CSR – Keeping it clean
- December 2008/January 2009
- Français
The numbers are impressive – a massive 4.1 million surgical instruments and patient care devices are cleaned and sterilized every year at Niagara Health System sites. Whether it's a surgical forcep or a scope used in endoscopy, the Central Sterilization and Reprocessing (CSR) department uses a range of rigorous cleaning and sterilizing processes to guarantee that the items coming into contact with patients are clean, sterile and safe.
"The NHS has 500,000 patient visits per year at our seven sites, and most of those visits involve using medical devices or instruments for a procedure," says Joanne Della Ventura, Regional Manager CSR. "In CSR, we cover it all – surgical and emergency department equipment, outpatient clinics, respiratory procedures and all specialties in the OR."
The cleaning equipment and sterilizers used by CSR are costly, both to purchase and to maintain. "This is an area the hospital cannot scrimp on and the last five years have brought the quality of our equipment up to where it needs to be," Joanne says. "We look forward to getting more automated equipment in the coming years, to bring a higher degree of efficiency."
The high-tech instruments used in specialty surgeries receives the same attention as a bedpan or basin. Most pieces are stainless steel, so they can withstand high temperatures for cleaning and sterilizing. Using the OR as an example, the process for cleaning the dozens of items used in a surgical procedure begins in an area near the OR suites. Items are manually cleaned by CSR technicians using a special enzymatic detergent that helps break down proteins. Instruments are stacked on a transport cart and taken to the CSR department, where trays of instruments are loaded into a washer/disinfector unit. This cleaning unit uses enzymatics and detergents and is similar to a dishwasher, to make the devices safe for technicians to handle for the next stage.
CSR technician Debbie Bugye wraps a bundle of instruments, before it goes to the autoclave sterilizer. The washer/disinfector unit is behind Debbie in the right of the photo.
Sterilization Processes
There are three different sterilization processes. If the items are stainless steel, a technician will examine, wrap and package small trays of instruments according to pre- determined content lists in a j-cloth-like disposable paper wrapper, securing the bundles with special packing tape. These bundles are loaded on a large cart and placed in a steam sterilizer, which bakes the items at 273 degrees Fahrenheit – a validated process which makes an item free of viable micro-organisms. Read-outs are checked several times during the sterilization cycle, to verify that the temperature is constant. The packing tape which changes colour during the process, is used as a visual check for the end user to confirm that sterilization has occurred.
Items made of plastic can't withstand high heat, so a pasteurizer does the job. "For items such as respiratory tubing or anaesthetic masks, we use pasteurizers which make the equipment safe for reuse," Joanne explains. "This is achieved by submersion in a hot water bath at a minimum temperature of 160F, for a minimum 30 minutes. The entire process takes usually three hours." The third sterilization system used is an ethylene oxide or gas sterilizer, which is widely used for heat-sensitive items such as flexible scopes and fibreoptic lenses.
Putting it Back Together
When all the cleaning processes are complete and the devices are ready for repackaging for the next patient case, the skill and knowledge of the CSR technicians really comes into play. A typical instrument tray will include 30 different instruments, and many of these items require reassembly after cleaning. Complex surgical tools being put back together make the technicians look like engineers, as they nimbly connect the tiny bits of long surgical laparoscopic instruments, using magnifying lamps and double-checking functionality that the devices are ready to become part of the instrument tray once again.
From left, CSR Supervisor Jacky Bergsma, Technician Carrie Boutilier and new hire Dulce Isorena reassemble surgical instruments in preparation for sterilization.
Because there are so many different patient procedures in many types of hospital clinics and operating rooms, as well as at the bedside, the technicians must have an encyclopaedic knowledge of what's required on a tray of instruments. The range of instrument trays varies with each hospital, depending on the services and procedures carried out there, but there are at least 500 or more instrument trays containing a specific set of instruments that are assembled, wrapped and sterilized, ready for delivery to the patient care area.
"All our technicians have received their certification and it takes about two years of on-the-job experience before they have mastered every part of our departmental functions," Joanne says. "Not only do the technicians have to know all the instruments and how they work and are assembled, they have to know the proper procedures for sterilizing every single instrument or device, and how and what to put on a specific instrument tray. Add to that the need to work extremely efficiently and to accomplish all the extra work that can happen when a lot of babies are born on one day or there are several emergency surgeries, and you have a very high-functioning department." In addition to being technically complex, the technicians' work is physically demanding. Technicians are on their feet all day, pushing heavy carts and lifting trays and containers, many that weigh as much as 11 kg.
"The staff members of CSR are often the unsung heroes of a hospital, for they are responsible for ensuring that all medical devices and surgical instruments coming through the department are in top working condition and germ and bacteria-free," Joanne says. "Our staff is second to none and they are making our programs and services safer for patients.