[This guest column was written by Beyond Clean Advisory Group member Brandon Todd, MDiv, ThM, CRCST, CHL, CIS, CER, Sterile Processing Manager at Norton Healthcare in Louisville, KY]
November 4, 2021 is a date burned into my mind forever. It is the date of the last time Norton Hospital had to Immediate Use Sterilize a set for surgery. That means it has been over 500 days since we last flashed. In 2021 alone we flashed 204 times! How were we able to completely eliminate IUSS from our standard practice? In this brief article I will explain the steps we took to go from a hospital with over 200 IUSS events a year to 0.
Culture Shock
Flash sterilization was initially promoted as an emergency alternative to terminal sterilization. Over time it became much more common place across the US, and began to be seen as an acceptable alternative for convenience, not just for emergencies. In 2010, this practice began to be questioned by healthcare leaders and accrediting agencies. After much observation and deliberation, best practices were defined in ANSI/AAMI ST79: 2010. Yet over a decade since, many hospitals are still struggling to reduce IUSS. Habits are hard to break. Bad habits ingrained over decades are even harder to break. It takes determination, leadership, and collaboration to change a culture and to completely eliminate the practice of IUSS. Below is how Norton Hospital beat the odds.
Unity of Purpose
Unity of purpose by far is the most important ingredient for change. Without it you will not succeed in any endeavor of this scale. I have seen multiple hospitals try and fail to reduce, let alone eliminate, IUSS. What made it successful at Norton Hospital was a unity of purpose across all disciplines. When I joined the team and we realized the frequency of IUSS and the lack of documentation. We put together a task force to address the issue swiftly. As an SPD leader you will not be able to address this problem alone. Call together all stakeholders to educate them on the need for change. Often OR and SPD staff are not aware of the risk associated with IUSS. So the first step in developing a unity of purpose is collaborating with and educating all key stake holders. Surgeons, scrub techs, OR leaders, infection preventionist will all need to be involved to impact the reduction or elimination of IUSS. I had the privilege of having understanding and motivated stakeholders who were willing to make immediate change. Heather Smith, Director of Surgical Services, and Carolyn Snell, OR Manager were two invaluable partners in this monumental achievement at Norton Hospital. They understood the importance of reducing our IUSS events and the need to improve documentation. Through their leadership they persuaded the surgeons of best practices. This reduced the occasions where IUSS was even requested since the whole team understood the standards and risks associated. You may not have the same level of cooperation but you must win over every stakeholder because it is only through a unified front that you can change the culture. Provide them with the clearly defined standards and advocate for your patients. Remember you are the sterility expert, it is your job to lead this charge.
Communication and Chain of Command
After you have unity of purpose you will need to clearly define the process for deciding if a request to IUSS meets the ANSI/AAMI standards. At Norton we instituted a very clear chain of command. If any OR room requested to IUSS the OR manager and Director must be notified to make a decision. Knowing intimately the required justifications, they would have to sign off for IUSS to be operated. This proved successful because no amount of excuses or politicking would be tolerated, if it did not meet the standards it was not permitted. Prior to this communication change, individual techs or unit coordinators would make the call. At the time not knowing the standards and under pressure from the surgeon they would often acquiesce. Create a well-defined Standard Operating Procedure (SOP) and chain of command for who will make the decisions if IUSS is appropriate. After a few times of being told no, everyone will get the picture and take steps to improve preparations to avoid the risk.
Documentation/ Inventory Management
Documentation is key for any process improvement. ANSI/AAMI requires that all items sterilized by IUSS must be documented.
You must record:
1) Item(s) sterilized,
2) date/ time,
3) patient name or identifier,
4) cycle type,
5) sterilizer operator,
6) monitoring results
7) reason for IUSS.
Analyzing this data will discern trends and root causes of the need to sterilize. We found that the majority of our IUSS event were stated because “set was not sterilized in time for surgery”. This alerted us that we either had a communication/ prioritization problem or an inventory problem. We then highlighted the common sets that were IUSS and determine that we needed to increase our inventory of certain sets. To improve communication, I began to require our SPD supervisors to join the OR daily huddle to discuss next day needs. This informed SPD of priority sets and if a turnover was anticipated, our SPD leader could speak to turn over time required and cases could be moved around to ensure enough time was available to appropriately reprocess each component and avoid the risk of needing to IUSS. Follow the data, discern inventory needs, and create communication channels.
SPD Operates IUSS Autoclave Process
This one may be a controversial take. We also made changes to the way that IUSS was being performed. Previously, IUSS was being performed by staff in the operating room. We decided to shift the responsibility to maintain and operate the OR autoclaves to sterile processing where trained technicians could perform the process in a controlled environment. I advocated for this change because we in SPD are the trained professionals in instrument reprocessing and sterilization. Scrub techs and OR staff rarely have adequate education on proper protocol. This was controversial because it added additional duties to our already over worked staff. But by shifting responsibility we could better control process compliance. With SPD being involved in every step of reprocessing for an IUSS request, we were an additional roadblock. My technicians could ask probing questions and find possible alternative; sets that contained the dropped item, or equivalent items that the OR may not have been aware of. This change improved communication and built greater trust between the OR and SPD.
Regularly Review, Update, and Educate
Finally, we recognized that eliminating IUSS was not a one-time event. It required ongoing monitoring, adjustment, and continued communication. Instrumentation needs change frequently, so you must keep a close eye on inventory management. Likewise, we continue to educate and inform stakeholders of the risks of IUSS and the steps we are taking to ensure we never have to do it again. We made a commitment to regularly review and update our policies and procedures to ensure that we were continuing to meet our goals. Just because we have not IUSS in over 500 days does not mean we have completed our progress. We must keep our eye on the ball and never lose sight of the goal. By regularly reviewing, updating, and educating we build ourselves up to be a hospital that can continue the success of eliminating the need for IUSS.
Conclusion
Eliminating immediate use steam sterilization from our hospital was not an easy process, but it was an important one. I am grateful to each and every stakeholder who saw the vision and was willing to collaborate. By creating a unity of purpose across all disciplines, following the data, documenting and implementing inventory management systems, moving IUSS to SPD, providing training and education, and regularly reviewing policies and procedures, we were able to eliminate IUSS from our operations. The impact of this change has been significant, both in terms of patient safety and operational efficiency. We hope that our experience can serve as a model for other hospitals looking to reduce IUSS from their operations.
Works Cited:
American National Standards Institute/Association for the Advancement of Medical Instrumentation. (2010). ANSI/AAMI ST79:2010 Comprehensive guide to steam sterilization and sterility assurance in health care facilities.