A recent emphasis on sterilization issues in The Joint Commission inspections directs surveyors to ask this question: “Are there enough surgical instruments to minimize the use of immediate-use steam sterilization (aka ‘flash’ sterilization)?”1

The Centers for Medicare & Medicaid Services (CMS) also has cited for immediate use sterilization. The thinking is that it is all right in an emergency if you have no replacement for the dropped piece of equipment, but it cannot occur on a routine basis. CMS requires that any equipment subjected to immediate use sterilization is used “immediately and handled in a manner to prevent contamination during transport from the sterilizer to the patient.” Thus, the abiding principle is that if you must rapidly sterilize an instrument — usually in an effort to return it to the sterile field — you must immediately use it.

It would be extremely difficult to directly link a dropped, flash-sterilized instrument to a subsequent surgical site infection, but there is enough evidence that the powers that be have banned the practice except for emergency situation.

The VA Hospital System was ahead of the trend on this, issuing a directive in 2010 to, with rare exceptions, phase out all immediate-use sterilization. Sharon Alexander, MPH, BSN, CIC, MT(ASCP), an infection preventionist at the VA Medical Center in Pottstown, PA, outlined her successful program recently in Portland at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

The first step was to track and analyze the common reasons staff were using immediate-use steam sterilization.

“Decreasing immediate-use steam sterilization—what those of us who have been around for a while used to call ‘flash’ sterilization — is an important component of [preventing SSIs],” Alexander said. “We can utilize best practice guidelines, but each facility faces challenges. In our case, the immediate challenge was actually getting a team together to [create] guidelines and best practices and to develop an attitude of zero tolerance for flash sterilization.”

The baseline rate in 2010 was 18.5 immediate-use sterilizations per 1,000 operative cases.

“I assure you it was much higher prior to that,” she said. “We didn’t have an implementation gap; we had an implementation chasm. We had to find a way to actually identify and make sustainable interventions. We researched implementation science.”

This is, essentially, plan, do, check, act — with the twist being the somewhat unpredictable nature of human behavior.

“How did we get to zero and how did we sustain it?” she says. “First of all, we needed to support the selection, development, and scale up of improvement strategies. We had the research and we knew the best practices. But you don’t know where you are going until you know where you are at. So, we developed a database. We needed to drill down. The biggest thing was what was flashed, why, and how often?”

Reasons cited for flashing a surgical instrument include: a replacement was not available, batteries were not charged on equipment, or it was a one-of-a-kind instrument.

“We staged our interventions,” Alexander said. “We didn’t try to eat the elephant all at once. And I think that is why some programs fail — they say, ‘Let’s tackle it all.’ No, you have to tackle it a bite at time. The biggest issue was that the batteries were not charged. If you knew you were going to have a case, don’t you think you should plug it in the night before? Also, if you knew you were going to need a camera, don’t you think you would find it beforehand? Those kinds of things — a lack of anticipation. This wasn’t just at the frontline level; it was at the supervisory level.”

With regard to one-of-a-kind items, she said, “If you keep dropping one-of-a-kind items, maybe you need to buy some more. Also, it is not all about instrumentation. We found out after we did some of this that we had had holes in [instrument] wrappers that you could drive a truck through. We ended up going to rigid containers, and that solved a lot of the problem.”

The program enjoyed steady success, from 18.5 per 1,000 operative cases, to 15.8, to 10.2, and to 2.6.

“We had zero for both fiscal year 2014 and 2016,” she said. “We actually dropped one instrument in fiscal year 2015. You would have thought the roof was failing. There were questions, concerns, everybody was upset — it was wonderful! I am proud to tell you that to date since that dropped instrument [in 2015], we have not flashed anything. Your team can do this, too. You have to get the folks on the frontline engaged. They have to truly believe that their efforts recording on that [flash sterilization] log are actually going to be taken seriously and we are going to utilize the data. Now, we are doing no flashing. None. It’s possible. You can do this.”


  1. Joint Commission. Improperly sterilized or HLD equipment — a growing problem. Quick Safety 2017;33. Available at: http://bit.ly/2qUn8q1.