“Oh, I just work in Sterile Processing “

Wava Truscott, PhD

Director, Medical Sciences and Clinical Education

Halyard Health Care

“OH, I JUST WORK IN STERILE

PROCESSING”

Objectives

• Describe what makes your career critical to optimal patient outcomes

• Identify consequences of doing an inadequate job

• Explain why a mindset of continual learning and improvement is essential

in your profession

• Determine how you can be a mentor in teaching, example and attitude

So, What Do You Do?

Oh, I just put my time at Sterile Processing…

I decontaminate, wash, assemble, pack, process, store---

Day in; Day out, same old thing

I wonder where I’m going.

I Feel I’m just coasting; Watching life go by.

I Never filled the shoes I thought I would.

…And Poop

I’m always in the dog house or

shoved in the corner

SOMETIMES I JUST FEEL I’M TRAPPED IN THIS JOB; WHO CARES

If I hear one more lecture beginning with:

“You’re not cleaning up well enough”

or, “You need to do an extra process now…”

or, “I want you to work closer with the OR and Cath Labs”

Holy Cow!! I’m just about to be wheeled into surgery.

How I survive (if I survive) may depend on that pack you prepared yesterday

I want you to think hard about the next few slides

Now The Patient’s Perspective

OH, I JUST WORK IN A CAR FACTORY

I Just…. Connect parts on engines

Install brake assemblies

Weld the same frame joints

Check hydraulic assembly pressures

Align and tighten wheel mounts

Connect the same freakin’ electrical leads

Install safety belts

Order parts from vendors

Do you think these car-assembly workers are an

important part of protecting you and preventing potentially

disastrous life-long complications for you and your family?

YOU CAN BET YOUR LIFE ON IT!EVERY DAY!!

All I do is check

elevator sensors

Hey man, all I do

is put air in tires

Genesis Solar Sampler 3yr journey

crashes. Sensors to deploy

parachutes mounted backwards

Woman dies as

shoot fails

Genesis Solar Sampler

OH, I JUST PACK PARACHUTES

In Seconds, Poorly Performed Tasks

Can Alter Lives and Families Forever

You bet your next surgical patient’s quality of life it is

As is their very life and the future of his/her family

So does the successful outcomes for invasive procedures in the

ICU, ED, Trauma, Ophthalmics, Anesthesiology, Respiratory

therapy, Research, Diagnostics, Interventional Radiology, Cath

Labs and the OR.

SO, YA’ THINK YOUR JOB IS NOT MISSION CRITICAL?

YOU & YOUR SP STAFF ARE ESSENTIAL MEMBERS OF THE MEDICAL TEAM

YOU ARE—AND MUST ALWAYS BE ---PROFESSIONALS

• A professional is a person working in an occupation

which requires extensive knowledge, skills and expertise

• A profession is limited to individuals with formal education in a

specialized body of knowledge

• Members of a profession are governed by a universal code of

ethics

Define a Professional

“First, Do No Harm”

….Know deep within, at your very core’ that what you do

has the power to save, improve, injure, ruin or take

lives….and with that comes serious responsibility

Both for you personally and as a part of

your Hospital or Ambulatory Surgery Center SP team

Started Not All That Long Ago

A Profession That

1774 Swedish chemist Scheele

discovered chlorine

1825 Frenchman Labarraque

used calcium hypochlorite

(chlorine compound) to remove

the smell of:

• morgues

• sewers

• privies (toilets)

• horse stables

• hospital wards

• ships

• prisons

French surgeons in late

1800s first used to reduce

odor of gangrene then to

treat:

• gangrene

• ulcers

• burns

• carbuncles

Germicides

Vienna 1840s: 1 of 5 mothers died giving birth

Semmelweiss thought connection with hands: Docs

did not wash between autopsy and examining mother in labor

He began to required surgeons wash hands with dilute bleach

Death rate dropped from 18.7% to 1.7% for an entire year!!

Staff did not like angry Semmelweiss, refused to believe data

Went back to contaminated hands and lab coats

High mortality rate returned

Semmelweiss committed to insane asylum; beaten by guards

because of his insulting obnoxious personality

Child-Birth Fever

Ignaz Semmelweiss

Managers: How you deliver a requirement makes a difference

Staff: If you ignore the evidence because you don’t like

messenger, patients could die

Florence Nightingale

Crimean War 1853 - 1856

Florence Nightingale visited wounded soldiers

10 times the soldiers died from infections they

acquired in the hospital than directly from their

battle wounds!

Advances in Earliest

Ambulatory Surgery Centers

She and recruited volunteers

cleaned & disinfected everything

Result: 6 months of disinfection dramatically

reduced infections & deaths of wounded soldiers

Wounded died of infection:42% before disinfection started

2% after disinfection procedures in place

Nightingale

Joseph Lister 1827-1912

Mid 1800s post-surgical infections accounted for

death of almost 50% of all patients undergoing major surgery

Common medical report:

“Operation successful, but the patient died”

Lister used carbolic acid to clean the skin, mist over surgical site,

soak wounds and disinfect the instruments

No systemic infections or infection-related deaths for 9 months!

Father of surgical antisepsis

During the Franco-Prussian war: of the 13,200

men who had limbs amputated 10,000 died of

infection (gangrene)

Koch was appalled. He entered the war served

as a physician: learned of the work of Lister and

the germ theory proposed by Pasteur,

so used hypochlorite (bleach) with success

Father of Steam Sterilization

Then, in 1878 steam sterilized instruments

and dressings with similar results to the

hypochlorite - starting the era of steam

sterilization

Robert Koch 1843-1910

25

WHAT A WONDERFUL TIME TO BE IN HEALTHCARE!

Public Reporting

of Errors,

Infections

Pay for

Performance &

Penalties for Poor

Performance

26

JOY OF NEW LIFE Joy of New Lives

27

JOY OF EXPERIENCED LIFE

1 in 10,000 individuals in the US reaches age 100

Now 60,000 in US >100; up to 70 are beyond age 110!

Charles Yogi age 85

28

THERE’S NEVER BEEN A BETTER TIME TO HAVE CANCER

29

OR TO NEED A HEART TRANSPLANT

30

OR REQUIRE HEART SURGERY

Open on pump

Open off pump beating heart

31

OR TO FIND HOPE & A NEW LIFE

32

PENG SHUILIN

• 1995, 37 yr old Peng was hit by freight truck severed his body in half

• 2 years in the hospital with series of surgeries to reroute nearly every major organ or system

• Kept exercising, taking care of hygiene, positive attitude

• Fitted in socketed bucket with prosthesis

33

DALLAS WIENS

• 26yr Dallas face touched live electrical wire while repairing church window

• Burned face & half of scalp completely off

• Doctors series of surgeries 2.5yrs then skin from his back onto face

• Could not smell, breathe through nose or see

• Assumed this would be the rest of his life

• May 2011 received first US full face transplant

• Feels his lips and nose - can smell

• It is believed that in a few years, technology will be able to restore sight in his one eye

Daddy, you’re so handsome

34

FACES OF YOUR SUCCESSFUL PATIENTS!!

YOU ARE A PROFESSIONALA Member of The Healthcare Profession

That should give you and your family great pride

You should find personal joy and fulfillment in those successes

….and must embrace this very serious responsibility

36

SURVIVORS OFTEN INCREASED VULNERABILITY

“HOSPITAL OF CRITICAL PATIENTS”

Cancer treatment

Burns-extent and severity

Diabetes

Hemodialysis

HBV, HCV

HIV/AIDS

Implants: knees, hips, etc

Leukemia

Obesity

Organ transplants-human

• Extreme life saving procedures

Organ transplants-animal

Premature neonate survival

Poor nutritional status

Premature births

Smokers

Trauma severe

Tubes used in body

Very old and aging

New heart for baby

Along With Advances in Medicine and Progress in

“Enjoying the Good Life” comes increased vulnerability

37

WHEN THINGS GO WRONG

And What If It Was Your Fault

100,000 die of a

Hospital acquired

Infection - yearly

240 will die today

38

DON’T LET SOMEONE ELSE MAKE THAT MISTAKE

• Mistakes should not recur

• But an even more egregious mistake is failing to make certain sure no one else repeats it

• Golden opportunity is the “it almost happened”

39

• Remember the joy of learning

• …the joy of sharing knowledge of how to do things with children?

• …and the child’s thrill at accomplishing something new?

KNOWLEDGE AND EXPERIENCE: SHARE IT!!

Knowledge and Experience: Share It!!

40

• Learn best by example

• Learn why something must be a certain way

• Get deep into the problems; tackle them one bite at a time

• Seek support when needed rather than guessing

41

BE MENTOR!Be A Student!

42

DON’T BE A LUKEWARM ONLOOKER

• Be active; Be vital

• Be helpful, Be positive

• It’s OK to adjust the way you have been to be more

• Don’t live your life looking at a rearview mirror

• Everyday: learn, grow, teach, appreciate

43

Though sometimes difficult and unwelcome, change is absolutely necessary for Progress to proceed: Be a part of it!

Change

“A year from now you will wish you had started today.” -Karen Lamb

“It doesn’t matter where you are, you are nowhere compared to

where you can go.” -Bob Proctor

“Never too old, never too bad, never too late, never too sick to

start from scratch once again.” -Bikram Choudhury

“Nobody can go back and start a new beginning, but anyone

can start today and make a new ending.”-M Robinson

“Today is the first day of the rest of your life.”

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Two Categories:

1. Corrective Change. Required to correct compliance errors committed against:

• established guidelines

• manufacturers’ instructions

• best practices

• facility policies

2. Progressive Change. Required to implement new technologies and discoveries:

– new devices

– new cleaning agents, disinfectants, sterilization units

– new ways to work with OR

– new knowledge, learning opportunities

– new government policies (healthcare plan, CMS, OSHA)

Change Required

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Corrective Change

PATIENTS SUSCEPTIBLE TO OUR ERRORS

• 2008 Las Vegas: 50,000 former patients notified

‒ Hepatitis B

‒ Hepatitis C

‒ HIV

• 2010 Vancouver: 500 former patients notified

‒ Hepatitis B

‒ Hepatitis C

‒ HIV

Hepatitis C

Liver

MORE POSSIBLEHIV, HBV, HCV AND E. COLI

• 2011 Ottawa: 6,800 patients notified they may have been exposed to infectious agents as proper cleaning protocols not always followed

• 2009 Miami: thousands of patients notified of possible infection: endoscope irrigation tubing rinsed, but not disinfected

• 2009 Tennessee: thousands notified of possible infection: misassembled endoscope replaced one way valve with two-way valve

• 2006 Los Angeles: Endoscope infected 19 heart surgery patients with E. coli within 2 week period. Leak identified, intended for repair, but not quarantined, so went back into use – poorly processed and not observed for damage

48

CDC: CLUSTER INFECTIONS 1996 AND 1998

• 2006: Several infants.Bacterial infections contracted in Los Angeles

NICU due to inconsistent and improper cleaning practices

• 2003: 42 surprise inspections found fewer than half had adequate

sterilization standards

• 1996 and 1998 28 clusters reported by CDC: bronchoscopy

– Klebsiella

– Pseudomonas aeruginosa

– Mycobacterium tuberculosis

– Mycobacterium intracellulare

– Mycobacterium avium

49

DRYING ENDOSCOPES: SO IMPORTANT• Dry prior to disinfection/sterilization to prevent:

– over dilution of high level disinfectants– cycle cancellation in some sterilizers– colonization of waterborne pathogens

• 70% alcohol and forced air after every reprocessing (that is between patients and before storage)

• Dry and store safely

• Trapped residual moisture encourages biofilm formation

• 70% alcohol wipe-down outside surface before each use

Pseudomonas

50

Progressive Change

PROGRESSIVE CHANGE

• Colored television

• Slide projectors

• Star Trek

• Computers: binary punch cards

• Man on the moon

• Desk top computers

• PowerPoint

• Star Trek Next Generation

• Internet

• Laptop computers

• Cell phones

• Star Trek Voyager

• Smart phones

• Social media

• Tablet computing

52

Better vaccines

Non-woven fabrics

Small-pox eradication

Polio almost eradicated in the US

Phenomenal life-saving procedures

Implants

Viral treatment drugs (e.g. HIV)

Minimally invasive procedures with endoscopes

Automated endoscope reprocessors

Ambulatory Surgery Centers (>65% all elec. surgeries)

RF technology

Plasma sterilization

Role of particles complications

Biofilm studies

Progressive Change

53

LINT & PARTICLES IMPACT ON POST-SURGICAL RECOVERY

Breast implant capsular contracture is a hard scar tissue capsule that form around the implant

Now understood that this is often caused by a tissue reaction to a subclinical infection (e.g. Staphylococcus epidermidis) micro-biofilm on implant surface

Lint, powder, debris increase likelihood of biofilm formation and resulting inflammation initiating capsule to prevent spread

Dobke MK 1995 // Pajkos AB 2003// Netscher D 2004// Mladick RA 2005// Netscher DT 2005

54

FRUSTRATED WHITE CELLS “SPIT” DESTRUCTION

• Activated white blood cells (WBC) recognize bacterial biofilm threat on implant

• WBCs spit out biocidal oxygen radicals and enzymes trying to kill biofilm bacteria

55

ACTIVATED NEUTROPHIL SPITS KILLER RADICALS & ENZYMES TRYING TO STOP INVADER PARTICLES

56

FRUSTRATED WHITE CELLS “SPIT” DESTRUCTION

• Activated white blood cells (WBC) recognize bacterial biofilm threat on implant

• WBCs spit out biocidal oxygen radicals and enzymes trying to kill biofilm bacteria

• Injure the tissues that were trying to accept the implant

• Result: inflammation, delayed poor quality healing, capsule formation, potential spread of biofilm infection

57

Convinced particles + few bacteria responsible, Surgeon performed all breast implant surgeries:

– Lint-free materials sterile drapes, wrap, gowns, etc.

– Powder-free gloves

– No implant placement on drapes

– No touch of patient skin (even though thorough skin prep)

Mladick RA. Plast Reconstr Surg 2005; 1426-27

Eight years without a single capsular contraction!

Little things like lint, powder, other particles matter!

Principle applies to all implants!!

BREAST IMPLANTS

58

FRUSTRATED WHITE CELLS “SPIT” DESTRUCTION

15 to 20% breast implants still result in

capsule formation and contracture

• Activated white blood cells (WBC) recognize bacterial biofilm threat on implant

• WBCs spit out biocidal oxygen radicals and enzymes trying to kill biofilm bacteria

• Injure the tissues that were trying to accept the implant

• Result: inflammation, delayed poor quality healing, capsule formation, potential spread of biofilm infection

59

Distraction

CRIME OF DISTRACTION

• Things that strongly attract the attention of the immune system – become the center of attention so microorganisms are ignored and can multiply

germ

60

Bacteria(Pseudomonas)

Bacteria(Pseudomonas)

ParticulatesOr dead biofilm chunks

Macrophage Protecting Against Invasion

of Particles and Bacteria

61

BACTERIA MULTIPLY UNCHECKED: BIOFILM HALO

Particulates

White Blood CellMacrophage

Pseudomonas

Biofilm initiated by and now surrounding

particle

62

ALTERED THRESHOLD FOR INFECTION

Jaffray:• Wound: no particles + 1,000 Staph: 1/10 infected

• Wound: 2mg sterile particles + 1,000 Staph: 9/10 infected

Staphylococcus aureus

Elek:

• Wound: no particles = 10,000,000 to cause infection

• Wound: with particles = 100 to cause infection

63

OPHTHALMIC SURGERY

• Tissue, mineral particles, biofilm left after reprocessing

• One practice: 2.5 yrs: over 100 cases of endophthalmitis– Lint in air & on devices

attracted to eye

– Realized too late-lost practice

• Lint, glove powder, suture trims, dead tissue fragments:

– Increased inflammation (white cell enzyme spit)

– Capsule formation (hard scar “walling-off” tissue)

– Increase in infections (immune distraction)

– Granulomas (like little rocks/barnacles)

– Blood clots (form around particles)

– Adhesions (sheets of tissue to “wall-off particle threat”)

64

PARTICLE CONTAMINATION OF INSTRUMENTS CAN CAUSE COMPLICATIONS

Intestinal obstruction:

Contracted Band Adhesion

Granuloma

Blood Clot

Thick chronic AdhesionMultiple Adhesions

65

LINT & PARTICULATE SOURCES

Poorly cleaned devices: tissues, fat, blood

Linting sterilization wrap

Gasket seals oxidizing on containers or devices

Sweaters, fleece vests in SPD room

Devices dried with/on linting materials

Hair, lint, debris from staff and traffic

Corrugated cardboard, newspapers, tissues

Rigid containers not washed clear of debris

OR: gowns, hair, drapes, back table cover,

sterilization wrap, glove powder

66

ENDOSCOPE BIOFILM

Two different air/water channels

• (A) Multilayered biofilm – Held days before processing

• (B) Low-power view showing a confluent layer of soil and biofilm after processed, dried and sterilized

Pajkos K J Hosp Infec 2004;58:224-9

B

A

67

POST CLEANING AND DISINFECTION

• Electron micrographs of suction channel damaged inner surface: cracks, grooves pits, cuts

– (a) Cleaning brush caused damage

– (b) Residual soil and bacterial biofilm with its gooey coating

A

B

Pajkos K J Hosp Infec 2004;58:224-9.

68

BIOFILM DRIED ON; BLOCKED EFFECTIVE DISINFECTION

• Electroencephalogram electrodes not properly cleaned

• Biofilm left on preventing adequate sterilization

• Several patients acquired hepatitis B (HBV)

• $27.5 million legal settlement against neurologist & hospital

Mackay B CMAJ 2002; 166(7):943

69

FDA INSPECTIONHAWAII 2008

• “Dirty instruments in sterile trays, specifically orthopedic (bone) trays.” In one documented case, “three out of three trays in one day had instruments with bone or cement on them.”

• “Residue and debris on sterile instruments in sterile surgical containers.”

• “A dirty and grimy sink in the Sterile Processing Department work area.”

• “A number of outdated sterile devices and other outdated supplies”

• “Failed to ensure the integrity and cleanliness of surgical suites, procedure rooms and sterile processing department.”

• “Technician washed dirty surgical instruments with gloves on, then opened a door and answered the phone without removing the wet gloves”

70

SPD ERRORS REPEATED

• 2009: 17% of ambulatory surgery centers (ASC) who responded to a Sterile Processing News online poll reported outbreaks of toxic anterior segment syndrome (TASS) at their facilities.

– TASS is a post-operative, acute inflammation of the anterior segment of the eye that linked to ophthalmic devices

• Oct 2011: Poll of ASC “compliance challenges”:

20% stated sterile processing continues as a major compliance challenge

71

TASS WITHOUT INFECTION(TOXIC ANTERIOR SEGMENT SYNDROME)

• Abnormal pH or osmolarity,

• Impurities of autoclave steam

• Residual biofilm, tissues (sterile, but present)

• Irritants on surfaces of surgical instruments

• Corroded or chemically altered devices

• Improperly rinsed devices

• Heat stable endotoxins

• Anesthetic agents and preservatives

• Topical ophthalmic ointments

• Instruments & Intraocular lenses – chemical leach out

Van Philips L.A.M, 2011

INCOMPATIBILITY ERRORS: DAMAGE

• Inappropriate sterilization modes or disinfectants can be incompatible with instruments and surfaces

• Example: Plasma sterilization for ophthalmic instruments

– degraded brass into copper & zinc that deposited into patient’s eyes during surgery

– corneal decompensation, loss of visual acuity, irreversible injuries

– several cases of blindness

• Microorganisms can be protected from sterilization in corroded crevasses

Duffy RE, 2000

73

May we:

Accept change as probable progress, we are part of the future

Embrace that changes may need new procedures, new techniques

Recognize changes may help us to do things that will:

• improve ease of compliance

• be more efficient or effective

• be more cost effective by reducing time, effort, do-overs

• be safer for staff to perform

• better for the patient

However, as experts we must still determine if:

• anticipated benefit is real

• puts the patient at increased risk

• does not cause ancillary incompatibilities or problems

May we instigate improvement changes wherever needed

Progressive Change

74

American Civil War 642,000 soldiers died

2/3 from infection

Barton vowed to address healthcare conditions

Founded American Red Cross

CLARA BARTON – THE PASSION

“I have an almost complete disregard of precedent and a faith in

the possibility of something better. It irritates me to be told howthings always have been done .... I defy the tyranny of precedent.I cannot afford the luxury of a closed mind. I go for anything newthat might improve the past.” Clara Barton

75

BE CHALLENGED NOT DISCOURAGED

76

BE CHALLENGED NOT DISCOURAGED

77

ATTITUDE IS A DECISION AND IT INFLUENCES OTHERS POSITIVELY OR NEGATIVELY

• Decide right now what your Attitude will be the first day back to work

• How will you influence your colleagues?

• How Will You Impact Patient care?

78

CHANGE IS NECESSARY FOR PROGRESS HELP MAKE IT POSITIVE!

I am only one, but I am one. I cannot do everything, but I can do something. And I will not let what I cannot do interfere with what I can do. ~Edward Everett Hale

I've learned that you shouldn't go through life with a catchers mitt on both hands. You need to be able to throw something back. ~Maya Angelou

The destroyer of weeds, thistles and thorns is a benefactor, whether he soweth grain or not.

~Robert Ingersoll, inscription to Volume I, Collected Works

If you have time to whine and complain about something then you have the time to do something about it. ~Anthony J. D'Angelo,

If you have no will to change it, you have no right to criticize it. ~Author Unknown

79

IS THIS CAREER FOR YOU? FOR YOUR STAFF?

• Everyone of us can make changes where needed

• A very few will choose not to

• This profession is too critical to patient safety for:

– “This is sooo stupid”

– “No body’s going to tell me what to do!”

– “I hate what I am doing”

– “blah, blah, blah”

• If this is how you really feel:

– SPD may not be the right place for you

– You may be happier in a different career

• Patients will be safer and SPD teams more efficient when all are dedicated to the same purpose

• Managers: addressing “poor fit” personnel issues is never easy, but is a very important responsibility

Because:

80

Patients Entrust Their Quality Of Life And Life Itself Into Our Care

81

So that’s what you do!

Wow, that’s really a lot of Responsibility!

But, Man it’s really Cool!

Yah Dude, I’m Impressed!!

Thank You!!I Wanna become the Best SPD Professional I can Be

I don’t understand a lot of stuff, but I’ll learn!!

I wanna be certified!!

I’ll help you Bro! Cause……..

“I’m A Sterile Processing Professional”

Wava Truscott, PhD

Director, Medical Sciences and Clinical Education

Halyard Health Care