Workers Suffering in Central Sterile Supply
Many healthcare workers in central sterile supply (CSS) are experiencing pain and ergonomic injuries, particularly as the emphasis on meticulous reprocessing of duodenoscopes has increased due to patient infections and deaths, researchers reported.
In a survey from ECRI, 74% of 341 respondents answered “yes” to the question, “Do you experience fatigue or discomfort in any part of your body as a result of cleaning duondescopes?”1
“That concerned us,” said Amanda Sivek, PhD, a principal project engineer at ECRI. “By far, the area of greatest discomfort was the lower back, followed by the neck and shoulders.”
Sivek presented the findings at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).1 She was joined by co-researcher James Davis, MSN, RN, CCRN, CIC, HEM, FAPIC, a senior infection prevention analyst at ECRI.
“This one really kind of disturbed me,” Davis said. “We have 74% of the people telling us that they have a pretty decent amount of discomfort when they do their job.”
The ECRI survey link was distributed to target healthcare worker email addresses in December 2020 and closed in January 2021. It primarily targeted healthcare workers who perform pre-cleaning or manual cleaning of duodenoscopes. Most respondents said they complete duodenoscope pre-cleaning in 10 minutes or less, and manual cleaning in 16 to 30 minutes. However, they felt pressure to keep the process moving, which sets off a cascade of adverse effects, the researchers reported.
Duodenoscopes are flexible tubes that run down the mouth, throat, and stomach to the small intestine. They are used during endoscopic retrograde cholangiopancreatography (ERCP), a procedure to diagnose and treat pancreatic and bile duct diseases.
FDA Urges Transition to Disposables
However, in the last several years, infections following ERCP procedures have been identified, some of them caused by multidrug-resistant organisms. FDA investigations revealed the devices cannot be reprocessed and sterilized with absolute safety because they are complex and difficult to clean. A recent FDA safety communication2 renewed the urgency of this issue, noting two completely disposable duodenoscopes are on the market, and another five models include disposable parts to replace fixed endcaps that are hard to clean and can be a common source of pathogens.
“Hospitals and endoscopy facilities should complete transition to innovative duodenoscope designs that include disposable components such as disposable endcaps, or to fully disposable duodenoscopes,” the FDA stated. “The use of a removable component to facilitate cleaning leads to significantly less contamination; interim results from one duodenoscope model with a removable component show a contamination rate of just 0.5%, as compared to older duodenoscope models which had contamination rates as high as 6%.”
Duodenoscope manufacturers no longer market fixed endcap duodenoscopes in the U.S., but they are used in many facilities, including most of those surveyed by ECRI. The FDA action does not recall these scopes, as some kind of transition time will be required. Money also is an issue.
“I would like to see it happen sooner, but we all know that we’re going to use these scopes until they’re unusable, because they cost a lot,” Davis said.
The FDA recommended hospitals contact duodenoscope manufacturers, some of whom are offering to replace fixed endcap designs with disposable cap models. “Using models with single-use distal endcaps eliminates a lot of that worker stress and cuts down on some of the reprocessing time,” Davis said.
In the ECRI survey, CSS workers were asked what factors would help them manually clean duodenoscopes. The top answers were mentoring, staff retention, experience, visualization tools, checklists, staff certification, and timely feedback. Davis gave an example of a CSS department that was discouraged by the lack of response to its reported need for magnification equipment to inspect scopes.
“There was a holdup and things were backordered, but they never communicated this to the workers,” Davis explained. “[The CSS] workers felt that no one cared about them, even though they were trying to do the right thing. Simple things like that can impact workflow and attitudes.”
Eighty-two percent of survey respondents reported they had been adequately trained, but 35% said they received no feedback on their performance. “How are you going to improve if you’re not getting the feedback to improve?” Davis asked.
Overall, 59% of surveyed workers were certified in cleaning flexible endoscopes. Certification efforts should be redoubled as both a way to retain staff and provide them important training.
“It’s a good thing. It actually helps set the bar higher with the techs doing the work, and it’s a feather in their cap,” Davis said. “That should be a goal for them, if not build into their [job expectations].”
An encouraging finding is 86% of respondents use automated flushing devices instead of manually clearing them. “You’re giving the person doing the work some time to recover — some muscle recovery time,” he said.
However, 14% were using the more strenuous manual flushing. “I’ve flushed scopes manually where it could take quite a bit of force, especially with a slight obstruction or a big obstruction after brushing and things like that,” Davis said.
A surprising 7% of survey respondents said they do not repeat manual cleaning of duodenoscopes if debris is found in the channels. This is in violation of both manufacturer’s instructions for use and CDC guidelines, Sivek said.
Beyond duodenoscopes, there have been reported problems and challenges with CSS workspaces for years.
Beginning as a CSS technician 29 years ago, Damien Berg, BS, BA, CRCST, is vice president of strategic initiatives for the Healthcare Sterile Processing Association (HSPA).
“It is a very repetitive-based job in nature,” Berg tells Hospital Employee Health. “It’s not manufacturing, but it is in the same type of work. You are working in austere conditions, such as decontamination, where you’re in full PPE for an extended amount of time. You’re hot, you’re lifting, you’re bending, you’re pulling, you’re doing the same motions over and over.”
With as many as 140 cleaning and reprocessing steps listed by some scope manufacturers, the job requires concentration as well as physical demands.
“That’s a lot of time over a sink if you don’t have the [table] height properly adjusted or the proper padding where you are standing,” Berg says. “If you are there all day long, that is where the ergonomic problems begin to set in.”
As CSS injuries are frequently underreported, employee health professionals should assess their sterilization department periodically, observing work conditions and talking to staff about ergonomics and other concerns.
“Usually, we don’t involve the safety or occupational health people until someone has an incident, and then you have an employee out,” Berg says. “They’ve got a back injury or a shoulder injury, and then they are evaluated. I always recommend people do a proactive evaluation of the department to avoid those costly and timely injuries and shortages of staff.”
In doing so, inspect every work station to determine if there are ergonomic problems that can be addressed and solved immediately, says Kay Ball, PhD, RN, CNOR, CMLSO, FAAN, perioperative consultant and adjunct professor of nursing at Otterbein University in Westerville, OH.
“We wouldn’t expect a surgeon to work on a patient who was on a surgical table that was way too low, or without good lighting,” says Ball, nurse planner for Hospital Employee Health. “We provide those things in surgery, so why wouldn’t we provide them in CSS for the employees who are taking care of our delicate instruments that must be reprocessed and cared for appropriately?”
Injury and illness reports should be reviewed along with workers’ compensation reports. Reports of injuries and complaints of injuries should be welcomed without the fear of punishment or negativity.
In addition to employee health, an expert on human factors engineering could provide important insights in a CSS assessment. “Talk to the sinkside and tableside workers — whoever’s in there doing the actual work,” David said. “Have that empathy and understanding. They may have the best suggestions.”
A Mission-Critical Job
Workers should have input in any redesign or remodeling in the CSS space. “Talk to all these people about the existing space and what would be the essential ‘haves’ and the ‘nice-to-haves’ in a new space,” Davis said. “That can really impact the quality. Happy workers — especially if we’re making it easier for them to do their work, not harder — will hopefully perform better. This is a mission-critical task. Patients aren’t going to get treated, ORs aren’t going to function without the CSS folks and without quality instruments making it to the patient.”
There is a lot of pressure to reprocess quickly and keep the flow of devices and instruments moving, but the health and safety of workers and patients also should be considered.
“We need to give these folks time to do their jobs. I’ll stand on that soapbox until it happens,” Davis emphasized. “Again, they are doing a mission-critical task, and the safest thing to do is to let them ‘breathe.’”
Although room design is improving at many hospitals, small, cramped spaces have been the norm for central supply for too long. “We see this all the time when we do consults — there’s five people in a room that’s the size of a small janitor’s closet. I’m not even exaggerating. How do these folks move around, not only in that space, but how uncomfortable is that as they are bumping into each other?”
The mental effects should not be discounted, as these workers feel “stuck in a box” and under pressure to reprocess instruments. Although many manufacturers offer excellent training programs, too many central supply worker are under-trained. “We’d like to see an increase in that educator role,” Davis said. “You’re lucky if you have them, so they should be utilized a lot.”
In addition to ergonomic injuries and burnout caused by high demand for rapid instrument turnover, there is the risk for slips and falls in this wet, moist environment as well as biological exposures to dirty equipment and devices. There also is the risk of blood exposures and sharps injuries from contaminated instruments. These injuries should be reported promptly to see if post-exposure prophylaxis is indicated — which can be complicated to determine if there is no system to trace the instrument back to a patient. In the ECRI survey, 71% of respondents had put a system in place to track back instruments.
With staffing woes hitting all healthcare sectors, the argument for safe work conditions in CSS is a business case for retaining staff and protecting patients, Davis emphasized.
REFERENCES
- Sivek A, James DJ. Ergonomics and duodenoscope reprocessing: Is there a problem? Session 3003. APIC Conference, June 13-15, 2022.
- Food and Drug Administration. Use duodenoscopes with innovative designs to enhance safety: FDA Safety Communication. April 5, 2022.
Many healthcare workers in central sterile supply are experiencing pain and ergonomic injuries, particularly as the emphasis on meticulous reprocessing of duodenoscopes has increased due to patient infections and deaths, researchers reported.
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