Sterile Processing Department Research Articles

Revealing complex interdependencies in surgical instrument reprocessing using SEIPS 101 tools

Sterile Processing Departments (SPDs) must clean, maintain, store, and organize surgical instruments which are then delivered to Operating Rooms (ORs) using a Courier Network, with regular coordination occurring across departmental boundaries. To represent these relationships, we utilized the Systems Engineering Initiative for Patient Safety (SEIPS) 101 Toolkit, which helps model how health-related outcomes are affected by healthcare work systems. Through observations and interviews which built on prior work system analyses, we developed a SEIPS 101 journey map, PETT scan, and tasks matrices to represent the instrument reprocessing work system, revealing complex interdependencies between the people, tools, and tasks occurring within it. The SPD, OR and Courier teams are found to have overlapping responsibilities and a clear co-dependence, with critical implications for the successful functioning of the whole hospital system.

What is the Marginal Cost of Using Robot Assistance or Navigation for Transforaminal Lumbar Interbody Fusion? A Time-Driven Activity-Based Cost Analysis.

Our primary objective was to compare the marginal intraoperative cost of 3 different methods for pedicle screw placement as part of transforaminal lumbar interbody fusions (TLIFs). Specifically, we used time-driven activity-based costing to compare costs between robot-assisted TLIF (RA-TLIF), TLIF with intraoperative navigation (ION-TLIF), and freehand (non-navigated, nonrobotic) TLIF. Total cost was divided into direct and indirect costs. We identified all instances of RA-TLIF (n = 20), ION-TLIF (n = 59), and freehand TLIF (n = 233) from 2020 to 2022 at our institution. Software was developed to automate the extraction of all intraoperatively used personnel and material resources from the electronic medical record. Total costs were determined through a combination of direct observation, electronic medical record extraction, and interdepartmental collaboration (business operations, sterile processing, pharmacy, and plant operation departments). Multivariable linear regression analysis was performed to compare costs between TLIF modalities, accounting for patient-specific factors as well as number of levels fused, surgeon, and hospital site. The average total intraoperative cost per case for the RA-TLIF, ION-TLIF, and freehand TLIF cohorts was $24 838 ± $10 748, $15 991 ± $6254, and $14 498 ± $6580, respectively. Regression analysis revealed that RA-TLIF had significantly higher intraoperative cost compared with both ION-TLIF (β-coefficient: $7383 ± $1575, P < .001) and freehand TLIF (β-coefficient: $8182 ± $1523, P < .001). These cost differences were primarily driven by supply cost. However, there were no significant differences in intraoperative cost between ION-TLIF and freehand TLIF (P = .32). We demonstrate a novel use of time-driven activity-based costing methodology to compare different modalities for executing the same type of lumbar fusion procedure. RA-TLIF entails significantly higher supply cost when compared with other modalities, which explains its association with higher total intraoperative cost. The use of ION, however, does not add extra expense compared with freehand TLIF when accounting for confounders. This might have implications as surgeons and hospitals move toward bundled payments.

Predictive Analysis of Endoscope Demand in Otolaryngology Outpatient Settings

Background: There has been a trend to transit reprocessing of flexible endoscopes from a high-level disinfectant (HLD) centralized manner to sterilization performed by nursing staff in some Ear, Nose, and Throat (ENT) clinics. In doing so, the clinic nursing staff are responsible for predicting and managing clinical demand for flexible endoscopes. The HLD disinfection process is time-consuming and requires specialized training and competency to be performed safely. Solely depending on human expertise for predicting the flexible endoscope demands is unreliable and produced a concern of an inadequate supply of devices available for diagnostic purposes. Method: The demand for flexible endoscopes for future patient visits has not been well studied but can be modeled based on patients’ historical information, provider, and other visit-related factors. Such factors are available to the clinic before the visit. Binary classifiers can be used to help inform the sterile processing department of reprocessing needs days or weeks earlier for each patient. Results: Among all our trained models, Logistic Regression reports an average AUC ROC score of 89% and accuracy of 80%. Conclusion: The proposed framework not only significantly reduces the reprocessing efforts in terms of time spent on communication, cleaning, scheduling, and transferring scopes, but also helps to improve patient safety by reducing the exposure risk to potential infections.

Emergency Preparedness: Strategies for Maintaining Water Supply Quality and Access for Sterile Processing.

Sterile processing department (SPD) technicians are responsible for providing properly reprocessed surgical instruments for procedures. They use utility (ie, tap) water for precleaning, cleaning, and disinfection; and critical (ie, treated to remove impurities) water for the final rinse and steam sterilization. Water maintenance personnel should work with SPD personnel to ensure that the facility's water supply meets the quality parameters for hardness, pH, conductivity, chlorides, bacteria, and endotoxins. Inadequate water quality and quantity can affect SPD technicians' ability to reprocess instruments correctly and may result in pathogen transmission. When water quality concerns arise, SPD personnel should notify perioperative personnel. Health care facilities should have a water management program to address both normal and abnormal water operations and an emergency water supply plan. Pandemics, geopolitical conflicts, and natural disasters may disrupt water supplies. Proactive planning for water shortages should help facility leaders respond quickly and effectively when shortages occur.

Use of real-time immersive digital training and educational technologies to improve patient safety during the processing of reusable medical devices: Quo Vadis?

Hospital acquired infections stemming from contaminated reusable medical devices are of increasing concern. This issue is exaggerated with the introduction of complex medical devices like endoscopes and robotic instrumentation. Although medical device manufacturers validate their cleaning instructions for use, evidence in the literature demonstrates that effective device processing is not being performed consistently within sterile processing departments in clinical settings. The result is increased risks to patient safety. As a solution to this problem, focused one-on-one training increases compliance to the medical device manufacturer's processing instruction. However, often this is not a practical solution for the volume of healthcare staff responsible for device processing activities. This constitutes the first paper to address the blended use of educational and digital technologies to address these challenges and as a result inform safety and sustainability for the medical device sector. Cognitive learning theory is an evidence-based framework for learning. It supports the use of immersive educational experiences using emerging extended reality technologies (e.g., virtual or augmented reality) to increase learning comprehension. The delivery of educational content via these technologies provides an innovative option for repeatable leaning and training outcomes. The motivation is to decrease patient risk of contaminated reusable medical devices. The proposed approach while primary motivated by safety can also enhance sustainability and efficiency enabled by artificial intelligence and robotic instrumentation.

Do formal education or certification opportunities in sterile processing enhance career advancement?

BackgroundSterile processing is an essential, yet often overlooked, aspect of surgical operations. An efficient and precise sterile processing department is critical for providing clean, functional instruments without disrupting operating room workflow. Despite the importance of sterile processing in the day-to-day function of operating rooms, little is known about the educational background, opportunities, or incentives for career advancement for individuals working in sterile processing. We conducted a comprehensive online national survey of sterile processing employees to define the role of education in this space. MethodsFollowing IRB approval, surveys were sent via email to 50,000+ sterile processing employees querying them about their work role, education background, and certification history. Data was collected and maintained on the Qualtrics platform and analyzed for descriptive statistics using built-in tools. ResultsIn total, there were 958 respondents. The average age was 47 years, 67% were women and 86% reported working as hospital employees. The average length of employment was 13.5 years. Half (50.52%) reported working as technicians, 16.76% were supervisors, 16.18% were managers, 5.01% were Directors and 3.49% were educators (Table 1). The minority of respondents held a 2-year (19%) or 4-year (21%) college degree Table 2). Approximately half of respondents (427 of 857) had enrolled in a post-high school education program in sterile processing, with an average of 7.2 months of training. Nearly all respondents (92%) held some form of sterile processing certification. Formal training or certification in sterile processing did not correlate with a higher-ranking position of employment. The majority of employees engaged in self-directed learning at least on a monthly basis. On average, directors and managers worked in sterile processing longer than supervisors and technicians and were more likely to have 4-year, master, or doctoral degrees when compared with technicians. Although higher-ranking employees were more likely than technicians to have completed leadership courses, employees overall were significantly less likely to complete leadership courses if they were not provided or reimbursed by their institution (P<0.001). ConclusionThere exists wide variation in formal training and certification backgrounds among sterile processing employees. In most states, a standardized pathway to employment does not exist; rather, individual employers assume responsibility for SPD employee training. Employment requirements are variable, and certifications specific to this space do not correlate significantly with workplace roles or positions of leadership. Managers and Directors are more likely to hold an advanced degree. There is little financial or career incentive to obtain formal training or additional certifications that may improve the quality of sterile processing. Nonetheless, the majority of respondents appear actively engage in self-directed learning consistent with a highly motivated, resourceful workforce. Our data suggest that sterile processing employees would optimize opportunities generated through the creation of formal, incentivized education pathways.

Abstraction networks: adapting abstraction hierarchies to map important relationships for system design

Abstraction hierarchies (AHs) are essential to a work domain analysis (WDA), the “most important and unique” phase of cognitive work analysis (CWA) (Vicente, 1999). Although AHs have been the industry standard for assessing and describing work systems for several decades, they are not without limitations (Vicente, 2002). We have developed an evolution of AHs called Abstraction Networks (ANs) to address several of the limitations Vicente identified. ANs are designed to (1) improve engagement with practitioners, thereby facilitating greater shared understanding of the system, (2) better integrate with existing systems analysis tools, and (3) provide a more direct bridge between systems analysis and display design. We document a case study that uses ANs to better understand a sterile processing department (SPD) at a Southeastern tertiary care hospital, detailing the extent to which AN’s achieve these three goals.

Breast Surgery Cost Savings Through Surgical Tray Instrument Reduction

IntroductionRemoving unnecessary instruments from surgical trays used in the operating room conserves resources and time. We aimed to assess the cost savings impact of breast surgical tray instrument reduction. MethodsBreast surgeons at a single institution reviewed the standard surgical tray used for lumpectomies and mastectomies and removed underutilized instruments to create a breast-specific tray. This tray was used for all breast surgeries performed throughout the 2019 calendar year. Data for breast-specific tray usage, instrument reprocessing costs, and instrument maintenance costs for inspection, sharpening, aligning, and lubricating were retrospectively obtained. ResultsThe breast-specific tray was reduced from 82 to 65 instruments. The cost of reprocessing each instrument is $1.69. After 30 tray sterilizations, each tray was sent for maintenance at a cost of $2.00 per instrument. With 10 breast-specific trays in circulation, the trays were used a total of 656 times during the calendar year. Each tray was sent for maintenance an average of two times during this time period. Thus, instrument reduction resulted in $18,847 in instrument reprocessing and $680.00 in maintenance savings, with total annual cost savings of $19,527. ConclusionsOptimizing surgical trays by removing unused instruments yields significant cost savings and contributes to improved efficiency in the sterile processing department. As efforts to eliminate wasteful practices and reduce costs within the health care system continue, opportunities remain for standardization of trays across all surgical departments and institutions.

Patient Safety Incident Reporting in Sterile Processing: A Systems Perspective

After use, surgical instruments are sent to a Sterile Processing Department (SPD) or facility to be cleaned, reorganized, maintained, sterilized and stored for eventual re-use. Though essential for safe, efficient and cost-effective surgical delivery, the functions, trade-offs and outcomes within SPDs have rarely been studied. Patient safety incident (PSI) reports are the most ubiquitous form of safety data collected within acute care environments and are often used to report issues in the SPD. Using the work systems analysis perspective we developed in previous work, we created a framework for areas where system failures might occur and manually evaluated PSI reports to investigate a period of possible system strain. We identify the assembly stage as a potentially significant contributor to system strain in the SPD and suggest that several issues related to sterile processing may be interconnected with an aim to assist decisionmakers and healthcare team members in SPD system management.

Management of a large tuberculosis contact investigation related to a contaminated bone graft product used in spinal surgery

Background: In March–April 2021, 23 patients at a 906-bed hospital in Delaware had surgical implantation of a bone graft product contaminated with Mycobacterium tuberculosis; 17 patients were rehospitalized for surgical site infections and 6 developed pulmonary tuberculosis. In May 2021, we investigated this tuberculosis outbreak and conducted a large, multidisciplinary, contact investigation among healthcare personnel (HCP) and patients potentially exposed over an extended period in multiple departments. Methods: Exposed HCP were those identified by their managers as present, without the use of airborne precautions, in operating rooms (ORs) during index spine surgeries or subsequent procedures, the postanesthesia care unit (PACU) when patients had draining wounds, inpatient rooms when wound care was performed, and the sterile processing department (SPD) on the days repeated surgeries were performed. We created and assigned an online education module and symptom screening questionnaire to exposed HCP. Employee health services (EHS) instituted a dedicated phlebotomy station to provide interferon-γ release assay (IGRA) testing for HCP at ≥8 weeks after last known exposure. EHS managed all exposed HCP, including nonemployees (eg, private surgeons) via automated e-mail reminders, which were escalated through supervisory chains as needed until follow-up completion. The infection prevention team notified exposed patients, defined as those who shared semiprivate rooms with case patients with transmissible tuberculosis. The Delaware Division of Public Health performed IGRA testing. Results: There were 506 exposed HCP in ORs (n = 100), the PACU (n = 87), inpatient units (n = 140), the SPD (n = 54), and other locations (n = 122); 83% were employed by the health system. Surgical masks and eye protection were routinely used during patient care. All exposed HCP completed screening by December 17, 2021. Furthermore, 2 HCP had positive IGRAs without symptoms or chest radiograph abnormalities, indicating latent tuberculosis infection, but after further review of records and interviews, we discovered that they had previously tested positive and had been treated for latent tuberculosis infection. In addition, 5 exposed patients tested negative and 2 remain pending. Conclusions: This large investigation demonstrated the need for a systematic process that encompassed all exposed HCP including nonemployees and incorporated administrative controls to ensure complete follow-up. We did not identify any conversions related to this outbreak despite high burden of disease in case patients and multiple exposures to contaminated bone-graft material and infectious bodily fluids without respirator use. Transmission risk was likely reduced by baseline surgical mask use and rapid institution of airborne precautions after outbreak recognition.Funding: NoneDisclosures: None

Initial application of deep learning to borescope detection of endoscope working channel damage and residue.

Background and study aims Outbreaks of endoscopy-related infections have prompted evaluation for potential contributing factors. We and others have demonstrated the utility of borescope inspection of endoscope working channels to identify occult damage that may impact the adequacy of endoscope reprocessing. The time investment and training necessary for borescope inspection have been cited as barriers preventing implementation. We investigated the utility of artificial intelligence (AI) for streamlining and enhancing the value of borescope inspection of endoscope working channels. Methods We applied a deep learning AI approach to borescope inspection videos of the working channels of 20 endoscopes in use at our academic institution. We evaluated the sensitivity, accuracy, and reliability of this software for detection of endoscope working channel findings. Results Overall sensitivity for AI-based detection of borescope inspection findings identified by gold standard endoscopist inspection was 91.4 %. Labels were accurate for 67 % of these working channel findings and accuracy varied by endoscope segment. Read-to-read variability was noted to be minimal, with test-retest correlation value of 0.986. Endoscope type did not predict accuracy of the AI system ( P = 0.26). Conclusions Harnessing the power of AI for detection of endoscope working channel damage and residue could enable sterile processing department technicians to feasibly assess endoscopes for working channel damage and perform endoscope reprocessing surveillance. Endoscopes that accumulate an unacceptable level of damage may be flagged for further manual evaluation and consideration for manufacturer evaluation/repair.

960. Creation of an Infection Prevention and Control (IPAC) Elective for Infectious Disease (ID) Fellows

BackgroundID specialists often function as leaders of IPAC for healthcare systems, with variable training. Our graduates have noted feeling underprepared for this role despite completion of a computer-based training course on IPAC basics. We developed a 2-4 week IPAC elective (IPACe) rotation to address this gap to increase familiarity with key IPAC concepts, introduce learners to approaches to IPAC investigations, and develop understanding of common IPAC challenges and controversies. MethodsMethodology followed Kern’s 6-step approach. A reading list focusing on key areas in infection prevention was developed. Instructional methods included flipped classroom, learner led discussions, performing tracers, and integration with the IPAC team. Key hospital processes including High Level Disinfection (HLD) and Sterile Processing Department (SPD) were reviewed in detail with and observed by learners. In addition to an IPACe, periodic required IPAC essay questions on real-world investigations as they arose were delivered to the learners. Learner Assessment: Learners were assessed on elements of IPAC consistent with the ACGME 6 core competencies at the end of their rotation. Program Assessment: Anonymous narrative feedback was solicited post rotation completion and at semi-annual program evaluations. Additionally, learners were asked to rate the elective on a 5 point Likert scale (1 lowest, 5 highest) and specific feedback was solicited for improvement. Finally, feedback was solicited from graduates in IPAC roles.Results8 learners participated over from 2017-2021: 2 for 4 weeks, and 6 for 2 weeks. 4 of 8 surveys included a response to the questionnaire, all survey respondents (4/4) rated the elective 5: “rotation should be required of all trainees in the program.” Narrative assessments revealed the elective was highly valuable. Graduates reported feeling well-prepared after the IPACe for their roles as IPAC leaders. Highlights identified were: exposure to interdisciplinary teamwork, participation in tracers in identifying gaps, and using real-world IPAC challenges as cognitive frameworks for outbreak investigation.ConclusionAn IPACe was highly valued by fellow learners and narrative assessments identified key areas for further focus. Disclosures All Authors: No reported disclosures

Droplet dispersal in decontamination areas of instrument reprocessing suites

BackgroundPersonnel working in sterile processing or endoscope reprocessing departments are at high risk of exposure to tissue, blood, and patient fluids when decontaminating reusable medical instruments and equipment. The effectiveness of protective measures for reprocessing personnel has not yet been systematically evaluated in real-world settings. ObjectiveThis pilot project aimed to identify reprocessing activities that generate splashes, determine how far droplets can travel in decontamination areas, and assess personal protective equipment exposure during routine activities. MethodsMoisture-detection paper was affixed to environmental surfaces and personal protective equipment in a sterile processing department. Droplet dispersal was assessed after personnel simulated performance of routine reprocessing tasks. ResultsVisible droplets were generated during every reprocessing activity except running the sonication sink. Droplets traveled at least 3 feet when filling a sink, brushing a ureteroscope, and using a power sprayer to rinse a basin. Some activities dispersed droplets up to 5 feet from the sink. Personal protective equipment was splashed during most activities and did not prevent skin exposure even when properly donned and doffed. ConclusionThis hypothesis-generating pilot project found that routine reprocessing activities generated substantial splashing, and currently recommended personal protective equipment did not adequately protect sterile processing personnel from exposure.

Local 3-Dimensional Printing of a Calvarium-Anchored Ventricular Catheter Occlusion Device

ABSTRACT Three-dimensional (3D)-printed objects have been incorporated into many surgical specialties for various purposes. These devices can be customized and used as implants or surgical instruments. This study describes the use of a 3D-printed device that eliminates the need for a surgical assistant to occlude and retain the intracranial catheter during ventriculoperitoneal shunt creation and revision. After we identified design considerations and solutions, we modeled the device dimensions using computer-aided design software. Prototypes were 3D printed using stereolithography. Iterative design improvements were tested on cadaveric cranial samples. A final design was established, prepared by the in-hospital sterile processing department, and deployed successfully for clinical use. The design process for 3D-printed surgical instruments can produce straightforward idea-to-prototype pipelines. Because 3D-printed devices are easily duplicated and modified, small adjustments and new models can be developed, printed, and tested in a short time span.

Assessment of laparoscopic instrument reprocessing in rural India: a mixed methods study

BackgroundLaparoscopy is a minimally-invasive surgical procedure that uses long slender instruments that require much smaller incisions than conventional surgery. This leads to faster recovery times, fewer post-surgical wound infections and shorter hospital stays. For these reasons, laparoscopy could be particularly advantageous to patients in low to middle income countries (LMICs). Unfortunately, sterile processing departments in LMIC hospitals are faced with limited access to equipment and trained staff which poses an obstacle to safe surgical care. The reprocessing of laparoscopic devices requires specialised equipment and training. Therefore, when LMIC hospitals invest in laparoscopy, an update of the standard operating procedure in sterile processing is required. Currently, it is unclear whether LMIC hospitals, that already perform laparoscopy, have managed to introduce updated reprocessing methods that minimally invasive equipment requires. The aim of this study was to identify the laparoscopic sterile reprocessing procedures in rural India and to test the effectiveness of the sterilisation equipment.MethodsWe assessed laparoscopic instrument sterilisation capacity in four rural hospitals in different states in India using a mixed-methods approach. As the main form of data collection, we developed a standardised observational checklist based on reprocessing guidelines from several sources. Steam autoclave performance was measured by monitoring the autoclave cycles in two hospitals. Finally, the findings from the checklist data was supported by an interview survey with surgeons and nurses.ResultsThe checklist data revealed the reprocessing methods the hospitals used in the reprocessing of laparoscopic instruments. It showed that the standard operating procedures had not been updated since the introduction of laparoscopy and the same reprocessing methods for regular surgical instruments were still applied. The interviews confirmed that staff had not received additional training and that they were unaware of the hazardous effects of reprocessing detergents and disinfectants.ConclusionAs laparoscopy is becoming more prevalent in LMICs, updated policy is needed to incorporate minimally invasive instrument reprocessing in medical practitioner and staff training programmes. While reprocessing standards improve, it is essential to develop instruments and reprocessing equipment that is more suitable for resource-constrained rural surgical environments.

High-Level Disinfection in Ambulatory Care: Overcoming the Barriers of a Decentralized System through Auditing and Education

Background: High-level disinfection (HLD) of semicritical instruments in a multispecialty ambulatory care network has the potential for increased risk due to the decentralized instrument reprocessing and lack of a sterile processing department. Attention to HLD practices is an important part of device-borne outbreak prevention. Method: An HLD database was developed to identify specific departments and locations where HLD occurred across a 30-medical practice ambulatory care network in eastern Massachusetts, which included otolaryngology, urology, endoscopy, and obstetrics/gynecology departments. Based on qualitative feedback from managers and reprocessing staff, this database centralized information that included the supply inventory including manufacturer and model information, HLD methodology, standard work, and listing of competency evaluations. The infection control team then led audits to directly observe compliance with instrument reprocessing and a monthly-driven HLD calendar was developed to enforce annual competencies. Result: The results of the audits demonstrated variability across departments with gaps in precleaning, transportation of used instruments, the dilution of enzymatic cleaner, and maintenance of quality control logs. Given the uniqueness of shape and size of various ambulatory locations, proper storage and separation between clean and dirty spaces were common pitfalls. Auditing also revealed different levels of staff understanding of standard work and variable inventory management. Centralized education sessions held jointly by the infection control team and various manufacturers for the reprocessing staff helped to create and reinforce best practices. Conclusion: Decentralized HLD that occurs across multiple ambulatory care sites led to gaps in instrument reprocessing and unique challenges due to variable geography of sites, physical space constraints, and an independent approach to procuring medical supplies. Through the auditing and feedback of all areas that perform HLD, an effective and sustainable strategy was created to ensure practice improvement. Streamlining standard work, seeking direct input from frontline staff, and collective educational events were critical to our success in the ambulatory setting.Funding: NoDisclosures: None

Targeting Zero—preventing Surgical Site Infections by Reducing Immediate Use Steam Sterilization (IUSS) of Surgical Instruments

Background This hospital went through a reorganization, at which time the IUSS (Immediately Use Steam Sterilization) rates were currently 25.95%, with an average of 200 cycles being ran each month. The SPD leadership made the decision, in partnership with Infection Prevention and hospital leadership, that the IUSS rates were a priority for the facility to prevent Surgical Site Infections (SSIs) and increase patient safety. The hospital defined the target of 2%, which the health system later followed as the system-wide target. Methods The facility made a “hard stop” date where IUSS cycles were no longer going to be allowed without OR (Operating Room) and SPD (Sterile Processing Department) leadership approval. Before the start date, education was given to surgeons, clinical teams, and SPD to ensure process understanding and risk of infection due to IUSS. The facility also recognized workflow as a large part of why instruments were being sent through IUSS, due to a backup in the department. Many items were purchased to increase workflow, such as a new washer, sonic, adding a pass-through window, a low-temperature sterilizer and replacing 3 sterilizers with newer models. The facility also purchased more instruments to create additional trays to accommodate the surgical volume. The Sterile Processing Department also underwent LEAN Kaizen events in both the clean and dirty sides to improve workflow and efficiency to prevent further IUSS. Results The facility saw an immediate reduction of IUSS cycles being performed and were able to drop below the goal of 2% after the first month of using the new process. The rate has continued to be below 2% for more than 5 months. Conclusions Communication and partnership between the OR, Infection Prevention and SPD proved to be beneficial and will continue to move the facility forward in a shared decision-making model in the future as improvement continues.

Data Analysis of Plastic Surgery Instrument Trays Yields Significant Cost Savings and Efficiency Gains.

Inpatient surgery costs have risen 30% over the past 5 years, and the operating room accounts for up to 60% of total hospital operational expense. On average, only 13.0% to 21.9% of instruments opened for a case are used, contributing to significant avoidable reprocessing, repurchase, and labor expense. A comprehensive review of 40 major instrument trays at UNC Rex Hospital was conducted using a technology service (OpFlow; Operative Flow Technologies, Raleigh, NC). Among the full scope of the project, the general plastics tray and breast reconstruction tray were evaluated for the plastic surgery service line over a 3-month period. Intraoperative data collection was performed on the exact instruments used across a standard breadth of cases. Data analytics were conducted stratifying instrument usage concordance among surgeons by tray and procedure type. After a surgeon-led review of the proposed new tray configurations, the optimized versions were implemented via a methodical change management process. A total of 183 plastic surgery cases were evaluated across 17 primary surgeons. On average, the instrument usage per tray was 15.8% for the general plastics tray and 23.5% for the breast reconstruction tray. After stakeholder review, 32 (45.1%) of 71 instruments were removed from the general plastics tray and 40 (36.7%) of 109 were removed from the breast reconstruction tray, resulting in a total reduction of 2652 instruments. This resulted in a decrease of 81,696 instrument sterilization cycles annually. The removal of the instruments yielded an estimated cost avoidance of US $163,800 for instrument repurchase and US $69,441 in annual resterilization savings. The instrument volume reduction is projected to save 383.5 hours of sterile processing personnel time in tray assembly annually. An analytics-driven method applying empirical data on actual case-based instrument usage has implications for better efficiency, improved quality, and cost avoidance related to instrument repurchase and sterile processing. Given increasing cost constraints and the transition to value-based care models, leveraging a technology-based solution enables meaningful change in the sterile processing department as a source for cost reduction and quality of care improvement.

Investigation of Sterilizers Causing Wet Loads Through Root Cause Analysis

Belimed Incorporated sterilizers are used in the sterile processing department (SPD) to decontaminate operating room instruments and tools used during surgery. There are 3 phases to the sterilization process: conditioning, exposure, and the exhaust phases. During the conditioning phase, air is removed from the chamber using a vacuum system; otherwise, it would inhibit steam contact with the instruments being cleaned. Steam is then released to fill the space in the chamber during the exposure phase, increasing the pressure and temperature inside to a desired level. This sterilizes the items inside over a fixed period based on the predetermined settings. Finally, during the exhaust phase, the drain is opened to release steam, which lowers the pressure inside the vessel and allows the items to dry. 1 The quality of sterilization steam is vital for operating room (OR) surgeries to proceed as planned. During the month of July, our New England–based teaching hospital witnessed multiple wet loads, which resulted in the cancellation of several surgeries and delaying pivotal patient care. These wet loads were caused by condensation of equipment after being sterilized as A/C units are placed too close to the sterilizer units. Also contributing to wet loads was the temperature of incoming cold-water lines being out of specification by 4 degrees. Warm water causes inefficient vacuum pumps, which prevents the air in the system from being removed during the conditioning phase. Additional investigation found procedures and policies were occasionally neglected resulting in contaminated trays. A root cause analysis (RCA) was conducted by our Risk Management (RM) department as these issues affected patient care. The root/proximate causes were identified, and an action plan was formulated with the help of Clinical Engineering (CE), Belimed, and the facilities staff to prevent wet load recurrence.

Improvement Initiative to Ensure Quality Instrumentation in the OR.

Introduction:At Seattle Children’s Hospital, in November 2016, the operating room (OR) physicians reported experiencing a high number of issues occurring during cases and believed a significant amount was related to sterile processing department (SPD) errors. These errors, hereafter called “defects,” were not defined or routinely reported. There was no method of capturing these defects. There was no root cause analysis or trending of defect data. This project aimed to improve the quality of surgical instruments received in the OR.Methods:The SPD and OR leaders collaborated to develop an OR Case Sign-Out form to capture defects during the case. The data were triaged and assigned to specific departments for root cause analysis. The SPD related data were depicted with a Pareto chart to highlight the most significant opportunities for improvement. We developed a driver diagram and identified the following interventions: orientation and competency, technician OR rotation, capacity/full-time employee analysis, surgical instruments inventory, instrument pouch work trigger, work environment, preventative maintenance, and instrument wrap reduction.Results:A 56% improvement in “Non-Sterile” defects was achieved. While a centerline shift in “Sterile” defects was not observed, the most significant “Sterile” defect, “breach of soft instrument wrap,” dropped from 8 occurrences (at baseline) to 1. The number of OR case sign-out forms collected plateaued at 47%, which could indicate missing defect data.Conclusions:SPD improved quality in the OR by reducing instrument defects. The physicians gained a mechanism for reporting barriers and tracking improvements. Ultimately, the utilization of lean tools and a quality improvement approach helped drive process changes, creating a more efficient, collaborative, and safe procedural environment for patients and staff.