Tackling the complexity of orthopedic instrumentation reprocessing in ASCs

One of the most common challenges that ambulatory surgery centers (ASCs) face is the reprocessing of orthopedic instrumentation. Despite its complexity, this workflow can often be overlooked when constraints related to space, resources and staffing are tight.

During a September Becker's Hospital Review webinar sponsored by Healthmark, Adam Okada, clinical education specialist at Healthmark Industries and owner of Sterile Education, a mobile application dedicated to sterile processing education, discussed steps ASCs can take to achieve consistency in instrument reprocessing.

Three key insights were:

1. Modern orthopedic instruments are complex and difficult to sterilize. Orthopedic surgical instrumentation has evolved since the 1970s, when it mainly consisted of single stainless-steel pieces whose straightforward design made them easy to clean. Nowadays orthopedic surgical sets contain flexible reamers and long narrow lumens with serrations where bioburden builds up, making it difficult for sterile processing department (SPD) technicians to see or reach.

 With these complex instruments come complex reprocessing instructions, which are not always clear about how the tools should be disassembled to sterilize. Compounding the problem is the limited space in which SPDs typically operate. "The reality in the ASC setting is that we are cramped and often in a one-room design with things that are way too small to do the instruments that we need to do," Mr. Okada said. He emphasized that space constraints have an outsized impact on ASCs' ability to properly reprocess instruments and prevent cross-contamination and infection.

According to The Joint Commission, the most vulnerable locations for lapses in reprocessing are ambulatory care sites, and most high-risk findings are related to infection control.

 2. Observing best-practice standards is essential for cleaning properly and preventing infections. Following best practices for each step in the orthopedic reprocessing cycle, from point-of-use in the operating room (OR) to sterile storage, can help SPD staff avoid lapses and minimize infection risk. Recommendations include:

  • Pre-cleaning: Any visible "gross soil" should be wiped off immediately and instruments should be kept wet until transported to the decontamination area to avoid the accumulation of biofilm.
  • Transportation from the OR: Once pre-treated, instruments should be placed into biohazardous containers and then into a containment device.
  • Decontamination at the sink: Four key factors are the chemical used (dilution, action), soak time, temperature and mechanical action.
  • Decontamination of powered equipment: Powered instruments should not be submerged, unless otherwise specified in the manufacturer's manual; the correct cleaning brush should be used for their various components and sizes of openings.
  • Decontamination of shavers: The key action is to test for leaks, which is where bioburden and rust often accumulate.
  • Decontamination of Kerrison Rongeurs: Because of the extreme difficulty of cleaning these instruments, SPD technicians should consider using a take-apart version.

Best practices also cover steps for properly performing:

  • Decontamination of drill guides, reamers, ultrasonic and irrigating ultrasonic
  • Decontamination using automatic washers and lubrication
  • Inspection and assembly, using the proper tools to test for cleanliness and function
  • Sterilization
  • Sterile storage, specifically event-related sterility and area requirements

3. Solutions for dealing with the complexity of orthopedic instrumentation are within reach. Orthopedic ASCs and SPD staff do not have to hope for the best when it comes to instrumentation reprocessing; there are solutions that can help them neutralize or eliminate many of the risks associated with cleaning and sterilization.

Solutions include: inspection tools, such as microscopes and borescopes to detect bioburden; extra sets of procedure trays to reduce the number of turnovers; data and analytics to monitor how long instrumentation turnover takes; having a QA policy and highlighting problem trays but also things done well; up-to-date instructions for use and continuous education and training from vendors; adequate space; gaining perspective by having leaders and managers spend a day in the SPD to grasp the challenges; and education by supporting certification for reprocessing staff.

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