Surgical Site Infections a hidden Hospital

1. Surgical Site Infections a hidden Hospital Leslie Teachout MT(ASCP), CIC Infection Prevention Riverton and Lander Hospitals

2. Objectives • Discuss the five steps in Sterilization Process • Learn what processes in the OR the Infection Prevention should review and/or understand. • Learn the five steps to monitor sterilization

3. OR Suite is hidden in the Hospital • Behind closed doors • Special clothing-only scrubs • Red lines to cross • Very busy • Sterile! • Patient privacy very important • A very specialized team

4. Sterile Processing Department (SPD) deep in the bowels of the hidden hospital • Sterilize instruments • Remove bio-burden!!! • Proper type of sterilization • Proper instruments in each tray/wrap • Monitor autoclaves/sterilization equipment • Maintain autoclaves/sterilization equipment • Immediate use sterilization

5. ANSI/AAMI ST79 Association for the Advancement of Medical Instruments Standards

6. AORN Standards Association of Operating Room Nurses

7. Five steps in Sterilization Process • Clean/Disinfect • Prep/pack • Sterilize • Store • Issue/use

8. Clean/DisinfectInstruments • Open hinged instruments to remove bio-burden • Must clean before sterilization! • Rust and/or pitting are the enemy! • Instruments design and material • Don’t reprocess single use instruments • FOLLOW MANUFACTURE RECOMMENDATIONS!!

9. Prep • Enzymatic cleaner immediately • Washer sterilizer can be used • Monitor process with indicator • Load size? • Maintenance

10. Pack or Wrapping • Hospital specific trays or sets • All surfaces of the instruments must be contacted by sterilant • Wet packs mean water can contaminate instruments • Weight limits of trays

11. Autoclaves/sterilization • Best way to sterilize • steam (see below for types) • ETO • Sterrad (plasma) • Types of steam cycles • Gravity • Pre-vacuum • SFPP (Steam Flash Pressure Pulse) • Regular Cleaning • Lint trap • Maintenance

12. Five Steps to Monitor Sterilization • Equipment Control • Load Control • Pack Control • Exposure Control • Record keeping

13. Equipment Control How to determine if your sterilizer is doing it’s job. When using dynamic-air removal (i.e. vacuum-assisted steam cycles or pre-vac) Begin each day with a Bowie-Dick test to detect air leaks. Air leaks, poor steam quality, inadequate vacuum and air pockets can lead to poor steam penetration. Monitor the rest of the day by watching physical monitors

14. Load Control • Foundation of successful sterilization process monitoring: • Biological Indicator or BI • Only way to detect actual killing of microbial spores • Most reliable test • Rapid read outs reduces risk of recalls and is less expensive • Required with implantable devices

15. Pack Control • Use of chemical indicators (CI) for internal monitoring of packs • Verifies the sterilant has penetrated the pack/peel pouch • Chemical indicators are designed to react to two or more of the critical variables required for steam sterilization: • Time • Temperature • Presence of steam • CI have classes (not hierarchical!) • Staff aware and understand importance!!

16. CI Classes

18. Exposure Control • To know at a glance if the packs have been exposed to the sterilization process. • These are CI class 1 process indicators • So packs don’t have to be opened

19. Record keeping • Provides documentation that items have been processed along with evidence of their monitoring results. • Extremely important in a recall investigation • Required for accrediation

20. Store • How long is the wrap good for/shelf life? • Inventory control • Look for wet packs

21. SPD Immediate use (IU) • Are “flashed packs” being used- preferred • Instruments cleaned prior to IU? • Types of cycles • Monitor for frequency of IU as this may indicate an instrument need • Is all the OR staff educated and aware of the whole process?

22. How to combat “colon cancer” of SPD in the bowels of the hidden Hospital • Gown up or bunny suit up and go to the OR! • Ask questions! • Ask questions! • Watch processes! • Get educated by staff as well as know the standards! • Who cleans the OR rooms/how often • Check for cleanliness-white glove test

23. How to combat “colon cancer” of SPD (continued) • Review logs for monitoring and maintenance! • Watch processes in the OR! (i.e. medication administration) • Open doors! • Check carts be NOSEY! • Look at storage areas especially sterile storage • Look for storage in “hidden sterile storage areas”(i.e. ED, PT and OB)

24. How to combat “colon cancer” of SPD (continued) • Remember and remind we are all on the same team! • Find out who does and owns the processes • Open doors on cupboards! • Check drawer in carts for open skin preps or medication! • We all have the patients’ safety in mind!

25. How to combat “colon cancer” of SPD (continued) • Monitor Surgical Site Infections for trends: • OR staff • OR Room • Surgeon • Was the immediate use autoclave used for instruments • Customize for your hospital • Share findings with OR Staff! • Share findings with Surgeons • Share findings with Anesthesia • Keeping patients’ is everyone's responsibility

26. Check list • Who process the instruments at your hospital? • Are the individuals employed by your organization! • Check packages – have a process just like checking outdates • Initials • Date • Condition of package • Indicator on peal pack • Is SPD cleaning instruments well before sterilization? Watch process • Are any instruments being used in your facility coming form outside (vendors, dentists, etc.)

27. Check List (cont.) • Is washer used? Then how is it monitored? • Are all autoclave cycles and autoclaves monitored? • Know what class of monitors are being used • Frequency and documentation of Biological Indicators (BI) • Assure all implants are being monitored with a BI • What is your recall process when there is a failure? (make sure your on the list)

28. Check List (cont.) • How are autoclaves cleaned (how and frequency)? • Monitor room cleaning • All patient rooms (ATP or Diazo) • White glove the tops of high surfaces/high dusting and vents? • Frequency of terminal cleaning and difference between daily cleaning • Who does the cleaning?

29. Immediate use Check list • Cleaned prior? • Walk through process; same a SPD • Cycles used for what and when • Are logs complete? • Who owns this process? • Is OR staff knowledgeable and handles instruments appropriately?

30. Objectives • Discuss the five steps in Sterilization Process • Learn what processes in the OR the Infection Prevention should review and/or understand. • Learn the five steps to monitor sterilization

31. Questions? • Be aware of the hidden hospital in your hospital • Stop the spread of the undiagnosed cancer! • Bring the process into the light!