One unseen Fogarty insert that makes its way back to the OR can cost your facility upwards of $10K if it is discovered on the sterile field, not to mention the unthinkable possibility of the instrument being reused on an unknowing patient. I need not even mention the danger lurking in poorly processed Ortho shavers, Andrews suctions, or Kerrison rongeurs...
So how do we ensure that our first line of defense against these processing breakdowns -- our department decontamination areas -- will actually stop these dangers in their tracks? What must CS/SPD leaders and frontline technicians do to break the chain of infection during this critical stage of processing? Here are a few ideas for how to make missing microbes a thing of the past...
1) Stock the Armory: It's Tool Time!
One of the most frustrating positions to be in as a frontline decontamination technician is to be asked to do a job, but not given the tools you need to do the job well. Flush every cannula: but how? Brush every suction: with what? When your team walks into the decontamination area to start the day, it should be fully stocked with every processing tool needed to complete the task laid before them: mass microbial destruction. At the very least, you should have the following items: Brushes of proper style, diameter, and length (including pass-through brushes), adequate flushing technologies (a low tech hose or high-tech flushing system), sinks of adequate height, width, and depth, the proper chemicals, appropriate PPE, sharps container, pre-processing equipment (such as stand alone ultrasonic washers), and any other supplies needed to safely restring and sort stainless steel instruments. Going back to the brushes for a moment, make sure these are organized and easily identifiable. Many an internal scope channel has been damaged by incorrect or compromised brush usage. Make it easy for your team to do the right thing -- and more often than not, they will.
2) Ensure OR Ownership: First Things Must Be First
As important as the proper tools are in the hands of a competent, well-functioning decontamination team, the SPD department is actually the second set of eyes to guard against possible microbial mistakes. The first opportunity to tackle potential processing pitfalls actually happens immediately post-op, before the instruments ever leave the OR room.
As a CS/SPD leader, it's your responsibility to work closely with OR leadership to ensure nurses and techs in the room are aware of the necessity of post-op prep of their instrument trays, such as removal of any inserts (Fogarty clamps, Brainlab tracking balls, etc.), disposal of (*ahem*) disposables (such as plastic/rubber attachments, suture, single-use towel clips, etc.), removal of gross bioburden (blood, fat, tissue, bone), restringing of ring-handled instruments (on a low-tech stringer or high-tech restringing technology), flushing of any suction devices (such as Frazier, Andrew, or Abdominal suctions), and finally, pre-treating the instruments (with a low-tech damp towel or high-tech pretreatment solution). To win this war on decontamination oversights, we need our partners in the OR to begin the process as soon as possible. Every minute counts.
3) Traffic Control and a One-Way Flow
Anyone who's ever worked in a busy decontamination room knows how easy it is to look up from your sink after 10-15 minutes, only to realize the room looks like an instrument bomb went off, scattering trays, carts, and container accessories to the four corners of the earth. Something about 2pm in the afternoon just seems to wreak havoc on an organized decontamination workspace.
And that is why it's imperative for CS/SPD leaders to implement clear "traffic control" policies for how, when, what, and where contaminated items enter/flow through the decontamination space. Some facilities struggle with inadequate staging areas, so they cram 20 carts into a decontamination room, which leads to poorly routed instrument trays coming through the work-flow. Not only does a crowded/muddled workflow take a lot of precious time to navigate in and out of, it often leads to missed steps and processing oversights because there's not one right place for a prepped/soaked/rinsed tray to go. Technicians struggling to keep up with the volume and feed the washers/cart washers, can inadvertently short-circuit a processing lifecycle without even knowing it. Well-marked staging areas (even if you need to physically delineate each space with colored tape on the floor) can go a long way in keeping each tray in its proper processing stage. Traffic control the one-way flow.
4) Johnny Cochran Inservice: If It's New You Must Review!
You know the drill. Some new surgeon just joined the organization and trained with some new fangled do-hickey that can tie a sternum together in half the time, so the OR or someone in purchasing surprises you with a new instrument at your doorstep. Oh yeah, and did I mention the doctor has a case scheduled for tomorrow at 7am? That kind of things never happens in our world...right? Riiiight. And it's a recipe for decontamination disaster. These are the kinds of items that show up in the OR still put together, because "No one told me it came apart..." The best way to combat this kind of last minute culture -- especially as it pertains to the processing of brand new surgical instrumentation -- is to create AND promulgate a clear policy/procedure for how new instruments comes into the organization and the timeline required by your team to properly inservice it for safe processing. At one of my previous facilities, the rule was that we needed at least a weekly staff meeting (which happened every Wednesday) to show the team the new instrument, discuss the instructions for use (IFUs), and answer any questions they may have about the item. When unknown instruments show up in the decontamination area, you often end up with unknown results. And that's not what anyone wants, nor is it what the patient needs. If it's new, you must review!
5) Post it, Train it, Do it -- Repeatable Excellence
The last tip I'll mention here has to do with what I like to call repeatable excellence.
A decontamination technician is only as good as his habits; his habits are formed by his training; and his training (hopefully) is contoured by your department's standard operating procedures (SOPs) or assignment competencies. Simply put, you can only get out of a technician what you put into him. And in particular, as we talk about tackling quality issues in your decontamination area, you are going to want to ensure that every technician knows what to do, how to do it, and does it the same way -- every time. This idea is just as much cultural as it is technical. Yes, your teams need to know how long to soak an item in enzymatic detergent, but just as importantly, they need to be given a desire to do it correctly, every time, no matter what. When compromise becomes commonplace, errors take the place of excellence. While there is a place for preference in certain aspects of Sterile Processing, your training program and policies should not be open to interpretation depending on who is training that day. During new employee orientation, you should never hear the phrase, "...but I like to do it this way." Make it your mission to identify the one best way to complete each decontamination task and inculcate that into your training materials, SOPs, and assignment competencies. One sign that your decontamination processes are broken is that quality fluctuates depending on who is assigned there during certain shifts. If you're doing it right, even though productivity may vary depending on the person, excellence shouldn't. Post it, train it, do it.
We owe it to our customers (surgeons, nurses, techs, and ultimately our patients) to have the best decontamination practices we can. As you've read above, best practices are a team sport -- with a role to play by the CS/SPD leader, OR leader, OR staff (nurses/techs), purchasing, and decontamination technicians. With thousands of contaminated instruments coming through one area in a short amount of time, it's critical to have your engine of sterile processing excellence firing on all cylinders. Hopefully these tips help to keep you on the road to improvement, and on the way to an error-free SPD!
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