FLASH MOB Lancaster General's (left to right) Trish Stoutzenberger, ST, CRCST, CHL, manager of central sterile supply; Tom Gallagher, CRCST, sterile processing technician; and Zach Schulz, CST, certified surgical technologist.

Immediate-use sterilization is an effective way to quickly get instruments back into the hands of physicians when — and only when — emergent situations prevent the possibility of full reprocessing cycles. But there remains a disconnect between operating rooms and sterile processing departments about when rapid steam cycles are permitted, and how to properly perform them when they are. Let's clear up that confusion.

1 Pick your spots
My hospital has 25 operating rooms, including a dedicated orthopedic center where 30 surgeons operate. Loaner instrumentation and surgeon-specific devices are constantly moving in and out of the facility. It's a lot to manage in the sterile processing department, and sometimes has us resorting to immediate-use sterilization — despite even the best pre-planning. For example, we might not have enough of the custom-made forceps a surgeon needs for every case. In that instance, immediate-use sterilization is an option. If you face similar challenges, and you can't avoid immediate-use sterilization cycles, follow the national standards (see "What the Guidelines Say" on page 48). Try to flash less than 4% of your monthly reprocessing volume. Flashing should never be a routine practice.

2 Communicate with SPD
When you're using instruments that need to be run through a rapid steam cycle, alert the sterile processing department about 10 minutes before the case ends. It's also a good idea to look over the day's surgical schedule, anticipate the instrument requirements and create a potential rapid-cycle list based on the items you've picked for cases the night before. The more notice members of your sterile processing team have, the better; they need enough time to pick up items in the OR and transport them back to reprocessing. It takes longer to send items to sterile processing — we can get small trays cleaned and back to the OR in about 35 minutes — but all patients deserve the same level of care that your first patient received.

FIRST STEP You can't properly sterilize instruments without first properly cleaning them.

3 Decontaminate
You must transport instruments intended for immediate-use sterilization to your sterile processing department in a closed container for proper decontamination. The decontamination process before immediate-use sterilization is the same as it is for items prepped for regular reprocessing cycles — instruments need to be disassembled and cleaned thoroughly with enzymatic detergent. We do, however, put fast-tracked instruments through a quicker cycle in our automatic washers, which shaves about 10 minutes off the cleaning time. (The faster cycle skips drying and lubrication cycles, but is validated for proper washing.)

Your surgical staff must understand that it's unacceptable to wash instruments in the OR before putting them through immediate-use cycles. The lone exception we've made to that rule occurs when one-of-a-kind instruments fall on the floor in the middle of surgery. In those instances, OR staff can clean the items with enzymatic sponges before running them through rapid-cycle sterilization for continued use during the case.

4 Work by the book
Never place instruments intended for rapid-cycle sterilization inside the autoclave in an open pan. After that cycle runs, a scrubbed surgical team member would have to grab the instruments and walk them back to the sterile field. This "open sterilization" is a risky and improper practice that dramatically increases contamination risk. Rigid closed containers, on the other hand, are ideal for immediate-use cycles because there's no chance of contamination when staff removes them from the autoclave for transport to the OR.

Make sure the items you run through immediate-use sterilization are validated for rapid steam cycles. Full orthopedic instrument trays that require extended reprocessing, for example, are never suitable for immediate-use sterilization. Check the autoclave manufacturer's guidelines to ensure you're running the proper cycle at the appropriate temperature for the required time. Immediate-use sterilization is typically achieved with gravity cycles run for about 10 minutes at 270 ?F, although cycle type depends on the autoclave you use. Also run the appropriate rapid cycle based on guidelines issued by instrument and closed container manufacturers.

5 Validate cycles
Check that immediate-use cycles are properly completed before removing items from the autoclave. Include Class 5 chemical monitors with each item that's run through rapid steam cycles and test autoclaves with biological indicators once a day. Also include biological indicators in the immediate-use sterilization of implants — which should only be flashed in emergent situations. Don't put the implant in the patient until you confirm the results of the biological test, which takes about an hour to complete.

SOCIETY STANDARDS
What the Guidelines Say

SAFE SPEED Zach Schulz, CST, certified surgical technologist at Lancaster General, readies a rapid-cycle load.

Here's a rundown of acceptable immediate-use sterilization practices and key guidelines to follow at your facility:

• Establish standardized practices and ensure staff is appropriately educated and trained on rapid-cycle competencies. Educational courses and certification resources are available through the Certification Board for Sterile Processing (sterileprocessing.org/cbspd.htm) and the International Association of Healthcare Central Service Material Management (iahcsmm.org).
• As with all instrument reprocessing, don't ignore the importance of proper cleaning, rinsing and decontamination before immediate-use sterilization cycles. Preparing instruments removes soils for effective sterilization.
• Always transfer instruments in an aseptic fashion — in a closed container, for example — from the OR to the sterile processing area, and from the sterilizer to the point of use.
• Follow instrument manufacturers' written instructions for immediate-use sterilization, and compare them to autoclaves' capabilities and closed containers' instructions for use. When an instrument manufacturer's instructions are unclear or contradict guidelines issued by the makers of the autoclave or closed container, call the instrument company for guidance. If discrepancies between the various instructions cannot be resolved, the instrument manufacturer's instructions take precedence.
• Review physical, biological and chemical indicators to ensure sterilization cycles are effective.
• Never run immediate-use sterilization cycles for implants (unless in documented emergent situations); for the post-procedure sterilization of instruments used on patients who may have disorders or diseases such as Creutzfeldt—Jakob disease; for devices not validated for the intended sterilization cycle; and for sterile, single-use devices.
• Never run immediate-use cycles for convenience's sake. Have adequate instrument inventory to meet anticipated surgical volume and allow enough time between uses for completion of all phases of full-cycle reprocessing.

— Daniel Cook

6 Document and track
Staying on top of your instrument reprocessing practices to ensure rapid cycles are never used solely to keep up with case volume requires daily oversight. You might have to move cases or tweak the day's schedule to ensure instruments go through regular reprocessing cycles.

Look at your block schedules. Do you have several surgeons doing many joint procedures on a single day? Delaying the start time of a case or moving blocks around to ensure implants are run through complete sterilization cycles is never a bad option. If you can't move blocks, tell instrument vendors you won't have enough instrumentation to cover the caseload and request they send additional tools. Or perhaps you can alternate case types — hip, knee, hip, knee — to give your reprocessing team time to get needed instruments back to the ORs without resorting to immediate-use sterilization. The surgical team should document in the operative report every item put through rapid-cycle sterilization. Review the items they note monthly, looking for trends. If you're repeatedly putting the same instruments through rapid cycles, consider buying more of those items if you expect the trends to continue.

Buying more of the instruments you already have in stock might not be the sexiest choice when it comes to allocating budgeted dollars, but ensuring you have enough of the tools in regular use helps avoid immediate-use sterilization. Ticking items off of surgeons' wish lists is nice, but hard decisions have to be made out of respect for a more important consideration: patient safety.