Don't be one of the horror stories — Learn proper use of flash sterilization
'The rules have changed,' says author of updated practice
The stories abound:
- A hospital that routinely flash sterilize implants.
- Facilities where staff don't understand the difference between different types of flash sterilization or between indicators and integrators.
- An instrument falls in the field, and a staff person puts it under tap water in the scrub sink, then places it in the sterilizer without using any detergent and without making sure all gross soils are removed from the lumens.
With all of these problems, should you flash sterilize at all? "They should do it when they have no other choice," says Ramona Conner, RN, MSN, CNOR, perioperative nursing specialist at the Center for Nursing Practice at the Association of periOperative Registered Nurses (AORN). "It should not be routine."
That position is supported by AORN's Recommended Practices for Sterilization in the Perioperative Practice Setting, which has been updated this year. The recommended practice now states: "Flash sterilization should not be used as a substitute for insufficient instrument inventory."
Don't flash sterilize because of poor planning, says Stephen M. Kovach, director of education at Saint Claire Shore, MI-based Healthmark Industries, which features products for sterilization, decontamination, storage, and security of medical equipment and supplies. "It shouldn't be because you don't have enough instruments, or you scheduled cases incorrectly, or you have to turn cases around quickly," he says.
However, many outpatient surgery providers report that flashing is routine, often due to a lack of instrumentation, with seriously lacking documentation. The issue seems to be particularly problematic with ophthalmic centers, Conner says. "Often they don't want to invest in the appropriate number of instruments so they won't be flash sterilizing between every case," she says.
You need a policy, says Nancy Chobin, RN, CSPDM, primary author of the AORN sterilization recommended practice, and corporate consultant and educator with Saint Barnabas Health Care System in West Orange, NJ. The policy at Saint Barnabas, which follows New Jersey state law, says flash sterilization is used only in an emergency. [Editor's note: A copy of this policy is available with the on-line version of Same-Day Surgery. If you're accessing your on-line account for the first time, go to www.ahcpub.com. Click on the "Activate Your Subscription" tab in the left-hand column. Then follow the easy steps under "Account Activation." If you already have an on-line subscription, go to www.ahcpub.com. Select the tab labeled "Subscriber Direct Connect to Online Newsletters. Please select an archive." Choose "Same-Day Surgery," and then click "Sign on" from the left-hand column to log in. Once you're signed in, select "2006" and then select the August 2006 issue. For assistance, call Customer Service at (800) 688-2421.]
Keep in mind that many manufacturers no longer provide instructions for flash sterilization, Chobin says. "That means that if I do it, and the manufacturer did not give me instructions, I, as a practitioner, assume full liability for it," she says. Few nurses understand this liability, she says. "In the old days, you put it in and flashed it, but that's not the world we live in anymore."
Joint Commission weighs in
Accreditation groups also are following this issue, Chobin says.
"Frankly, when the Joint Commission [on Accreditation of Healthcare Organizations] comes in and sees abuses, they're going to come down on you, too," she warns.
Standards from the Joint Commission do not address flash sterilization specifically, says spokeswoman Charlene Hill. However, some standards apply indirectly, including IC.3.10, EP 5 and IC.4.10, and EP 1.
"While we do not survey for [Centers for Disease Control and Prevention, Healthcare Infection Control Practices Advisory Committee] guidelines, we expect organizations' processes to be based on them and, if not, why not?" Hill says. The guidelines recommend a minimization of the use of flash sterilization, she says. "It should not be used as a convenience, to avoid the purchase of additional instrument sets, or to save time," Hill says.
Are you flashing correctly?
The issue with flash sterilization is how you do it, Chobin emphasizes.
"Often it's done under terrible conditions, in a substerile room," she says. "They're washing the item, which is not appropriate." Staff usually aren't wearing protective equipment, Chobin adds. Nurses aren't aware of these problems, she says. "The rules have changed."
The Association for the Advancement of Medical Instrumentation (AAMI) and American National Standards Institute (ANSI) have a consolidated and updated steam sterilization standard, expected at press time to be approved in early July. ANSI/AAMI ST-79:2006 says four conditions should be met for flash sterilization:
- Before sterilization, providers must ensure that cleaning and decontaminating, inspecting, and arrangement of instruments is being done properly in the recommended sterilizing trays or containers.
- The department must be laid out in a way that ensures sterilized items are delivered directly to the area where they are being used. For example, the sterilizer may open into an area within the procedure room or directly next to the room.
- Providers develop, follow, and audit procedures to be certain there is aseptic handling and staff safety while sterilized items are transferred from the sterilizer to the area where they are being used.
- The devices should be needed immediately following the sterilization.
Implantables should not be flash sterilized, according to AAMI.
To be in line with recommended practices from AAMI and AORN, consider these suggestions:
- Properly decontaminate before flash sterilization.
When someone needs an instrument right away, staff often cut corners on cleaning, "and that is the last place you want to cut corners," Chobin says.
The No. 1 precaution for flash sterilization is that the instrument must be properly decontaminated, Conner emphasizes. "They often abbreviate or entirely skip what is a critical factor in flash sterilization," she says.
Instruments should go through the same decontamination process regardless of how they are sterilized, Kovach says. "Is the staff [members] who are cleaning trained, and are they taking shortcuts?" he asks. Doing the cleaning over a sink is not correct, Kovach maintains.
- Develop a safe procedure and mechanism for transporting the sterilized instrument from the sterilizer to the point of use.
AORN staff often suggest that providers use sterilization containers that are designed for flash sterilization, Connor says. "They can be enclosed and help facility transporting sterilized items to the point of use and protect it from contamination," she says.
- Take steps to avoid injury from hot instruments.
Use trays designed to facilitate handling of hot instruments, Conner suggests.
Also, "I am aware of incidents when patients have been injured by hot instruments taken straight from the autoclave and used in patients," she says.
- Maintain proper documentation.
The AORN recommended practice states that "a sterilization log or database should include information on each load, including the device(s) processed, the patient receiving the item(s), and the reason for flash sterilization."
Those records need to be maintained for about three years, Connor says.
Staff often forget to document everything, Kovach says. "The [AAMI] guideline is very specific: Write down the item, monitor the cycle, sign off, document in the patient record what was flashed, so you have all that."
Saint Barnabas maintains a flash sterilization log, to meet state requirements. (The log is available with on-line edition of SDS.) "Our health department wants to see the reason you did flash sterilization as part of the [quality assurance] process," Chopin says. "You have to record why, and you'd better not show it was because the doctor didn't have the instrument."
Chobin suggests that surgery managers can develop a quality assurance (QA) project that documents the flash sterilization and uses that documentation to help prioritize the purchase of instruments. Saint Barnabas conducts a quarterly audit of the flash sterilization records in the operating room that includes a review of sterilization logs to ensure they include signature, chemical indicators, doctor's name, etc. If flash sterilization is known to be excessive (after QA data collection), then QA monitoring should be performed monthly with process improvement implemented until the instances of flash sterilization are according to national standards, Chobin says. (A copy of the audit form is available with the on-line version of SDS).
- Match technology to the device.
Not all medical devices can withstand steam sterilization, Connor emphasizes. "There is not one sterilization technology that fits every device and every need," she says. While steam sterilization is the most common and fits most devices in the OR, "it doesn't meet all needs," she says.
For more information on flash sterilization, contact:
- Stephen M. Kovach, Director of Education, Healthmark Industries, Saint Clair Shores, MI. Phone: (800) 521-6224, ext.6621. E-mail: email@example.com.
Kovach maintains a web site at www.healthmark.info/CPDGuy/InfoOnFlash.htm. It includes articles and case studies on flash sterilization, a step-by-step explanation of the technique, and a sample policy.