Perhaps no area of infection control has been the focus of as much of the surveyor's scrutiny as flash sterilization. And for good reason. Flashing might be the most misunderstood, abused and controversial practice in surgical facilities today.

"Is it OK to flash? Yes and no. Yes, if you do it properly. No, if you do it the way I'm seeing it done in a lot of facilities," says Chuck Hughes, general manager and lead educator for SPS Medical Supply Corp. in Rush, N.Y.

Mr. Hughes audits the sterile processing departments of hundreds of hospitals and surgical centers each year. It is the rare exception, he says, when he doesn't see flash sterilization either being abused or done incorrectly.

• By abused, he means that facilities are giving in to the temptation of flashing routinely for reasons of convenience, as an alternative to purchasing additional instrument sets or to save time.

"Why do we end up having to flash? Because we haven't purchased enough trays to sustain our volume and to allow for proper sterilization. But it shouldn't be done for that reason," says Betty Casey, RN, BS, manager of surgical services in the ambulatory services division at Yale New Haven Hospital in New Haven, Conn. "If you track why we flash, most of the time it's because we didn't have enough equipment, not because we dropped equipment on the floor."

• By incorrectly, he means flashing entire instrument sets instead of single instruments, or flashing for the wrong time, at the wrong temperature or in the wrong mode (gravity displacement vs. dynamic air-removal cycles [pre-vacuum]). You can use either sterilization cycle for flashing as long as you follow the manufacturer's recommendations for time, temperature and steam contact — something many techs don't bother to do, says Mr. Hughes.

How certain is he that flashing is fraught with problems? If we were to judge by the tongue-in-cheek title of a presentation he gave at this year's AORN Congress — "Flashed Instruments: Are They Sterile or Did They Just Get Hot?" — the answer is obvious:?very.

Confusing standards
The fact remains that it's sometimes OK to flash. And sometimes it's even necessary to flash, as in the case of an inadvertently dropped instrument you must immediately reprocess for the case to continue. When done correctly, flash sterilization is a safe and effective process for sterilizing instruments intended for use during surgery. Yet there's no universal law for when it's OK to flash.

• Can you flash full instrument sets? In the truest sense of the word, flash sterilization is the process by which surgical instruments are sterilized for immediate use should an emergency situation arise during the surgery. But unless your facility has a policy against flashing full instrument sets, the Association for the Advancement of Medical Instrumentation (AAMI) and recommended practices from AORN don't restrict you to flashing a single instrument — provided you flash in the proper mode and follow manufacturers' directives. (Note that AAMI and AORN say flash sterilization is "a process designed for the steam sterilization of patient care items for immediate use.") However, the Veterans Administration's directives and new Canadian standards expressly prohibit flashing full instrument sets. The VA, for example, requires full sterilization procedures to be used for all surgical instruments. Flashing, says the VA, is to be used during a surgical procedure only in cases of emergencies, such as a dropped, sterilized instrument.

Just because you can doesn't mean you should, however. "Nobody is encouraging flash sterilization as a method of sterilization," says Ed Septimus, MD, medical director for infection prevention at the Nashvillle, Tenn.-based HCA Healthcare System. "What people are saying is that it should be kept to a minimum and used only in certain select, clinical conditions and in a very controlled manner."

Mr. Hughes points out that some orthopedic sets have significant sterilization restrictions attached to them and can only be processed in pre-vacuum mode. "I see facilities routinely flashing full instrument sets and not a single dropped instrument," he says, "not because they don't care, but because they don't know."

Follow the manufacturer's instructions, he says, especially for short sterilization cycles. Remember that it takes time for steam to penetrate a sterilizer load and to achieve an acceptable sterility assurance level.

• Do I need to transport flashed instruments in a covered pan? Different surveyors have different interpretations of this new CMS requirement. What if the OR is directly adjacent to the sterilization room, allowing the scrub nurse to pass the instrument through a window without having to cross an unsterile corridor? Here's what Marilyn Hanchett, RN, MA, CPHQ, CIC, infection control technical lead for the division of acute care services at CMS Survey and Certification in Baltimore, Md., has to say: "The expectation is that the instruments will be protected from the time they leave the sterilizer until they're delivered to the sterile field. Obviously wrapping is preferred. But the exact method you use is up to you. Container systems are an acceptable option. Regardless of the method you implement, routinely transporting unwrapped instruments in an open tray is not an acceptable practice. The distance from the sterilizer to the operative field does not matter; you must make sure the instruments are protected from possible contamination."

One of the 4 conditions for flash sterilization found in the latest AAMI standards contradicts this: "The physical layout of the work area allows direct delivery of sterilized items to the area where they're being used (sterilizer opens into area either within or directly adjacent to the procedure room)."

"Some of the experts are going around saying if you have an autoclave that's immediately adjacent to an OR or in a clean hallway you don't have to cover instruments. Not true," says Karen Andersen, RN, LHCRM, of Healthcare Risk Management Consultants in Melbourne, Fla. "Read the new CMS conditions of participation and it's very clear what the new requirement is for flash sterilization: Any instrumentation that is moved from the autoclave into the OR has to be within a closed or wrapped system. You're no longer allowed to transport open trays."

• Can flash sterilization be used as a substitute for insufficient instrument inventory? The answer here is an unequivocal "no," yet this is one of the main reasons why many facilities flash.

Joint Commission surveyors will cite your facility if you flash and then reuse instruments repetitively and routinely. You won't be cited for a violation of the ASC infection control requirements if you're properly using short sterilization cycles for wrapped or contained loads. "Don't use flash sterilization as a convenience," says Dr. Septimus.

Freestanding eye centers could be particularly hard hit by this new rule of infection prevention, says Mary C. Wilson, BSN, RN, CNOR, clinical preceptor at West Virginia University Hospitals in Morgantown, W.Va., and chair of the AORN special assembly of ophthalmology. "They would have to purchase at least a dozen more cataract trays to function on a daily basis and not flash," she says. "A cataract tray with a diamond knife costs $14,000."

Acts of avoidance
Perhaps because of the confusion over flashing protocols, many facilities avoid the practice unless there's an absolute absence of alternatives.

"We don't do it unless it's an emergency," says Dawn M. Yost, RDH, RN, BSN, CNOR, manager of nursing operations and the sterile processing department at West Virginia University Hospitals, which recently doubled its cataract tray inventory from 4 to 8. "We absolutely, totally frown upon any flash sterilization."

Ms. Casey says Yale New Haven Hospital is on an 18-month flash-free streak, thanks in part to staff incentives for reducing the incidence of flash sterilization. She says surgeons who show up with their own instrument trays and expect staff to flash them are a special challenge. Her policy: "If we can't duplicate it, give it to us the day before so we can autoclave it, or else we'll move the case back."

The surgical schedule is a good place to look if you want to reduce the incidence of flashing, says Ms. Casey. Look at the items you routinely flash and see if you can juggle the schedule to avoid having to do so. For example, instead of doing shoulder and knee cases back-to-back, can you alternate between the procedures to give your processing techs time to sterilize the instruments?

Ms. Casey's surgeons objected to the concept at first, but she repeatedly hammered home the reason behind the case juggling. "Routine flashing is not an acceptable practice," she told them. "We're all here for the same mission: Anything we can do to avoid an infection in a patient is the best practice."