Would you place your life in the hands of an unseen someone? Skydivers often do. Jumping from an airplane demonstrates the ultimate level of trust in the person who packed the parachute. The slightest lack of confidence in the chute’s function would keep even veteran skydivers onboard.
Would you place your hair in the hands of an unknown stylist?
Admittedly, your hair falling to the salon floor cannot compare to your body plummeting to earth. Hair grows back. Your body is not as resilient – far from it. A haircut isn’t surgery, but you still expect the stylist to use a clean comb and razor.
Like the scissors used on your head, most surgical implements – from scalpels to clamps – are not disposable, and require thorough decontamination and sterilization to prevent the spread of infection.
“You have to have a license to cut hair,” said Cheron Rojo, sterile processing department (SPD) educator at Children's Hospital Central California. “But you don’t need a license to sterilize instruments that go into a person’s body.”
Even as Rojo calls for statewide certification requirements for the sterile processing industry, he can rest in the confidence of knowing that SPD technicians at Children’s Hospital must be certified. “SPD techs aren’t just dishwashers,” said Rojo, who also serves as educator director for the California Central Services Association (CCSA). “What we do can affect outcomes,” he said of the technicians in sterile processing. “It’s an important part of healthcare, and it needs to be recognized as a profession.” Rojo stressed the value of quality assurance at Children’s Hospital. He knows that failing to properly process and carefully track medical instruments can have life-threatening consequences.
Rojo’s passion to protect patients undergoing surgery not only drives him to set high standards for the sterile processing department at Children’s, but it also inspires him to teach certification classes here at Children's Hospital Central California. Rojo’s 18-week curriculum helps prepare students to become a certified registered central service technician (CRCST). Certification by the International Association of Central Service Materials Management (IACSMM) requires 400 hours of internship in sterile processing and a passing grade on their examination, which tests knowledge and proficiency in the following areas and more:
- Cleaning and Decontamination
- Sterile Packaging and Storage
- High Temperature Sterilization
- Low Temperature Sterilization
- Complex Surgical Instruments
- Regulations and Standards
- Anatomy and Physiology
- Inventory Management
- Medical Terminology
- Quality Assurance
- Tools for Cleaning
- Tracking Systems
- Infection Control
At Children's Hospital Central California, education persists even after certification. "Training will never stop,” noted Rojo. “We are committed to ongoing education, so we can continue to do the best job possible for each and every patient."
Innovation and Education
In summer 2010 Rojo introduced a new multi-phase training initiative he named the Annual Exercise Program. “I pulled two weeks of random surgery schedules to look for terminology related to the type of instrumentation a surgeon would need to perform that procedure,” said Rojo. He then created quizzes to test his technicians on their knowledge of medical terminology. “They really got into it,” said Rojo. “They got competitive.” Random locations – including restroom doors – contained flash cards with medical terms and their definitions. “The techs even began identifying new medical terms that weren’t on the quiz,” said Rojo. “We’re teaching the staff a full course of medial terminology.”
By August 2010 Children’s 17 SPD technicians completed all phases of the Annual Exercise Program. Rojo proudly displayed their test scores. Almost everyone achieved 100 percent. Rojo’s approach to SPD education has garnered national attention and has positioned Children's Hospital as a true innovator in the industry.
Processing ever-evolving medical instrumentation demands vigilance. "The practice changes all the time, so you have to stay on top of things," said Pamela Brisendine, SPD manager at Children's Hospital and CCSA marketing & Valley Region director. Brisendine understands quality assurance in her department depends on staffing skilled technicians comfortable in an atmosphere of continuous learning.
As an SPD educator, Rojo facilitates a personalized education program carried out by preceptors who work one-on-one with technicians to give them hands-on training. “Everyone learns at a different pace,” said Rojo. “The preceptors can tailor what they do to the needs of the individual.” Rojo took pictures illustrating processes for individual instruments. He then created PowerPoint slides with titles detailing the procedures. The slide show walks a technician step by step through assembling instrumentation to manufacturer specifications.
The department conducts biannual competencies to address new or forgotten processes that are unfamiliar or rarely done. Held every June and December, the biannual competencies also provide an avenue to redirect variances from manufacturers’ recommendations. “We used to have annual competencies,” said Rojo. “But studies have shown that errors can set in after six months.”
Children’s Hospital has received national recognition for the competencies developed by our SPD leadership team, and Rojo is often invited to speak around the country as an expert consultant. The comprehensive training and biannual competencies developed by Brisendine and Rojo promote safe, consistent, standards-based practices, and ensure patients receive the highest degree of quality care.
To further advance patient safety, Brisendine and Rojo conduct regular audits to hold every technician accountable to consistently adhere to the manufacturers’ instructions for use, as well as the recommended standards from state and federal governments and from professional organizations such as the Association of Perioperative Registered Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI).
Rojo serves on the AAMI board, which gives him a voice in recommending practices for instrumentation nationally. “It’s really nice because I’m coming in as a user and I have voting power,” said Rojo. He pointed out the importance of gaining perspective not only from the surgeon who uses the instruments, but also from the SPD tech who must disassemble and disinfect them, inspect for signs of damage or wear, reassemble unspoiled instruments and test for proper function, and finally sterilize and package them for the next surgery.
Decontamination and Sterilization
Sterile processing departments are expected to test the lethality of their sterilizers by placing a contained living bacterial microorganism – known as a “biological” – into the sterilizer with the instruments being sterilized. The bacterium of choice is known for its resilience. “If it can kill this, it can kill anything,” said Rojo, holding up the packaged germs. After the sterilization process, the vial containing the presumably dead microorganisms is placed in an incubator. “3M calls for a final read after three hours in most cases,” said Rojo. “If the biological still has not begun growing in the incubator after three hours, the sterilization process worked.” Rojo pointed out a tiny incubator containing several vials. He inspected them and gave a nod. “We never release implants for surgery until the required time has passed,” he said. “Trays are held until biological passes.”
Rojo explained the accepted standard for sterilization monitoring compared to the higher level of screening Children’s Hospital employs. Industry norms call for biological testing once daily and for all implants. “An implant must pass a biological test because it stays in the body,” said Rojo. “But when we test every load, every patient has that level of security.” Rojo pointed to the racks of surgical instruments ready to be loaded into the sterilizer. All included a small green box containing the vial of hardy microorganisms. He referred back to the incubator with almost every slot occupied. “It requires a lot of steps, but it’s worth it,” he said. “Our children deserve this standard of care.” Children’s received an award from 3M in recognition of this above-and-beyond practice.
Tracking and Inventory
Children’s sterile processing department does far more than sterilize. The industry has been called “Central Service” for many years, and more recently the international community has adopted the name “Central Sterile Supply Department.” Brisendine’s department is responsible for the tracking and inventory of all instruments used in surgery.
“We want to make sure that everything that leaves this department comes back,” said Brisendine. Stray implements can easily spread infection. The computerized instrument tracking system used in our SPD allows for an extremely detailed and accurate accounting of every article in our inventory. “We have the Porsche of them all,” said Brisendine of the state-of-the-art system. “We’re able to not just track, but be effective with productivity.”
When sterilized instruments arrive in the operating room, they are perfectly arranged in a pack or tray. Surgical nurses have immediate access to all the tools surgeons require. The first instrument used by the surgeon is placed at the front of the pack. The last one is found in the back.
The Microsystems program illustrates precisely how to arrange each pack for a particular surgery. Many instruments are tagged with a tiny microchip for tracking purposes. A scanner – like those seen at department store registers – reads the chip and instantly receives the instrument into inventory. A visible checkmark on the computer monitor acknowledges the process and furthers confidence that every patient requiring surgery at Children’s Hospital receives safe and properly-functioning instrumentation.
This cutting-edge tracking equipment is very expensive, but critical to patient safety. “We use the technology to its full potential,” said Rojo. The software allows our technicians to print and attach a barcode sticker to each surgery tray, so that our risk management team can easily determine who inspected and assembled the decontaminated instruments, who packed and sterilized them, who read the biological test, and which operating room received the instruments. When surveyors from The Joint Commission inspect our records, looking for well-documented sterilization monitoring results, they find organized and accurate accounts.
“Everything is tracked for risk management purposes,” said Rojo. “We can determine whether or not an infection originated in SPD.” He smiled. “That’s never happened for as long as I’ve been here.”
Communication and Interaction
The open communication between SPD techs and management has created an environment where technicians are not afraid to point out errors. Brisendine assigns numbers to employees so she can address a problem publicly without humiliating an individual. Management speaks privately to technicians responsible for an error so they can make necessary adjustments, and the entire staff learns from the mistake as well.
Positive interaction also exists between sterile processing and surgery. “The relationship between the OR and SPD is amazing!” exclaimed Rojo. “LuAnn Joy makes the difference,” he said of the surgical director at Children’s Hospital
Surgical teams at Children’s Hospital often perform life-saving operations on critically ill kids. “It’s a very stressful environment,” said Rojo. “And when the trust is not there it breaks down.” Rojo acknowledged that medical professionals in operating rooms have a much higher level of schooling than the technicians in his department. “If the SPD staff isn’t educated, the OR is going to see that,” he said. “As part of their training, our techs spend a whole day in OR with a nurse. It really opens the techs’ eyes to even answering the phone quicker because these doctors have patients open in OR.”
Brisendine and Rojo shine, and their efforts have been noticed on a grand scale. Articles hailing their successes have recently appeared in two different trade publications. Due to publicity, Children's is sought as a beta site for our vendors to test new products. With education, organization and technology, Brisendine and Rojo have raised the bar in the sterile processing industry, and have taken disinfection and sterilization of surgical instruments above and beyond the white glove treatment. If cleanliness is next to godliness, then the SPD techs at Children's Hospital Central California wear halos.