Are staff pressured on sterilization? Intervene, or risk device compromise

Peer pressure. The problem isn't limited to middle and high schools across America. In fact, the problem has infiltrated outpatient surgery programs across the country as surgeons and other staff members pressure the central sterile supply (CSS) technicians to sterilize instruments quickly.

Where does the problem start? With facilities planning and management of reusable supplies, says David Jagrosse, CRCST, manager of the Central Service Department at Middlesex Hospital in Middletown, CT. Jagrosse is an executive board member of the International Association of Healthcare Central Service Materiel Management (IAHCSMM).

"More often than not during central sterile supply [processing], technicians are not involved in this planning phase; therefore, turnover times and complexity of the devices are not taken into consideration," Jagrosse says. As a result, a facility that is planning to perform six eye surgeries per day might purchase only three sets of instruments. "The facility managers think of this as a cost saver when, in reality, the stress and pressure of these turnovers can lead to high turnover rates of staff, poor teamwork, and possible patient infections which are no longer reimbursable." (For more on planning and quality monitoring, see story, below.)

Such infections have been in the spotlight recently with a national report that surgeons are using devices contaminated with blood and other debris.1 The report was published by The Center for Public Integrity, a Washington, DC, nonprofit that focuses on ethics and public service. The report suggests that because facilities aren't required to report contaminated devices, many incidents are unknown.

Sharon Greene-Golden, CRCST, FCS, president-elect of IAHCSMM, says, "The bottom line is that CSSD [CSS department] staff can't clean fast! The tech in the CSSD must take time to make sure they have followed the IFU [instructions for use] for cleaning the instruments, and the instruments must be clean." If an instrument isn't clean, then it can't be sterilized, says Greene-Golden, who is manager of the Sterile Processing Department at Bon Secours — Mary Immaculate Hospital, Newport News, VA.

The pressure to sterilize quickly is common, says Ron V. Runyon, CRCST, manager of supply chain/materials at St. Vincent Indianapolis (IN) Hospital. Runyon is also IAHCSMM's secretary/treasurer. "Staff must be made comfortable to express their concerns if they feel corners are being cut or demands and expectations are placed higher than achievable within the parameters given," he says. "It's a difficult position to be placed in, but the courage to speak up may save a life, on the other side of the coin."

To resist pressures, CSS techs must arm themselves with knowledge and education, Jagrosse maintains. The first step? Certification, he says.

Patti Koncur, CRCST, CHMMC, ACE, IAHCSMM's educational specialist, points to Association for the Advancement of Medical Instrumentation (AAMI) ST79 4.2.2, which recommends that "all personnel performing sterile processing activities be certified as a condition of employment. At a minimum, all such personnel should successfully complete a central service certification examination within two years of employment and should maintain that certification throughout that employment." However, since certification is not mandatory across the country, it isn't always possible to hire certified techs, she acknowledges. In the absence of certification, surgery centers, which often don't have time for on-the-job training, should look for someone with 3-5 years of experience, Jagrosse advises. Certification is preferred, but if absent, could be required within 12-24 months, he says.

Training central processing techs

The issue of training central processing technicians is "huge and never-ending," says Darlene Stephenson, vice president of operations at Bon Secours Mary Immaculate Hospital in Newport News, VA.

Focus on your high volume procedures, she suggests. "If you handle every piece of instrumentation, you need to understand it, and we need to educate you on the personal risk of handling contaminated devices and make sure you comply with regulations," Stephenson says.

Your total focus should not be solely on mandatory annual classes, sources say. Instead, consider local and national seminars, digital media, subscriptions to central sterile supply-related trade magazines, department in-services from the equipment manufacturers, as well as IAHCSMM membership and access to its website, Jagrosse advises. (For information on IAHCSMM, see resource at end of this article.)

In terms of the topics that need to be covered, Koncur says "programs in cleaning, assembly, sterilization, storage, and distribution need to be an integral part of any education program." Additionally, techs must be educated on the importance of avoiding pressures and following set cleaning, assembly, and sterilization instructions, she says. AAMI St79 2010 guidelines can support any resistance to deviate from established best practices, Jagrosse adds. Also, ensure you have access to instructions for use (IFU) and decontamination instructions for your devices, and that they are understandable. Make sure your instructions are updated on an ongoing basis. (See resource at end of this article that offers electronic access to these and other documents.)

Don't limit your education to your central sterile supply staff, Stephenson emphasizes. The OR nurses begin the sterilization process when they remove blood and bone off the instruments, she says. "Education is critical all the way across the board," Stephenson says.

Runyon says that when OR staff place impractical demands upon the CSS department, it is because they don't understand the processes and the time required. "We must educate our customer so our concerns are understood, not dismissed," he says.

Education requires the involvement of your vendor reps, Stephenson emphasizes. "With technology changing so rapidly and designs so advanced, it's critical to work closely with reps on the intricacies of equipment," she says.

At Bon Secours Mary Immaculate, 100% of new instruments are targets of vendor education, Stephenson says. The vendors provide one-on-one education, as well as group instruction, on topics such as minute areas that have to be cleaned, she says.

Education goes a long way in reducing staff turnover, which is a common problem in central sterile supply, Koncur says. "In some areas of the country a well-trained CS technician can make as much or more money working in a fast food restaurant without the stress of the CSSD daily pressures," she says.

Education, knowledge, and certification lead to competence and confidence, and greater retention, says Runyon. "It's not always about pay," he says. "It's about knowing you're making a difference and being given the work environment in which to succeed."

Workers are more likely to stay in a job where they are comfortable with the processes, Koncur says. "That includes working with service departments to keep stress at a manageable level by treating each other with respect and dignity," she says.

The easiest and least expensive method to retain staff? "Show appreciation for a job well done," Koncur says. "A simple heartfelt thank you goes a long way and doesn't cost a thing."


  1. Eaton J. IWatchNews. How dirty medical devices expose patients to infection. Feb. 22, 2012. Accessed at


  • One Source is an electronic database of manufacturers' Instructions for Use documents. The price for facilities of 100 bed size or less ranges from $1,776 to $3,536, depending on which databases are purchased. The price for other facilities ranges from $1,995 to $3,772. For more information, contact: Best Practice Professionals, 1800 East 900 S., Salt Lake City, UT 84108. Phone: (800) 701-3560 or (801) 582-6470. Email: Web: When sending an e-mail, provide facility name, address, your name, phone number, and e-mail.
  • International Association of Healthcare Central Service Materiel Management (IAHCSMM).
    Web site offers publications, frequently asked questions, information on certification, and more. Web:

Sufficient number of instruments is key

Quality monitoring also critical

Want to avoid having dirty surgical instruments? Two critical pieces to achieving that goal are having a sufficient number of instruments and monitoring quality, according to sources interviewed by Same-Day Surgery.

"You get pressure to hurry up and rush," says Darlene Stephenson, vice president of operations at Bon Secours Mary Immaculate Hospital in Newport News, VA. "You can't cut corners in sterile processing."

Check your par level on instruments, Stephenson advises. "You want to make sure you have a sufficient number of instruments so you can control the amount of [turnaround] time and when those instruments need to be sterilized," she says. This step will help you minimize flash sterilization, Stephenson says.

Bon Secours Mary Immaculate now has a 24-hour sterile processing department, she says. "If the department runs later, there is a shorter time to turn instrumentation over if you have traditional business hours," Stephenson says. "We run 24 hours a day to ensure that when the last case ends, to when the first case starts tomorrow morning, we have had the proper resources and time to process instruments for that day."

Involve central sterile supply (CSS) technicians in the planning and design of outpatient surgery programs, suggests David Jagrosse, CRCST, manager of the Central Service Department at Middlesex Hospital in Middletown, CT. Jagrosse is an executive board member of the International Association of Healthcare Central Service Materiel Management (IAHCSMM). Otherwise, "needed space and specific required equipment is often left out of the plan and only realized once the facility opens," Jagrosse says.

Additionally, OR and CSS staff should configure instrument sets so they are workable for the OR and compact in size to allow for quicker processing, advises Patti Koncur, CRCST, CHMMC, ACE, IAHCSMM's educational specialist. "With budgets tight and not allowing for the purchase of many expensive instruments (sets), working together to schedule the order of surgeries to allow for proper turnaround of instrumentation will also help," Koncur says. Administrators also must back up the policies for cleaning and sterilizing instruments, sources say.

Don't neglect quality monitoring

In terms of continuous monitoring, ask these questions, she advises:

  • How do instruments arrive to you?
  • What time do they arrive?
  • When they are coming from an outside vendor for the case, ask: Do you allow enough time to process that instrument per guidelines? Are vendors working with you cooperatively? What are rules and expectations you set with them?

"They can't bring them in an hour before the case starts and think that can be processed appropriately," Stephenson says.

Monitor your surgical site infection rate, she advises: "Evaluate it through root cause analysis or failure mode analysis to determine: Where were opportunities to reduce risk of patient harm?"

Central sterile supply is a complex area, she emphasizes. "It takes continual education, oversight, and monitoring to ensure both patient and staff safety," Stephenson says.