EXECUTIVE SUMMARY
Immediate-use sterilization episodes decreased from more than 2,400 per year five years ago to zero in 2018 at the Andrews Institute Ambulatory Surgery Center in Gulf Breeze, FL. The ASC implemented changes in 2013, resulted in the surgery center virtually eliminating its use of flash sterilization.
- Staff used daily huddles to plan according to future surgery caseload, which was central to the ASC’s efficiency efforts.
- Another tactic was to adjust schedules in the sterile processing department.
- Talking to surgeons about reprocessing dropped instruments is an important part of the improvement process.
The Andrews Institute Ambulatory Surgery Center of Gulf Breeze, FL, logged more than 2,400 immediate-use sterilizations (IUSS) per year in 2013 and earlier. After starting a program to reduce IUSS practices, the ASC cut that number to 131 in 2016, one in 2017, and zero in 2018 (so far).
“It’s been a long process for us,” says Barbara J. Holder, RN, BSN, LHRM, CAPA, quality improvement/infection control/safety/regulatory officer at Andrews. “First, there was the change in the regulations ... up until that time, people were abusing the intention of the regulations and doing a lot of [IUSS]. New regulations said [IUSS] had to be used solely for emergency purposes only, like a dropped instrument.”
IUSS, which until 2014 was called flash sterilization, differs from short-cycle sterilization. Instruments undergoing IUSS are cleaned in a designated decontaminated area. These instruments cannot be stored for later use. Short-cycle sterilization follows device manufacturer’s instructions for use. The process includes use of a dry time and is packaged in a wrap or rigid sterilization container, which can be stored for later use.
Prior to the federal regulatory change, the operating room culture never viewed IUSS from a risk standpoint, says Danny Dillard, CST, CASSPT, purchasing manager and sterile processing department manager at Andrews.
“People just assumed that this is what you did: If you drop something, you flashed it; if you forget to wrap a set, and you need tools for a case, then you flashed it,” Dillard explains. “There was no emphasis put on the risk portion of what the process has for patients.”
Here’s how the Andrews reduced their IUSS rate:
• Streamline the process. One way to reduce IUSS is to invest in more instruments. “When we started this process, we thought we’d have to invest hundreds of thousands of dollars into instrumentation,” Holder says. “We did have to invest in some instruments, like retina trays. But when we looked at it, we actually [spent] less than $10,000 on new equipment.”
The main way the ASC streamlined the process was to use physician preference cards.
“This was a major undertaking,” Holder notes. “Danny and his team worked with surgeons ... to update, develop, and ensure accuracy of surgery preference cards for every type of surgery they do.”
The preference cards provide data related to physician and surgery type. Physicians confirmed their preferences after reviewing the cards’ instruments and equipment needs, Dillard explains. Review of preference cards takes place weekly or biweekly. When there are changes or requests for a change, these are listed and reviewed.
“We monitor our process to see if we’re as current as possible,” Dillard adds.
• Form daily huddles. “Our huddles in our sterile processing department occur the same time every day,” Dillard says. “We found them so beneficial, we do two huddles a day, one at 8:15 a.m. and one at 3 p.m.” The huddles also provide visual management, a reminder of the goal to eliminate IUSS, Holder says.
“The staff’s biggest fear in accomplishing this goal was the huddles and open communication. They were against this, but now the huddles are essential to our daily infrastructure and what we do.”
The huddles give staff time to assess each day’s, the next day’s, and even the next week’s schedules to determine how many trays and other resources they’ll need. Perhaps there are 20 cases scheduled one day, and the ASC only has 10 hand trays. Previously, Andrews staff would use the 10 trays and then perform IUSS on each hand tray as needed to complete the 20 cases, Dillard explains.“What we changed with our huddles is we talked about the schedule the next day, how many cases of each specialty and how many trays and resources we’d need,” he says. “Now, once that first set comes out of the OR, it’s processed and decontaminated and available by the time the OR is doing case number 11, and so forth.”
Daily huddles also can be used to educate sterile processing staff on new procedures, rules, and techniques.
“Every week, each department submits to me their huddle worksheet, and I put those together and post them on huddle boards in the doctor’s lounge,” Holder says. “I send these out by email and print colored copies that are posted.” This was a culture change, forcing sterile processing staff to explore this from a different perspective. The change helped staff accomplish the goal of not using IUSS of any trays.
• Adjust sterile processing staffing and schedules. “I didn’t have to hire new staff,” Dillard reports. “I just restructured how our staff was allocated on assignments.” Dillard says one sterile processing staff member’s role is to prioritize the goal of avoiding [IUSS]. Sterile processing employees’ shifts are staggered to provide full coverage throughout the day, Holder says.
Meanwhile, Dillard notes how many people are on staff on a particular day, and studies staffing over a six-week surgery schedule. Each employee is assigned to a certain task.
“All sterile processing department staff is 100% certified,” Dillard says. “They have a good aptitude and knowledge base and are fully engaged in patient safety and care.” Thus, staff know they are stakeholders in the surgery center’s patient safety, and they take their duties seriously.
• Work with physicians to better handle dropped instruments. “Even if there is an instrument dropped, we can avoid [IUSS],” Dillard says. “It’s just communicating with the surgeon.” Before, there was a perception that surgeons would be angry if an instrument dropped and they had to wait for reprocessing. Dillard and Holder spoke with physicians about the goal to eliminate IUSS, explaining how reprocessing a dropped instrument might cause a 15- to 17-minute maximum processing time. Once surgeons learned this information, they found the change more palatable. “Sometimes, there are other resources that can be used,” Dillard says. “You can get the instrument turned over without immediate use. We did this the entire time last year.”
Daily huddles, schedule adjustments, and surgeon education led to a dramatic decrease in immediate-use steam sterilization rates at an ASC in Florida.
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