CS CONNECTION Inspection at every stage
“Visual inspection is a critical factor to assure the function and safety of a surgical instru- ment. This inspection should be performed each time an instrument is handled,” said Gregg Agoston, M.B.A., VP Business Develop- ment, SPD Transformation Services. “It includes visual inspection of the packaged product so in essence, visual inspection is critical to every function that SPD performs in reprocessing and transporting the instruments.” He describes the following “critical touch points” for instrument inspection in health- care facilities: • Decontamination: The instrument must be inspected for any damage or missing parts. Damage can be in the form of dents, bends, cracks, mechanical malfunctions, insulation damage, broken wires or cables, broken lenses in telescopes, leak in flexible endoscopes, etc. Should a missing part be discovered the oper- ating room (OR) must be notified to ensure that the missing part was not retained in the patient.
• Assembly: Inspection here includes all of the same types of visual inspections performed in the decontamination area plus checks for clean- liness and functional testing (e.g. mechanical operation, sharpness, optics, etc.). Testing supplies should be readily available at each workstation to perform these critical tests.
• Quality assurance (QA)/quality control (QC) process: A QA/QC process is critical to ensuring that the sets are complete and accurate. This final visual inspection prior to sterilization is critical to ensure that the set is complete as described on the count sheet, all of the necessary integrators, filters and locks are in place, and that there are no con- taminates in the set. Agoston strongly recom- mends that this inspection be performed by a qualified person other than the technician who assembled the set.
• Sterilization/storage/transport: In each of these steps, visual inspection is critical to ensure that the packaging/contents have not been damaged or compromised. Each time that the set is moved, it should be visually inspected for holes and tears in the wrap. Rigid containers also require visual inspection; locks and the lid should be inspected. Both rigid containers and wrapped sets must be inspected to ensure that the package has not been compromised by water, dirt or any other contaminant. “In addition, visual inspection is also critical
in the OR as the nurse or surgical technician opens the packaged instruments and prepares them for use and when she or he receives a used instrument from the sterile field,” Agos- ton added. “These visual inspections must look for form, fit and function.”
tion control team members to help in the procurement of equipment that aids our natural eyes as we process instruments for surgery.”
Boosting visual inspection efficiencies
Visual inspections are a vital but time consuming process that can place a sig- nificant burden on CSSD technicians. t dvent Health, ichulo and his team have taken a Lean approach to stream- line decontamination and pack and prep processes from a direct visualization perspective.
“I teamed up with a Lean expert and we partnered on developing an SD process and facility that addresses the work that these professionals are tasked to complete yet had been under-supported for many years, said ichulo. The result has been a department that lends itself to good work and provides the technicians the tools necessary to achieve that goal.” In the department, technicians first inspect point-of-use preparation. Non- conforming trays that arrive from the OR are recorded in the health system’s uality module in CensiTrac, its instru- ment tracing program. Staff members track non-conforming practices from both the O and the CSSD and report this information on a monthly basis back to these teams. Next, all lumened stainless steel instru-
ments and other materialled instruments (if supported by the IFU) must pass through an ultrasonic process in the decontamination area. Once the ultra- sonic process is complete, instruments with lumens are then flushed with a high pressure reverse osmosis (O)deioniza- tion (DI) water source. rior to entering the washerdisinfector, staff members perform direct visualization using a lumen inspection scope. In the depart- ment, each third sink in decontamination has a borescope with monitor to support this task.
“We decided to perform this activity in decontam as the assembly area tends to lag behind decontam due to the time it takes to assemble and inspect a tray appropri- ately, said ichulo. Instruments that do not pass direct visualization in decontam do not go to the washer but are manually cleaned until the defects are eliminated. We use direct visualization for endoscopes in decontam as well. Each of our sink lines have a free-standing ultrasonic unit built into the line, so the technician does not
40 February 2021 • HEALTHCARE PURCHASING NEWS •
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have to move to another part of the room to use an ultrasonic.”
Once instruments arrive in the prep
and pac area, CSSD technicians tae the instruments through a full inspection to test for cleanliness and function. For lumened instruments that have lumens that are too small to pass a borescope through, technicians flush them with sterile water to validate that cleaning was effective. Any instrument that does not pass visual inspection, along with the entire tray, is sent back to decontamination to be reprocessed there. e utilize high magnification digital magnifiers in addition to analog lighted magnifiers in the assembly area for hard to inspect instruments, said ichulo. These provide an amazing image many times greater than our analog units can provide. We also have additional borescopes on the clean side for further direct visualization of lumened instruments if the technician desires a second look. We also perform traditional inspections for function, which are part of an annual competency the staff must complete.”
Visual inspection advances Recognizing the limitations of the human eye, equipment manufacturers offer a variety of products aimed at helping CS SD professionals detect and destroy dan- gerous bioburden, identify and address instrument damage, and verify that clean- ing processes have been effective. “First, we need to add adequate illu-
mination for better viewing, which will enable visual inspection of internal sur- faces for debris and damage,” said Ron Banach, Director of Clinical Training, uhof Healthcare. Secondly, there needs to be magnification of the image for easier identification of debris and damage. Then, there needs to be several lengths and diam- eters appropriate for many different types of devices. During inspection both still and video documentation and archive storage are necessary. Finally, added training that will support and comply with manufactur- ers’ IFUs.”
Light it up
A well-lighted work area is essential, eplains regg goston, .B.., Busi- ness Development, SD Transformation Services. ighted magnifiers should be at each workstation, as well as visual cues to reinforce proper inspection techniques.” ilder points to NSII ST 20 Comprehensive guide to steam
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