CLEAN ROOM: INSIDE THE SPD

Take an exclusive tour of our Sterile Processing Department, a fascinating area that plays an “instrumental” role in patient safety.

By Stephanie Marsau

Another surgery-packed day at Mary Greeley Medical Center. In operating rooms, trays of pristine surgical instruments draped in blue cloth are about to be put to beneficial use by surgeons.

In one operating room, an orthopedic surgeon begins a shoulder scope by using a scalpel to make a small incision in a patient’s shoulder. The surgeon inserts a tiny camera called an arthroscope into the incision. This provides a view of the shoulder from inside the patient’s body. The surgeon then uses an instrument called a duckling, which can get inside the shoulder joint and slice up unwanted tissue, such as scar tissue, into tiny pieces that can be suctioned out.

The skills of the surgery team—surgeon, anesthesiologist, nurses, and technicians—are vital to a successful surgery. What’s equally important are those instruments.

The complex process of getting instruments ready for surgery involves Mary Greeley’s Sterile Processing Department (SPD). This department has a roomful of sterilization equipment overseen by highly trained Mary Greeley staff whose work plays a central role in patient safety.

This team got those instruments ready for that shoulder scope. When the procedure is over, any nondisposable instruments, such as the duckling, will return to the SPD to be cleaned and prepped for another round of surgeries. SPD prepares literally thousands of instruments each day.

All this happens in the lower level of Mary Greeley. In many ways, it’s an out-of-sight/out-of-mind operation. In reality, though, the SPD is the foundation of Mary Greeley’s efforts to avoid surgical site infections and other adverse outcomes.

Here’s an exclusive look at the SPD process—a process that is crucial to our surgical program and one that few people get to see.

Inside the SPD Preview - Click image to play YouTube Video

Watch the SPD In Action

Want to get up close and personal with the cleaning process? Check out this behind-the-scenes video!

Life Cycle

Every surgical instrument has a sterilization life cycle. Although instruments have different parts to play in any surgical procedure, each goes through the same five stages:

  • Point of Use
  • Decontamination/Cleaning
  • Inspection, Assembly, and Packaging
  • Sterilization
  • Storage

Point of Use

It’s important to note that decontamination actually begins in the operating room (OR). Instruments must remain moist during a procedure. After an instrument is used, it is placed into a container of sterile water. This prevents bioburden, or biofilm, from drying on the instruments.

So what is biofilm? Let’s go back to that shoulder scope procedure. When those instruments go inside the patient’s body, they get blood on them. If the instruments don’t remain moist during the surgery and aren’t cleaned with sterile water, that blood begins to dry on them. That dried stuff is what we call biofilm.

The problem with biofilm is that the more it dries, the harder it becomes to clean. With our focus always being on the patients we serve, it is imperative that decontamination starts at the point of use for the sake of our patients’ safety.

SPD Fast Facts

  • Busiest day: Wednesday (This is the day cataract surgeries are performed. This procedure often takes no longer than 10 minutes.)
  • Number of instruments processed in a week: 29,990
  • Number of staff: 12
  • Surgery with least amount of instruments: Open carpal tunnel release uses just 6 instruments. This procedure releases pressure on the median nerve and relieves the symptoms of carpal tunnel syndrome.
  • Surgery with most amount of instruments: A total knee replacement uses 275 instruments.
  • Length of time it takes to sterilize: 4 minutes to sterilize, 50 minutes to dry
  • Temperature at which sterilization occurs: 275 degrees
  • Amount of time needed for the entire cleaning process: 5–6 hours

Decontamination/Cleaning

That shoulder scope is finished. The patient goes to recovery. The doctor heads to the waiting room to talk to the family. The instruments are sent to the basement. (It should be noted here that not ALL the instruments used head to the basement. Some instruments, such as scalpel blades, are single use. They are removed from the scalpel handle and are properly disposed of after one surgery.)

The first stop for instruments that make it to the basement is the decontamination room, where they are soaked and precleaned. Brushes, sponges, and smaller instruments make their way here and are manually cleaned.

Instruments then travel across the room to undergo ultrasonic cleaning. In this area, instruments are put into an ultrasonic cavitation machine. This machine uses low frequency sound waves to create tiny bubbles. When these bubbles come in contact with the surgical instruments, they implode and remove any remaining biofilm.

Then it’s time for the instruments to be mechanically cleaned. It’s not as simple as just loading the dishwasher and pushing start. There are very specific parameters for all of the surgical instruments that are based on manufacturer guidelines. It’s important that these guidelines are followed because it allows the instruments to maintain their integrity, which helps keep our patients safe.

Inspection, Assembly, and Packaging

Once the instruments have been through the wash cycle, they come out the other side of The washer into a different room where they are inspected, assembled, and packaged. That may sound like a fairly straightforward process, but there is a lot to it.

Every load that comes out of the washer includes a washer indicator. The indicator is a small device with a substance that mimics blood. When the wash cycle is done and the indicator comes out clean—or “blood free”—the SPD staff knows the load was properly cleaned and the instruments are safe to be assembled and packaged.

The instruments are then taken to stations where they are sorted and inspected to make sure they are still working properly. Most of the time, instruments come down from a surgery and all stay together. That’s not always a guarantee though, so prior to assembling a set of instruments, SPD staff are able to call up guidelines for the specific instrument set they will be putting together.

For example, if an SPD technician is assembling an instrument set for a shoulder scope, the tech will open the corresponding guidelines and go through the instruments. If one is missing, it will be replaced with a new instrument. It is important that all instruments are accounted for because once instruments are packaged in the next step, the actual instruments aren’t seen again until the package is opened in the OR.

Once assembled, instrument sets are then placed into a mesh basket. That basket is either placed into a rigid container or is wrapped with a special material called “blue wrap.” Both options allow the instruments inside to be sterilized. They also allow the instruments to remain sterile once they are moved to the storage area.

Sterilization

There are several different types of sterilization, and most surgical instruments are sterilized using steam. Once items have been packaged in the previous room, they are loaded onto a cart and are taken to the sterilizing area where they are loaded into the sterilizer.

Everything that goes into the sterilizer is tagged with a special tape that resembles white masking tape. This is no ordinary tape, though. When the items come out of the sterilizer, that tape should have dark diagonal lines on it. This allows staff to know at a glance that the sterilization process was successful. Indicators are also included inside the instrument sets so that surgical staff can tell upon opening them in the OR that they were indeed sterilized.

Sometimes a second indicator— a biological indicator—is included on sterilizer loads. This miniature test tube holds live spores. When the sterilization process is successful, the spores die, which results in a color change from green to purple.

Instruments are considered
sterilized after four minutes at 275 degrees. They remain in the sterilizer to dry and then are removed to allow them to cool down.

Storage

Once something has made it all the way through the cleaning process, it is moved into the sterile storage area. Imagine a grocery store, but one that only stocks surgical instruments and at any given time has an inventory worth millions of dollars.

In fact, some SPD staff are tasked with getting things ready for the next day’s surgical procedures. They use a checklist and walk up and down the aisles, locating the items needed for
the next day’s surgeries or any emergent surgeries that may come in that same day.

Once the items have been located, they are loaded onto case carts and moved into the staging area. It’s fairly easy to tell what the next day’s caseload will be like based on the number of case carts in the staging area.

The next morning, case carts are taken up to the OR in preparation for the day’s surgical procedures.

Full Circle

We’ve now come full circle. Soon the case carts and all of the instruments will head to the lower level and the sterilization process begins again.

Day in and day out, SPD staff handle hundreds of instruments, ensuring each has gone through the meticulous sterilization process to ensure the safety of every single patient that comes into our operating room.

 A laproscopic camera is decontaminated.

Interested in working in the Sterile Processing Department?

Qualified candidates should be a high school graduate or equivalent. They must have gone through Basic Life Support for Healthcare Providers (BLS) training, or do so within 90 days of hire, and must maintain it throughout their employment.
Being a graduate of an accredited Surgical Technologist program is preferred, but is not necessary.
Candidates should:

  • Have the ability to understand and communicate oral and written English,
  • Be able to pursue and foster a sense of team and partnership across all disciplines,
  • Be able to function promptly and appropriately under stressful conditions, and
  • Become certified within three years of hire.

For more information, visit www.mgmc.org/careers.

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