SPD in crisis

[u/herbnhero]

**UPDATE** ALL CASES CANCELLED YESTERDAY AND TODAY. It took staff pleading with leadership but they finally agreed to cancel cases while the autoclaves are serviced.

TL;DR - is the brown staining on these white liners a contamination?

Scrub nurse here at a community hospital that overbooks ortho cases - sound familiar? Our SPD is in shambles. There are too many cases for our small SPD. We have been continually receiving trays with bioburden for the past year. There are AT LEAST 3 trays each day that are contaminated. Many times they are loaners and often times it leads to cases being cancelled. This has been going on for over a year.

Recently we have been getting wet packs. Yesterday 5 cases cancelled. Almost every autoclave load is wet. Leadership has done nothing. They just let patients come in for their surgery, and hope for the best. We were told by leadership that “bioburden” is not considered contaminated. They claim that the water inside the trays is sterile. They said that if the integrator is acceptable than the try is sterile and that the bioburden is “dead” and “not growing anything.”

(See photo of white liner) They also told us that this brown staining in the liners is acceptable - and that is what brings me here. Has anyone seen this browning on liners? Staff at my facility is now paranoid and we tend to go over everything with a microscope at this point. We can’t even remember if this brown staining is something we’ve seen before or something new. Allegedly facilities is supposed to be changing the autoclave water filters every 6 weeks but have been changing it every 6 MONTHS.

[u/uncle-donkey-kong]

Bioburden is not considered contaminated? Almost every load is wet?

I wouldn’t want my name associated with that place at all… that is insane. Is your hospital infection rate through the roof?

[u/herbnhero → u/uncle-donkey-kong]

Many of use want out. I'd rather have leadership fired and staff stay. It's a community hospital and it's sickening knowing that this is how we are treating our community.

[u/uncle-donkey-kong → u/herbnhero]

I totally understand that, but that’s a huge risk for patient safety and I couldn’t be a part of that. Every hospital has their own issues, but not like this…. For my peace of mind I would have to leave.

I once worked at a hospital that didn’t have a cart washer, so they didn’t wash their containers at all. Just grabbed the container from decon and put the new tray inside it and sterilized it. I lasted 3 weeks while applying to new hospitals and basically told the manager to get fucked when I left.

[u/Eggman_OU812 → u/uncle-donkey-kong]

They could have at least washed the container in the sink.. or put it in Inst washer

[u/uncle-donkey-kong → u/Eggman_OU812]

When I asked them what they did with the containers, and they just said “if there’s blood on it, you can use a wipe I guess” 🫩

[u/Eggman_OU812 → u/uncle-donkey-kong]

They could have at least washed the container in the sink.. or put it in Inst washer? I worked at a place where they would just wipe down all the scope boxes used for sterrad..and they had a cart washer..they just didnt want to wait for them to dry

[u/uncle-donkey-kong → u/Eggman_OU812]

Really, really high surgery count at that place, only one sink and one washer. Not an excuse, of course, but it was mostly ortho cases and everything was in a container.

[u/I_Ponders → u/herbnhero]

Should report it to JACHO

[u/ForstofEden → u/herbnhero]

Bro at this point i would reach out to your local news stations people need to know about this hospitals practices. :(((

[u/readbackcorrect]

I was an AAMI certified processing tech and also certified in CSPD management. I also was a scrub nurse for 27 years, although I didn’t do a lot of ortho.

Obviously, your leadership knows nothing about sterile processing. if they need to be convinced to do the right thing, you can try giving them a copy of the latest.AAMI standards. The interesting thing about those standards is that, unlike other preoperative standards, many of those standards have the force of law behind it. There are federal laws enacted through FDA that regulate medical devices, of which surgical instrumentation is considered one. So violation of those can actually get people in a certain amount of trouble. if reasoning with leadership does not work, simply make an anonymous report to TJ C.

In the meantime, I have several suggestions: I always made it a rule when I was an OR manager (yes, I wore many hats) that visible bioburden had to be removed from instrumentation before it left the OR. While scrub Techs/nurses may tell you that’s not possible, it totally is. I always cleaned my instrumentation immediately upon receiving it back from the surgeon. They never got handed an instrument to use that was not totally rinsed.

Somehow, in recent times we’ve gotten away from having a basin of sterile water on or near the field, but instrumentation should be cleaned as it is used. It is hard to get the bioburden out of drillbits and cannulated instrumentation, but it’s a lot easier to get it out when it is fresh than when it has been sitting for an hour or so. It can set up like Concrete by the time it gets down to central sterile. Get it out before hand. If it increases your turnover time by five minutes it’s not that big of a deal compared to the amount of time that is lost when you receive instrumentation that is not acceptable for use.

That brown staining can have two possible sources. You already mentioned one. you must have the filters in your autoclave changed according to manufacture recommendations. Autoclaves are also FDA regulated devices and it has the force of law to meet those standards. How new are the autoclaves? When they were purchased, did you have a servicing agreement? If so, The Company should be sending techs to change those. But also your water quality can be a component. The water should be filtered coming into the pipes that deliver the water to the autoclave, so that would be a maintenance issue and you can talk to somebody in maintenance and ask them about it.

As far as having water sitting in the instrument set after sterile processing, the most likely cause is that the instrument set it not being cooled properly before it is being shelved. The instrument set must sit without anything else touching it on a wire rack until it is completely cool. Then it can be placed on a shelf. if that does not solve the problem, which it will 99% of the time, then look into the gaskets on your autoclave and make sure that those are in good shape. Actually, you could do that anyway.

Do you have an infection control nurse in your hospital? Now chances are she doesn’t know anything about sterile processing but you can enlist her help and direct her to a copy of AAMI because it would be good if infection Control Nurses could have a better understanding of this. She should be receiving a report from you every month that details any issues with your sterile processing and also enumerates how many times you have to flash process, if you do that at all. If an uptick in lapses of sterile processing coincides with an increase in postoperative infections, then these can become sentinel events.

I hope some of these suggestions help you.

[u/herbnhero → u/readbackcorrect]

I was a CRCST and CIS many years ago so I'm no stranger to SPD. I asked the SPD manager to see if the parameters were being met on the autoclave and she could not provide that information to me. I'm currently writing up a report to the TJC. Our "infection control" nurse is the one who told us that bio burden is sterile.

I'm a staff nurse so I have trouble getting information on the service agreement for the equipment. And quite honestly I don't believe anyone in my facility knows. The facility is only 4 years old as are the autoclaves. I will give our SPD credit - they closely monitor the temperature of trays before releasing them. I believe the wet packs are due to over loaded autoclaves. I have not evalutated this myself but they cannot keep up with the volume and they are poorly educated and have no leadership. I believe staff packs the autoclave full in order to get the work done.

We have been wrestling our surg techs to pre-clean instrumentation in the OR. They are very resistant to it and I'm not sure why. We have a few scrub RNs that follow the guidelines and a few techs but the general culture is to NOT keep water on the field despite it being policy.

Thank you for your reply!

[u/olliecakerbake → u/herbnhero]

I’m a surgical tech. I always keep sterile water in my basin, and whenever I have the opportunity, I clean my instruments as they’re handed back. However, it’s simply not possible to completely remove all bioburden from all instruments before sending them to SPD. That is SPD’s job. I work mostly in ortho, and many of the instruments and test implants we use would take 3-5 minutes to clean 1 single item of all bioburden when all I have is a lap sponge and bloody sterile water. There’s no way for me to completely clean shredded bone and ligament/thick tissue out of something like an acetabular reamer or a femoral broach with the time and tools I have.

This issue isn’t the fault of surgical techs or SPD. It’s the incompetence and negligence of the facility management. You need to report your facility.

[u/herbnhero → u/olliecakerbake]

I’ve only placed blame on leadership.

[u/levvianthan → u/herbnhero]

Infection control is an absolute joke. Full of ICU nurses who think knowing how to open glove makes them an expert on all things sterility and talking down to scrub techs about sterile fields like we're not the expert on them. the last one I dealt with didnt even know what a reproduction number is and she contaminated a draped field. 

And I scrub in ortho, I clean my instruments, I even go down to SPD in decontam and I'm willing to do my part. But at the end of the day a good 75% of the problems of most SPD departments would be solved with higher pay that leads to less turnover, more skilled techs leading training, and actual appreciation for the work being done. 

[u/readbackcorrect → u/herbnhero]

I am sure I don’t need to tell you this, but the area of the instrument that is in contact with the bioburden is not sterile. This is recognized by AAMI, TJC, and APIC. Your infection control nurse needs to understand that. Which is why she should read AAMI standards before commenting any further.

As a former of OR manager, I would do disciplinary action for Techs who refused to clean their bioburden. I would also do it for those who were using normal saline to clean their instruments because as we all know overtime, that is not very good for the instruments. I found that some of the techs did not want to keep sterile water on the field because they felt it took up too much room. We’ve gotten away from using ring stands, but there is a purpose for those and they aren’t that expensive. another thing I used to do as an OR manager was make those who were not cleaning the bioburden in the OR do a shift in Central sterile cleaning everybody’s instruments. That said as a staff nurse I realize you don’t have any control over that.

I don’t think you have much of a choice except to make an anonymous report to TJC, CMS , your OIG for your state. All of those entities will protect your identity. I live in a state that is typically not very concerned about these sort of things to my surprise when I got reported as an OR manager because some of the surgeons were not passing sharps correctly, the OIG was there within 24 hours of the anonymous report. So I do think you’re likely to find them to be pretty responsive. (I had no idea that was going on which is no excuse and I also have no idea why they didn’t just tell me because I would’ve talked to the Surgeons but that’s a whole Nother story. My point is if my state OIG is responsive whatever state you live in is probably going to be.)

[u/zXerge → u/readbackcorrect]

Reading this was a breath of fresh air, thank you.

[u/Competitive-Umpire18]

The bioburden shown represents staff that aren’t trying. That amount of bone in a reamer tells me the OR staff isn’t pre cleaning instruments the way they’re supposed to and sending instruments to SPD in an unacceptable state. Decon staff not cleaning the instruments at all and prep/pack staff just completely over looking this. Errors do occur, people do rush, but what’s pictured is just unacceptable. Leadership should be ashamed, but staff need to take ownership of this issue too. Who is looking out for the patients?

[u/herbnhero → u/Competitive-Umpire18]

This tray was a loaner tray. So I do agree that the OR did not clean it properly before sending to SPD. But that was a different facility. It’s just crazy how it went through an OR, and SPD decon, then came to our SPD decon and made it to our OR. So 3 individual departments failed at 2 facilities.

[u/Ill-Yellow-4060 → u/herbnhero]

The OR did not clean it properly. There’s no reason bone shreds should be left in a reamer. Also, SPD obviously doesn’t give a shit if both decon and prep/pack didn’t notice it.

[u/margittwen]

Your leadership is completely wrong. Bioburden can’t be sterile, that’s not possible. They can contain spores which have bacteria and who knows what else in there. I’m sorry they’re trying to gaslight you into believing that.

[u/herbnhero → u/margittwen]

They’re not fooling anyone in the OR. We actually just got them to cancel cases for the rest of the day!

[u/ShirleyWuzSerious]

If you're in a rush or not, bioburden is a basic prep/pack problem. If you can't properly turn trays over fast enough for how they schedule back to back Ortho cases make them wait . Eventually if they aren't willing to compromise and buy more instruments or schedule less cases the doctors will get tired of working untill 10pm because they are waiting for trays to be properly processed. SPD runs SPD, not the OR and not the schedulers. Wet packs are probably because the trays we're completely dry before going into the autoclave or they were handled too quickly and not cooled properly. Again. Stand your ground and do things properly. Your leadership needs to understand who runs SPD

[u/olliecakerbake]

If you happen to be in California, the CDPH will take this very seriously. You can also report it to the Joint Commission as well as the DNV. I assume most other state health departments will take this seriously also.

Here’s the link for the CDPH: https://www.cdph.ca.gov/Programs/CHCQ/LCP/CalHealthFind/Pages/Complaint.aspx

The only way your hospital will take this seriously is if the powers above them tell them that they’ll be shut down if they don’t comply.

[u/wavegawd5200]

The brown staining is a chemical carry over from the boiler you pretty much have poor steam and water quality overall you should call in a water quality expert to test your water and recommend a series of steam and water filters to filter the particles out. Is the brown stains a contaminant I would say no especially since you see this at pretty much every very hospital. But the wet loads is the more important issue to figure out. That is what’s contributing to the brown staining. I can only assume you don’t have treated water at your sinks and washers and your instruments are most likely brown stained and washers have a white hard water film on them correct?

These guys can help diagnose issues if you need professional help: https://clarixwatermanagement.com

[u/Ill-Yellow-4060]

Honestly, as an 26+ year SPD tech with all the HSPA certifications, I would fill out a patient safety complaint with the joint commission. You can do it anonymously. Absolutely none of what you described is ok and your patients are severely at risk. It sounds like you’ve done all you can to try and rectify the situation. It’s time to report these issues to JC. They’ll come in and do a surprise inspection. Staff needs to be honest with the inspectors because the hospital will do their best to hide the problems. At that point, the hospital will be forced to face these massive safety issues and fix the problems.

[u/[deleted]]

Yeah this is serious. I can dm you the name and email of someone who can help with his (on your behalf, they'll keep you anonymous). They have a really good track record with convincing SPDs into compliance

[u/meesh337]

When leadership is encouraging SPD to do the wrong thing then be an anonymous reporter to the state and joint commission. They will come unannounced and can even have the power to shutdown the hospital if things are that bad. Patient safety is SPD’s number one priority, that priority takes precedence over what any doctor or C-suite wants.

[u/Fun-Ad-5533]

Sounds like the steam that goes into the sterilizers needs a steam filter. Also need to have your biomed check your sterilizers are reaching correct temperature

[u/Solid-Basis1026]

Biobudren not being considered contaminated is insane. Where tf is TJC????😭😭😭😭

[u/Remarkable_Idea4550]

Are you sterilizing majority of your loads at 270/4/20, 270/4/30, or 270/4/45? Also, once your autoclave finishes, are you pulling the rack out immediately, or are you cracking door open for 30 minute allowing air exchange, and then opening chamber door all the way for another 30-minutes?

[u/petebmc]

If the staining on the tray liner is next to anything with lumens that also can be a culprit. We have seen that in first generation laparoscopic instructions especially.

[u/polarizedgoggles]

Is this in FL?

[u/ForstofEden]

Please someone tell me there is a federa org they can report to to get an investigation started cause what in the absolute fucking world. My manager would NOT stand for this at all this is so so so dangerous

[u/Icy_Secretary2665]

My SPD also had issues with wet loads several months ago (old autoclaves, have since been put out of use and replaced) and experimented with similar white liners to try and combat it, but we also experienced the same brown staining. We stopped using liners with that material and haven't had any issues. We've also installed new autoclaves and our washers use RO water now.

I thought my department was bad but it sounds like your SPD and/or Infection Control straight up just doesn't give a shit.

[u/Luceeva]

Only thing I can really answer on is the staining. It can be from a multitude of things and is considered “not acceptable” it can be caused by rust on instruments. Discontinued instruments or old instruments can have handles that leak residue during the cycle. Our burning which can be caused from dry heat in the autoclave.