Special Edition on Sterile Processing Imperatives Special Edition- Sterile Processing Imperatives - Page 26

What’s Keeping You Awake About Your Sterile Processing? By Mary Olivera, MHA, CRCST, CHL, FCS I processing department and procedures on its own, leaders should seek out the help from an expert or experts who can manage and advise on the process. These experts will also collaborate with physicians, nurses, and reprocessing techs to encourage adoption of new processes and protocol. At OSPECS Consulting, we use a four-step program to help facilities update and upgrade their SPD processes and protocol. The program, named PEER (Prepare, Examine, Educate, and Reform), helps facilities get to and stay in readiness mode. Remaining in continual readiness mode is not a simple task. It will require a constant assessment of the processes, policies, staff performance and the physical condition of the department. Sterile processing professionals must always be looking for the next improvement opportunity expecting the accreditation surveyor to enter the department in a moments time. The PEER program steps are detailed below. magine walking through the door of a hospital’s sterile processing department (SPD) to find original AMSCO steam steriliz- ers and ultrasonic machines, 1956 GOMCO suction machines with the reusable bottles, and a “central supply” setup where the operating team washes contaminated instruments in the OR and the central supply staff puts them in the “oven.” The PREPARE. Leaders should constantly ask sterile processing department’s library is themselves and their teams, “What are the full of books and manuals from 1956, and things we need to know and the things we its technique manual from the American Courtesy of Mary Olivera need to do in order to become a place of ex- Sterilizer Company is the 1969 edition. cellence?” After all, in hospitals, as in life, there Now imagine that it’s not 1970, but is no better prevention than preparation. Sterile Processing it is, in fact, the year 2020. And despite the technological leaps the field of sterile processing has made over the past Department leaders should be equipped with the most up- to-date manuals, regulatory standards, and manufacturers’ 50 years, this real-life facility has remained stubbornly in the instructions for use (IFUs). Leaders must regularly review past, manually fashioning items we now view as disposable them, seek out new information from regulatory literature and sterilizing single-use tools that should be thrown away. Things changed at this facility only recently, and only when and peers, and improve hospital processes. Most important, leaders must make this information easily accessible to their an extraordinary chief nursing leader spoke out and made teams, develop policies and procedures (P&P) that adhere the safety of her patients and her staff a priority. to regulatory standards and IFUs, and monitor compliance. This story, while shocking, is certainly not the only example A Sterile Processing Department’s library should include: of a lack of commitment to sterile processing and high-level ● Regulatory agencies disinfection (HLD) procedures at hospitals throughout the ● State Department of Health (DoH): Their regulations country. In 2019, the Joint Commission (TJC) reported that 70.9 percent of the hospitals surveyed were cited may mirror the Federal laws but may be more stringent. The DoH may conduct an unannounced survey. for failure to comply with the IC 02.02.01 standard: “The ● State Department of Transportation (DoT): Regulates the hospital reduces the risk of infections associated with medical equipment, devices, and supplies standard.” The Centers transport of contaminated waste. Healthcare leaders must for Disease Control and Prevention (CDC) has reported that review these guidelines especially if the facility is transporting contaminated instruments between hospital systems. although there have been advancements in practices to ● Food and Drug Administration (FDA): Regulates prevent infection, surgical site infections (SSI) remain the manufacturers of medical devices, sterilants and high-level most expensive hospital-acquired infection (HAI) in the U.S., costing the American people over $3 billion dollars per year, disinfectants. The FDA has systems to report any device related problems. according to the CDC. ● Centers for Disease Control and Prevention (CDC): And patients are paying attention. In the 2020 survey These guidelines are not regulatory but are relied on as by the ECRI Institute, ranked concerns about improperly cleaned, disinfected, or sterilized instruments as No. 5 on guidance and compliance. ● Centers for Medicare & Medicaid Services Regulations the top 10 list. and Guidance (CMS): Operates Medicare, Medicaid and It doesn’t have to be this way. Hospital leaders can rest administers the Health Insurance Portability and Account- easy if they prioritize the SPD and recommit to the processes ability Act (HIPPA) – this agency can perform announced and and procedures that make sterile processing and high-level disinfecting as quotidian as regular handwashing. They will unannounced surveys. Failure to pass the CMS survey may cause the hospital to lose all federal funding. likely save lives, and face, in doing so. ● Professional voluntary standards How? ● ANSI/AAMI Standards: ST79:2017; ST91:2015; Hospital leaders must make an honest assessment of their institutions’ sterile processing deficiencies and failings ST90:2017; ST58:2013; & ST41:2008 (R2018) – Recommend- and then decide if the hospital itself has the competency to ed standards for reprocessing surgical instruments, flexible bring about change. If the hospital cannot improve its sterile endoscopes and sterilization in healthcare facilities. Some 26 Sterile Processing Imperatives 2020 • www.healthcarehygienemagazine.com