The following article was originally published in Preventing Infection in Ambulatory Care, the quarterly e-publication from the Association for Professionals in Infection Control and Epidemiology (APIC). To learn more about receiving this resource and joining APIC, visit www.apic.org/ambulatorynewsletter. To learn more about APIC, visit www.apic.org.
Located in Tacoma, WA., MultiCare Health System has four hospitals, 100+ clinics, and ambulatory surgery centers. Like many other healthcare systems, MultiCare has acquired numerous general and specialty clinic practices which blossomed from about 24 to more than 100 over a seven to eight year time span. Many of these clinics were operating desktop sterilizers and/or performing high-level disinfection of endoscopes.
In 2001, the Infection Control Department implemented competency evaluations for clinic staff using the autoclave, and one for high-level disinfection. Employees performing these functions were trained, and one of the two infection control nurses did a paper quiz and visual evaluation of each employee involved in these functions. The outcome proved that the facility had a good handle on procedures and processes in the clinics to ensure patient and worker safety. At the time, this involved about a dozen clinics.
Upon return to the clinics one year later, it was discovered that over 75% of the original staff that had been trained and evaluated were no longer in the clinic. A few were in other clinics, but many had just moved on. Also discovered were many new sites of which the Infection Control Department was unaware. First addressed was the clinic acquisition and development problem, followed by assurance that Infection Control was at the table for all future clinic acquisitions, changes or renovations. Secondly was the realization that with the ever-increasing number of clinics, Infection Control did not have the staff to ensure that all employees performing cleaning, disinfection and/or sterilization were competent to do these critical tasks and ensure patient safety. In most cases, clinic supervisory personnel did not have the background or expertise to evaluate these functions among their staff.
MultiCare has several Central Services (CS) locations for inpatient and ambulatory surgery where there are trained, competent personnel who are supervised by trained, competent people. In looking at possible options, it was decided that clinics should send their instruments to one of the established Central Services locations in order to assure proper management. Already in place was a courier system that transported various items such as mail, smaller supplies, clinical specimens, etc., around the system. This is run by Materials Management, and couriers are trained in bloodborne pathogens, as required by OSHA.
Infection Prevention and Control met with representatives from the Central Service locations, Materials Management and clinic leadership. The decision was made to centralize instrument processing and eliminate desktop sterilizers, with one or two exceptions where there were stable staff who were well trained and had initial and annual competencies on file.
Staff decided which clinics would send their instruments to which CS location, based on proximity and courier routes. The clinics purchased Rubbermaid® tubs with tight-fitting lids, the size depending on the number and size of the instruments to be processed. This product was chosen because it is puncture-resistant and lids stay on, even if a container is turned over, which is important in order to protect couriers and others who might come in contact with the container. High-volume clinics purchased several tubs so they would have continuous flow. Instrument lists for each clinic were developed.
Instruments are washed with instrument cleaner to remove gross debris, then rinsed and dried. Sets are rubber-banded together; individual items are left loose. All the instruments are placed in a plastic bag and then in the Rubbermaid® container. The checklist of which instruments are in the bag is placed in the container. Containers have the clinic name and mailstop on the lid and sides, and are biohazard-labeled. The courier picks up the container and delivers it to the appropriate Central Services location. Instruments are processed per CS standards. The sterile packages are placed in a plastic bag and into the container for return to the clinic via courier. CS wipes out the inside of the container and lid with germicide when soiled instruments are removed for processing.
Because of a two-to-three day turn-around time, several of the clinics had to purchase more instruments, but these were mostly inexpensive items such as Kelly clamps, forceps, vaginal specula, needle drivers, and the like. This also provided the opportunity to remind the outpatient areas that reprocessing of disposable instruments was prohibited, unless done by an FDA-approved, third party reprocessor. Some of the less “invasive” clinics elected to switch to all disposables, but these were generally practices that used very few instruments and disposable items: suture and staple removal sets, which are readily available and not expensive.
As with any start-up, there were a few hiccups, but overall things have gone very smoothly. Periodically, one of the CS locations will report that a particular clinic is sending grossly soiled instruments. When checking with that clinic manager/supervisor it was often found that this only occurred when someone was on vacation or there was a new person on staff. This system has proven to be most successful. It is not very expensive because couriers were already in place, and adding containers for transport to and from Central Services did not increase costs. There was some initial need for additional instruments and the transport containers, but this was more than manageable. Clinic staff were happy to be out of the processing business whereas it gave them more time with patients. Most importantly, it provides the assurance that every instrument used on patients has been properly processed and is safe for patients and staff.
Read more from APIC:
- A Measure of Safety: Preventing Infection During Medication Administration