Regional One Health

Ruth Plotkin Shumaker

Sterility management has a big impact on hospitals. According to recent data, surgical site infections (SSIs) are common complications in acute care facilities, occurring in 2 percent to 5 percent of patients undergoing inpatient surgery. Approximately 160,000 to 300,000 SSIs occur each year in the United States, making these infections one of the most common and costly healthcare-associated infections (HAIs). A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. SSIs can be superficial infections involving just the skin, or they can be more serious. There is tremendous pressure to reduce SSIs. A key component to making patient care safer in your hospital is to track your process to improvement. When considering quality improvement initiatives, you must remember that quality improvement does not come without action. A good quality project should be SMART (Specific, Measureable, Attainable, Relevant, Time-Bound). When all of these elements fall into place, then you know you have a highly effective outcomes improvement project.

Many hospitals have difficulty ensuring that their sterile wrapped instrument trays stay sterile until they reach the OR. Once surgical instruments are cleaned, wrapped, and sterilized, multiple manual interventions lead to a high risk of perforations or damage to the packaging. Sterile packages should always be handled with care. Avoid dragging, crushing, compressing, bending, or puncturing, as this can compromise sterility. Be sure to inspect sterile packages before distributing. Do not use any package that is damaged, compromised, wet or opened. When sterilized surgical wraps are compromised by holes, the impact to the hospital and patient care can result in: delayed case start times, canceled surgical case, last minute change in clinical approach, increased anesthesia times, costly resterilization of trays (labor/supplies), decreased physician satisfaction, possible immediate-use sterilization of non-implant trays, and if the hole/ tear is not identified prior to the case, the patient can be exposed to pathogens during use. Ensuring sterility is a challenging but necessary factor.

"Implementing a surgical tray quality improvement process tracking holes in wrappers is a good fit into a hospital’s Total Quality Management (TQM) program"

Factors that contribute to holes in wrappers are lack of rigid containers, improper storage, handling, and your logistics flow. Each step of the process includes correct handling when transferring instrument sets into the autoclave, transport in dedicated open or closed transport carts, shelves without any hard edges or corners that can catch the wrapping and cause tears, storage with a space for each tray, without stacking and handling.

There are options available for sterile sets and packages, these include rigid containers, peel pouches of plastic and/ or paper, and sterilization wraps (woven and nonwoven). In “Choosing a Sterilization Wrap for Surgical Packs,” an article by William A. Rutala, PhD, MPH, and David J. Weber, MD, MPH, featured in an issue of ICT, the authors describe the elements to look for when assessing the ideal wrap. “These include an effective barrier, penetrability for steam or ethylene oxide, aeration, ease of use, draping ability, flexibility, puncture resistance, tear strength, toxicity, odor, waste disposal, linting, cost, and transparency. When wrapping items that are large, heavy, or unusually shaped, it is important to choose the appropriate grade of sterilization wrap to support the weight of the item to be packaged.” Most hospitals are using nonwoven wrappers. You should consider an extra measure of protection. Placing large wrapped containers in a hermetically sealed dust cover provides additional protection. A safer, more efficient, sustainable, and cost-effective choice are rigid, reusable sterilization containers. Rigid containers are cost effective because they’re reusable, and provide ultimate protection to instruments. You can stack them without worrying about crushing or tearing the packaging. Containers do present other issues. They are costly, may present challenges for drying and must be cleaned after each use. This means washing it completely inside and out after each use.

Another consideration is the weight of the tray. AORN and the Association for the Advancement of Medical Instrumentation (AAMI) recommend that instrument sets and trays prepared for sterilization not exceed 25 pounds. This weight limit includes the combined weight of the pan and the instruments.

The American Society for Healthcare Central Service (ASHCSP) and International Association of Healthcare Central Service Material Management (IAHCSMM) both supports having total quality management (TQM) within Central Service Departments. Implementing a surgical tray quality improvement process tracking holes in wrappers is a good fit into a hospital’s Total Quality Management (TQM) program. This improvement process can help you track and reach measurable and reachable goals.