CMS survey could boost central services departments
'Show me' is a phrase you can expect to hear
A Centers for Medicare & Medicaid Services draft infection control survey expected to be finalized for use in hospitals next year could lead to increased support and appreciation for the challenges faced by central services departments, says Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT, President/CEO of Seavey Healthcare Consulting, Inc., in Arvada, CO.
A specialist in reprocessing issues, Seavey notes that the CMS survey includes important and potentially problematic areas like endoscope reprocessing. For example, the CMS survey requires that such "items are thoroughly pre-cleaned according to manufacturer instructions and visually inspected for residual soil prior to high-level disinfection. For lumened instruments (e.g., endoscopes), pre-cleaning must include all device channels and lumens with cleaning brushes appropriate for size of instrument channel or port."
"They are spelling it out — you must use the appropriate size brushes," Seavey says. "Facilities may be tempted to save money on brushes, and that can lead to situations where the wrong-size brush is being used to clean equipment."
This could be a problem for equipment like endoscopes if you cannot pass the brush all the way through the lumen, she adds.
"You can't just go up one side and down the other or you are going to just pack it in," she says. In addition, forcing a brush into a piece of equipment could damage the interior surface, creating a possible breeding ground for bacteria.
"Once you harm the surface of a lumen it is a good place for biofilm to start going," she says. "Or if the brush is not big enough, you may not be doing a good enough job of cleaning. So you have to have the appropriate size brushes."
The CMS survey also addresses "immediate use sterilization procedures," requiring that any equipment subjected to them is used "immediately and handled in a manner to prevent contamination during transport from the sterilizer to the patient." Formerly termed "flash sterilization," immediate-use sterilization has been a confusing issue subject to some differing definitions. One abiding general principle is that if you must rapidly sterilize an instrument — usually in an effort to return it to the sterile field — you must immediately use it.
"If you do everything that you are supposed to — and that is a big if — remove the bioburden, get off all the blood and the tissues, rinse it off properly and sterilize it according to the recommended sterilization cycle of the instrument — it's sterile," says Patti Grant, RN, BSN, MS, CIC, an infection preventionist in Addison, TX. "The challenge with immediate-use sterilization is getting the sterile instrument from the autoclave to the patient's OR suite without bumping into anybody, without air currents putting stuff on it, somebody sneezing on it. The trick is in the transport."
In that regard, Seavey says the CMS should consider adding more detailed language in the transport of immediate-use items.
"I would really like to see them be a little more specific about that, like saying that it should be covered with a rigid container — the product is put in there before it is sterilized," Seavey says. "That is what the AORN recommends."
Other survey areas apply to reprocessing
The CMS survey dedicates seven pages to reprocessing issues but there are also other aspects of the survey that apply to central services. One example is the CMS survey's overall emphasis on "non-punitive" policies protecting workers who express concerns regarding patient safety and infection control.
"If you have a process failure — a positive biological [indicator] for example — that you think is unsafe it is important to be able to report it without fear of recrimination," Seavey says. For example, there can be logistical problems with "loaner" instrumentation that imperil patient safety.
"If we don't get those in time to adequately reprocess them and run biological indicators — then it might be 'guess work,'" she says. "We're in a hurry to turn them over, but we should have the authority — and not be punished — to say to the surgeon and the OR: 'Listen, I am not going to be able to get those instruments to you in time because I did not get them in time. I wasn't given, for example, 48 hours.'"
In addition, the CMS section on personal protective equipment (PPE) certainly applies to central services workers, she emphasizes. The hazards of exposure to body fluids and chemicals are clear, but that does not always translate to the workers being provided with the proper equipment and trained in its appropriate use.
"Who needs PPE more than somebody working in sterile processing," Seavey says. "But often times it is not adequately worn or they don't have the right PPE like extra-heavy duty gloves and fluid-resistant face masks — not just surgical masks."
To meet this need, it is important to have someone from central services on the hospital product evaluation committee. "That's where infection preventionists can help. Make sure that there is a representative from sterile processing," she says.
Likewise, the length of time that a given product will take to reprocess is critical, as that could affect labor and staffing needs. The time to address this is "before you actually purchase the devices, when you have the clout to make sure that this happens," she says.
It is also important to remember the CMS survey includes non-critical medical equipment and other possible vectors for contamination and potential infection. "It is not just sterile instruments, but also patient care equipment like pumps and other [medical equipment]," Seavey says.
In terms of inspections in general, the main phrase to keep in mind, whether it is a CMS survey, a Joint Commission visit or an in-house risk assessment: "Show me."
"Show me the written recommendations, the policy on that — don't just take people's word for it," she emphasizes. "That is what the CMS is going to do because now the biggest emphasis is on the manufacturer's instructions for use. You've got to have those. So if they are going to track something, if they are going around and interviewing, they are going to ask, 'Well, how do you know how that instrument set is cleaned? Show me those instructions for use.'"
The instructions for use, proper cleaning and sterilization must be provided by every manufacturer in order to get clearance by the Food and Drug Administration, she reminds.
By the same token, CMS surveyors will be looking for the manufacturer's instructions for the appropriate use and proper disposal of detergents and cleaning solutions — an area that could be overlooked, she said. "So many times we go into facilities and they may be using the right type of detergent, but are they using the right concentration?" Again, the prescriptive nature of the CMS survey could lead to a surveyor saying, "Show me. How do you know that is the right type of detergent for that kind of equipment?" Seavey says.
Log it now to avoid headaches later
Another important area is use of a log for recording each procedure specific to the scope or similar equipment, pieces of information that may be critical to avoid the massive headache of huge follow-up programs if the potential for contamination is discovered.
"You may not have always identified the specific endoscope that was used on that specific patient, but that's what you need to do," she says. "Each one has a serial number, so you should be identifying that [scope with the specific patient.]"
If some concern arises about inadequate processing or possible transmission of infection surfaces, "you don't have to alert 20,000 patients. You just alert the patients that particular scope was used on," she says.
Similarly, if you have five basic tonsillectomy instrument sets for OR use, they each should be clearly labeled with their respective numbers so you know which set was used on which patient, Seavey says.
A "hot button" issue that may come up during a CMS survey is the proper use and processing of laryngoscopes, she adds.
"Laryngoscopes need to be either sterilized or high-level disinfected because they touch mucous membranes," Seavey says. "Too many times they aren't. Even if they are high-level disinfected between patients, they may be [inappropriately] stored in a box containing a bunch of them. You really should be packaging them individually."
The CMS survey places appropriate emphasis on implantable items, with clear requirements for use of a biological indicator in processing, see adds. While prosthetics and other implantables have a well-known risk of infection, it is just as important to emphasize an area that can easily be overlooked: routine maintenance.
"So many times our equipment is not maintained the way it should be," she says. "It just like our cars, if we want them to run right we have to make sure that they are maintained. So I'm glad to see that they are mentioning that and requiring that the records be actually available."
A Centers for Medicare & Medicaid Services draft infection control survey expected to be finalized for use in hospitals next year could lead to increased support and appreciation for the challenges faced by central services departments, says Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT, President/CEO of Seavey Healthcare Consulting, Inc., in Arvada, CO.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content