The pressure to turn ophthalmic instruments over quickly cost a nurse manager her job. This accomplished nurse, with more than 20 years of experience in the OR, was caught literally stopping the sterilization process mid-cycle because she needed to get the instruments to an ophthalmologist who was throwing a fit over the delay. Ultimately, she put her own career and the patient's safety in jeopardy to placate an impatient physician.

Here are 7 common mistakes facilities make in the rush to speed up their turnover times. We'll also review the correct ways to keep your microscopic, complex ophthalmic instruments sterile.

1. Letting instruments dry in the OR
Decontamination begins during the case. Letting viscoelastic and bioburden harden onto the instruments' surfaces once the surgeon is finished with them will only make it more difficult to remove that residue later. Have sterile water on the back table for rinsing instruments used during the case. Don't use any chemicals at this stage — you just want to keep the instruments moist so debris doesn't harden. Do this even if you don't observe any residue on the instruments, as bioburden isn't always visible to the naked eye. When rinsing instruments that will be returned to the surgeon, treat them with balanced salt solution before handing them back, as you don't want to introduce sterile water into the eye.

2. Cutting corners with decontamination and cleaning
If ophthalmic instruments aren't properly decontaminated and cleaned, sterilization becomes moot. Cutting corners during these steps has become so common that you may not even know that you're doing the steps incorrectly. To get back to basics, consult the "little red book": The Care and Handling of Ophthalmic Microsurgical Instru-ments, published by the American Society of Ophthalmic Registered Nurses (ASORN). This short read tells you exactly what you need to do, from start to finish, to make sure these tiny, complex instruments with their narrow lumens are properly processed. Here are 2 key decontamination/cleaning steps that are often overlooked or done incorrectly:

• Flush with a 60cc syringe. Many microsurgical instruments have very small lumens, in which viscoelastic and tiny fragments of tissue can easily get trapped. Use a 60cc syringe to push distilled or sterile water through these lumens; repeat this process twice, then follow it with 2 pushes of 60cc of air through the device. A 3-, 6-, or even 20cc syringe isn't going to get the job done effectively. It's simple physics: You get more "push" with a 60cc syringe.
• Inspect with magnification. Once you've finished cleaning the instrument, inspect your work. Use a magnifying lens or mirror to enhance your view of the instrument's nooks and crannies. You can't always see what's on an instrument with the naked eye. While checking for residue or bioburden, be sure the device is intact and functional so you're not needlessly sterilizing a deficient product.

3. Having too much — or not enough — instrumentation
Any instrument that is brought into the OR, regardless of whether it touches the patient, has to be decontaminated and resterilized after the case and before it's brought in for the next one. You can't open a tray full of 35 instruments on the back table, use only 5 to 7 of them, put a towel on the unused instruments and stick them back in the sterilizer without cleaning and decontaminating them along with those that were used. Consolidate your trays to only those instruments you can reasonably expect to use in a case. On the flip side, resist the temptation to pare down your supplies so much that you're constantly having to rely on shortcuts, such as routine non-terminal sterilization cycles, to keep on schedule. Right-size the number of eye surgery trays and the amount of instruments on those trays.

4. Routinely relying on non-terminal steam sterilization cycles
Routine "flash sterilization," more accurately referred to as "immediate-use" steam sterilization, of ophthalmic instruments has long been frowned upon by both AORN's and ASORN's recommended practices. You shouldn't be using immediate-use steam sterilization cycles of eye trays between cases just because you haven't purchased enough instrumentation to support your schedule. It's not necessarily the short cycle that's the problem: If you routinely employ immediate-use sterilization, it's a sure sign that you're rushing through the process of turning over instruments. Spend the money to have adequate instrumentation for the cases you host, and take the time to decontaminate and clean instruments thoroughly. Use non-terminal sterilization cycles only when there's an immediate need for the device and you're literally taking it right from the sterilizer directly to the field. You should never use this method for devices that you plan to store for later use.

5. Sterilizing in open containers
The days of a circulating nurse putting on a pair of sterile gloves, removing the tray from the sterilizer with a sterile towel and walking the open tray to the OR's back table are over. This practice was never proper, and now it's coming under scrutiny from inspectors and surveyors. Buy a closed container system that's approved for the sterilization cycle that you're putting it through. No matter how close the sterilizer door is to the back table, instruments must remain in the closed container when you're transporting them from the sterilizer to the OR.

6. Putting instruments in contact with lint-bearing materials
Lint is a foreign body, and like any foreign body, you don't want to introduce it into the eye. Ophthalmic microsurgical instruments, with their fine tips and tiny lumens, are lint magnets if not handled properly. Although the textile industry has responded to concerns by making low-lint towels, gowns and other products for the OR, it's still good practice to keep eye instruments out of direct contact with towels or other lint-bearing linens, and to use lint-free cloths to clean and wipe them. Another safeguard against lint is your HVAC system. Make sure you're changing the filters per the manufacturer's recommendations. To get an idea of how much gunk is floating around your ORs, turn the room overhead lights off and the spotlights on. Those particles you see floating around could be landing on your eye instruments.

7. Reusing single-use instruments
Only an FDA-approved facility that has gone through a rigorous certification process can reprocess medical devices indicated for single use. It's almost impossible for an office-based surgical practice or an ASC to reprocess single-use devices in house. If you use a third-party company, the burden is on you to make sure that the vendor maintains its certification with the FDA and that it's approved to reprocess the devices you're sending to it.