With the emergence of drug resistant organisms like Methicillin-resistant Staphylococcus aureus (MRSA) occurring in healthcare facilities around the country, including to a lesser extent ambulatory surgery centers (ASC), the focus of maintaining a healthy, sterile operating room environment can be a trying one. An April report from the Society for Healthcare Epidemiology of America estimated that there are many as 23,000 to 64,000 preventable deaths each year from healthcare-associated infections (HAIs), which includes surgical site infections (SSI), a growing problem that up to 54 percent could have been prevented.
To make matters worse, the Centers for Medicare and Medicaid Services announced starting this month, they will no longer reimburse facilities for certain SSIs at the higher diagnosis-related group rate, putting the burden on ASCs, among others, to avoid them by keeping their offices as germ-free as possible.
The Role of Bio-burden
A problem that operating room staffs, along with sterile processing units deal with is bio-burden, the collection of microorganisms from blood and debris and various other sources on surgical instruments. “Any amount of bio-burden, no matter how miniscule, left on an instrument after cleaning can contain infectious diseases such as MRSA,” says Jack Kinville, an executive with Ruhof Corp. “That instrument can then transmit the disease to other patients and healthcare workers, sometimes with deadly results.”
Any ASC staff will tell you they have a specific process for sterilization, which includes inspection, packaging, sterilization and storage of instruments before use. According to the Association of periOperative Registered Nurses, surgical staff should be wiping off gross blood and debris from instruments and then wetting them with an enzymatic solution, so that the blood does not dry on those instruments between surgery and formal decontamination.
“If bio-burden is left to dry on an instrument, it becomes extremely difficult to remove,” Kinville notes, “requiring a lot of scrubbing and extra soak time.”
But it presents a challenge to the decontamination staff in the meantime, says Chuck Hughes, general manager and lead educator of SPS Medical Supply Co. “The challenge we have with bio-burden, particularly biofilms that form on instruments, like stainless steel that’s are commonly used, is that it takes direct friction to remove that bio-burden. And if they’re placed directly into a mechanical washer, then there’s an excellent chance that bio-burden will not be removed.”
The consequences, can of course, be harmful. “A person like you or I who may take elective surgery could probably handle some bio-burden contamination,” says Hughes. “But all of those people who are pregnant, small children, people whose immune systems are compromised, they’re the ones that are really going to have issues with SSIs in a situation like this.”
Lightening the Load
The thoroughness of cleaning protocols plays a key role in creating and maintaining a sterile environment. It starts with the cleaning of instruments and decontamination. “You cannot sterilize a product until all the bio-burden, blood and other things, etc., are totally removed,” says John Engles, portfolio executive for Novation. “Even after certain surgical instruments are cleaned, they still have to be put in a sterilization wrap or a sterilization container, so there’s still manual handling to see if there’s any bio-burden on it.”
Kinville suggests using an enzymatic foam spray or pre-soak directly after a procedure to keep bio-burden moist and begin to break it down. “This will play a significant role for the techs when they begin to clean the instruments.” He also proposes treating them with a specialized multi-enzyme detergent to remove all soil and organic matter. “This will allow the chemical sterilant to reach and kill all microbial contaminants such as MRSA. Single or dual enzymatic detergents do not contain enzymes to remove fats, starches or carbohydrates and can leave infectious microbes such as MRSA trapped beneath, not allowing the sterilant to reach them.”
Hughes, who audits facilities around North America, points out a lack of hand hygiene is another factor in lack of sterile OR environments. “You get to see people within the facility infrequently washing their hands — something they should be doing, but they don’t...It makes you wonder if those instruments that are being used in the next surgery truly is sterile or (do) they have a level of bio-burden there that hasn’t been detected, that’s going to enter the body cavity and create a SSI.”
Hughes also feels that bad storage shelving habits can be a cause for an unclean operating room. “We see a lot of very dirty sterilization storage shelving, that these devices are laid on and sometimes stacked on top of each other, which means the wrapping material, the packaging material is compromised,” he notes. “It’s best practices not to stack heavy wrap trays on top of each other, but that’s commonly done because of a lack of space.”
Processing and reprocessing instruments is important as well, states Engles. Many facilities now have decontamination machines that process equipment at a more rapid pace; cutting down the time it takes to them around for the next procedure. But in order to do that, it requires a different chemical mixture to speed up the process. “You don’t just turn the dial halfway and everything works. It’s a whole new process. It’s real important that people take the time to do it right.”
But time is always a factor in processing, Hughes declares. “We’re finding that the operating room is very critical of the sterile processing departments throughout the world and asking ‘all we need you to do is bring out instrument sets back to us that are sterile, on-time and complete.’ But most of the focus is on-time and complete.”
Kinville offers these ideas for ASCs: “The healthcare workers must be trained and strictly adhere to the documented cleaning protocol. Constant checking and validating the cleaning process will also help flag any inconsistencies that may result in patient to patient infections.”
Hughes gives four suggestions for achieving a sterile OR. “First, each shift should have a person or manager who is certified in sterile processing; next, organize sterile items in a central location that is cleaned regularly and environmentally controlled; perform an audit of sterility (SAC) of trays and inspect them; and lastly, establish a control quality improvement team to assess the concerns of each department.”