In outpatient surgery, physician staff often pressure techs to quickly turn around sets and scopes for cases, says Marcia Patrick, MSN, RN, CIC, a Tacoma, WA-based consultant, educator, and surveyor for the Accreditation Association for Ambulatory Health Care.
“Steps get missed, like adequate soak time in an enzymatic or other instrument cleaner,” Patrick says. “Scrubbing with a brush is done quickly, rather than carefully and thoroughly, or the soak time in the high-level disinfectant or sterilization times are shortened, which can lead to unsterile or not high-level disinfected instruments and/or scopes.”
To avoid issues, consider these suggestions:
• Ensure instruments are clean.
Cleanliness of the instruments is critical, Patrick says. “Thorough physical removal of debris and contamination will reduce the microbial burden substantially, making the high-level disinfection and/or sterilization processes effective,” she says.
Cleaning also prevents biofilms from forming, Patrick says. “These are conglomerations of bacteria that form colonies: first one bacterium, then a few more, and over time, they develop into masses that form a slime over the colony, and that slime prevents disinfectants and sterilants from penetrating to kill the bacteria,” Patrick says. “They are very hardy, and once on an instrument or scope lumen, are difficult to impossible to remove. (A graphic illustration is available of how biofilm forms. Readers can access it at http://bit.ly/2dMOe8F.) One way to fight the formation of biofilm is to keep debris off instruments by rinsing them in and/or wiping them with sterile water, Patrick says. “When the procedure is finished, the instruments must be quickly rinsed or soaked in instrument cleaner to remove as much contamination as possible,” she says. “If they can’t be cleaned immediately, which is often the case, there are spray and gel enzymatic products that can be applied to keep the soil moist so it can be removed easily when there is time to process the instruments.” Most manufacturers have a time limit on how long an instrument can be held before it is processed, she adds.
Be warned: Surveyors are looking to see if facilities are protecting patients from the effects of biofilm by immediately treating instruments or soaking them in a solution that has been labeled for instrument cleaning, Patrick says. “Soaking in plain water is not as effective,” she says. “Whatever product is used, it must be used according to the manufacturer’s written instructions for use, with regard to dilution, if it isn’t a ready-to-use product.”
If a product requires dilution, there are restrictions on how long the mixed solution should be used. “Often it is a single scope or batch of instruments,” Patrick says. “It loses its efficacy as the enzymes are used up.”
• Be certain your staff members have the proper tools.
Sometimes facilities don’t purchase the proper tools for cleaning, Patrick says.
“Brushes that are designed for the instrument or scope, as recommended by the manufacturer, are essential, as is proper PPE [personal protective equipment] for the level of exposure anticipated,” she says. “Usually this includes a moisture-proof gown, heavy-duty gloves, and eye and face protection: either a mask with an attached eye shield or a full-length face shield to prevent spray and spatter.”
• Organize the central sterile (CS) processing area.
Organize the CS area so that instruments come into the soiled receiving area and then go to the sink, Patrick says. It’s preferable for the sink to be a double: “one side for washing, one for rinsing, then rough-drying, at which time the device is inspected to ensure it is clean,” she says. If the instrument isn’t clean, it should go back to the washing sink and be rewashed, she says.
“The flow must be unidirectional with no crossovers, and everyone must understand the step the items are in so no steps get missed,” Patrick says.
Instruments should be packaged in the appropriate peel packs or sterilization containers. Ideally, “there would be a pass through window to the ‘clean’ side where the sterilizer is located,” Patrick says.
Next in line are the automated endoscope reprocessor or soaking containers of high-level disinfectant. “A thermometer and timer are required,” she says. “The soak time begins when the last item is placed in solution, and the temp must meet the HLD [high-level disinfection] manufacturer’s instructions, as well as the soak time.”
The autoclave must have a printout with demonstration that the load passed the time, temperature, and pressure parameters. This printout must be initialed by the person who is checking it before the load is released, Patrick says, and it must be filed.
“Manufacturer’s instructions for servicing the autoclave and automated endoscope reprocessor must be followed,” she says. “Surveyors will expect the report from the service technician to be available during [the] survey.”
Also, there must be documentation of any required user maintenance required by the instructions for use (IFU), she says.
• Have training from vendors, or learn from a hospital.
Most nurses, including those acting as infection preventionists (IPs), don’t know if the processing is being performed correctly, Patrick says.
“One way to improve this is for the IP to have the vendor rep for the complex instruments and scopes come to the facility and retrain everyone,” she advises. “Following along with the instrument/scope manufacturer instructions for processing will ensure the rep is teaching all the required steps and elements, and not skipping or downplaying the importance of each and every step in the process.”
The nurse/IP can review these steps and observe the techs doing the process to ensure the IFUs are followed to the “letter and spirit of what’s written,” Patrick says.
Another option for a surgery center nurse/IP is to talk with a colleague at a hospital to see if they would allow the IP and/or CS supervisor to observe processing being conducted at the hospital. “A good CS manager can teach a lot about the pitfalls, gaps, and standards that are to be followed,” Patrick says. “If this [observation] is done, be sure to document that it happened.”
• Conduct competency evaluations.
Conduct written competency evaluations based on the manufacturer’s instructions on each complex instrument and each type of scope for each tech, including the backup staff, on hire and at least annually, “and, of course, if there are changes in the processing instructions, as has happened recently with the cleaning procedures for duodenoscopes,” Patrick says. It’s essential to periodically monitor performance, she emphasizes.
• Ensure staff members understand quality measures.
CS staff often don’t understand the quality measures they are supposed to perform to ensure sound processing, Patrick says.
“I’ve seen the log for the high-level disinfectant minimum effective concentration test logged as ‘fail’ for several days, and nothing was done about it because the tech was simply told to log the results daily,” she says. “There was no connection that a failed test required immediate replacement of the high-level disinfectant solution, so all the patients scoped since the last ‘pass’ test were scoped with scopes that were inadequately disinfected.”
Such a situation would require a report to the local health department and CNS, as well as patient notification and, perhaps, patient testing. “No facility wants to have to do that,” Patrick emphasizes.
• Get physicians on board with CS processing.
Getting the providers on board is difficult, Patrick acknowledges. “Ideally, one would take them to the processing area and show them the instrument/scope instructions for processing, the rules that must be followed to produce a properly processed instrument set or scope,” she says. However, many physicians aren’t interested, Patrick says. “And it may not work to convince them,” she says. “They may feel that it’s taking too much time regardless of the quality of the product they get to use.”
Consider finding a physician “champion” who is concerned about quality processing and will work toward getting other providers in line.
• Ensure oversight.
Ensure that issues with processing are included in the minutes of the committee that oversees infection prevention and control, Patrick says.
“As a last resort, whisper in the ear of the surveyor to look at this when she/he is doing the tracer through the processing area,” she says. “Yes, it will be an infection control citation, but it’s all about patient safety.”
It’s unacceptable for surgeons’ complaints about dirty instruments to not be logged and addressed, Patrick says. “An instrument or scope with contamination on it is not sterile or high-level disinfected, respectively, and should not be used,” she says. Obtain a clean set or scope, Patrick advises.
Unfortunately, it can be common to see poor cleaning, disinfection, and sterilization practices, she says. “The good ones do it right each and every time,” Patrick says. “This protects patients, staff, and the bottom line, as it can help avoid the negative publicity that ensues when facilities are cited for bad practices, especially if that breach or breaches result in patients being exposed to bacteria or viruses.”
