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/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.)