. Every time you open the door you add moisture to the room, this along with a poorly maintained flash can really mess things up.

In my 21 years of CS management I have experienced a number of steam and water leaks with flash sterilizers due to faulty valves and operator errors. It’s just one more piece of equipment that can be replaced by better management of the instrument inventory.

Lets not forget that consignment instrument providers do not all provide flash sterilization parameters, only wrapped cycle be it gravity or pre-vac…good old extended cycles.

Getting your infection control coordinator into the process will also give you the support you need to stop flash and direct more attention to increasing the inventory to support a standard of care that patients deserve.

We as sterilization professional need to pay attention to the new CMS/Medicare never events list as it pertains to hospital acquired infections, its getting longer. Soon they may want to track infections back to the sterilization process which may be hard to defend given all the minutia that is out there.

[Tim Brooks]

"Amen" spd soup
And Chip, I will pick the hospital

[chipmoore]

Actually, forget flash sterilization or any sterilization, I'd be willing to have surgery providing the instruments were 100% "clean".

Tim, you can pick the hospital but here's my wish list because they are set up for the open tray method w/ central core processing.
St. Mary's/Methodist Rochester MN
Scott & White, Austin TX
Stanford, Palo Alto
Hospital for Special Surgery, NYC
Chip Moore
Somewhere in Western MN