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
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