SAFE KEEPING A reprocessing tech places a set in a container before it's sent off to be autoclaved.

If you're considering converting from blue wrap to rigid containers to store your instruments after sterilization as we did here at the Texas Orthopedic Hospital, I have a few pointers to share with you to help make your containerizing conversion a success.

First, a bit of background. Our facility is booming. When the hospital opened in 1995, it was 3 stories tall and had 10 ORs. How we've grown, literally bursting at the seams as we've become an international destination for patients seeking specialty orthopedic care. We're now 5 stories tall and have 17 ORs. We do about 10,000 surgeries a year. Our sterile processing department has 8 employees, including me. We process about 5,000 sets a month. Yes, that's a lot.

For years, we were wrapping about 75% of our instruments and containerizing 25%. During a 6-month transition last year, we flip-flopped those numbers, so now we're using rigid containers for 3 of every 4 sets. We still use blue wrap for those bigger, bulkier trays that don't fit into our 21-inch by 12-inch containers, but we've invested in about 200 containers. We are not alone in using rigid container systems more often than not. As you can see in "Blue Wrap or Sterile Containers?" on page 66, more than half (54%) of the 255 readers Outpatient Surgery Magazine surveyed last month place their sterile packs in containers at least 50% of the time.

Torn-wrapper syndrome
Besides efficiency and eliminating the use of towels, tape and wrap, our primary reason for switching to containers was to avoid "torn-wrapper syndrome." In the last few years, the instrument sets we reprocess have supersized. They've gotten heavier, bigger and sharper — especially the orthopedic equipment we primarily handle. Gone are the trays with soft edges that were easy to wrap. Now it's heavy sets with jagged edges. We knew we had a major sterilization (and scheduling!) concern when we began noticing an increasing number of holes in our blue wrap: punctures, pinholes, tears and shelf-slices.

PROOF OF STERILITY x 2 A rigid container can tell you that the items inside have been sterilized — the dot on the orange plastic padlock changes from blue to black and the strip on the white ID card changes from white to black.

What were the culprits? Were the hot instruments melting the wax coating on the wrap onto the wire storage rack? Were we carelessly slamming wrapped items on the shelves? We even asked each staff member who handled a wrapped instrument to initial the pack if there were no holes in it. In the end, we blamed the increased number of holes on the corners of the metal containers. It was as if someone had taken a box cutter and made a small slice in the wrap. Sometimes the slice would go all the way through so you could see the blue towel that's used for cushioning.

Think about why blue wrap punctures and tears so frequently. It's because you handle a wrapped set by the sterile barrier. The very fabric that protects the instrument set and maintains the sterile barrier is what you grab onto when you put the wrapped set on a shelf, slide it across a table or place it on the case cart.

I don't have to tell you that "torn-wrapper syndrome" is a serious setback to the surgical schedule. A hole, even the tiniest tear, will cause a delay in the case. When do you typically discover a hole in the blue wrap? Either the scrub discovers a hole when he's pulling instruments for a case or a nurse finds it when she's opening the room and there's a patient on the table already under anesthesia. Extra manpower and time is required to remove the set, find another if available or re-sterilize the set in question. This extra workload results in decreased efficiency, increased immediate-use steam sterilization (flashing), and increased frustration to the surgical team and central sterile personnel. How prevalent was the problem? There are typically 6 pans for total knee cases. Chances are, we'd find a hole in 1 of the 6 wrapped pans. Sometimes a slice is hard to see. Even when you're inspecting the inside of the wrap, it's hard to see a tear in the wrap.

I know the problem firsthand. In addition to managing our sterile processing department, I'm also a scrub. I've been in cases where you'd place the set on the table and then notice there's a hole, which means the entire table is contaminated. You have to tear the whole thing down and start all over again.

HARD TO SPOT Wrapper holes are often found at the point of use, causing a potential delay of patient care and increases in immediate-use steam sterilization. Even from the inside of the wrap, it's sometimes hard to see a tear.

Expect some pushback
Something unexpected happened during our switch to rigid containers. Our reprocessing techs, who were so accustomed to wrapped instrument trays, resisted the change. In their minds, the only way to ensure that instruments would be kept clean and safe before use was to wrap them as they'd been doing for many years. For them, it was like going from their trusty Yellow Pages to Google. Some complained that the containers were too heavy.

What got them on board? Containers are easy to use. You place the instrument set in the bottom of the container system, put the lid on, latch it and then secure it with a tamper-evident lock. It literally takes half the time to put an instrument set in a container and put a lid on it as it does to wrap a tray. We've also cut down on our supplies, as we don't need to stock nearly as many towels, as much tape, or as many sizes and kinds of wraps. A neat feature of containers: Wire baskets that sit inside the container can hold all the items of a set that don't fit into the container. Time savings are an additional benefit to containerizing. Having a vendor make a last-minute drop off for a surgeon who has an early case is time-consuming. Wrapping a large number of sets can lead to poor technique, compromised sterilization and potentially delayed start times.

Blue Wrap or Sterile Containers?

At most surgical facilities, single-use blue wrap and reusable rigid containers live together on the shelves. Most of our InstaPoll respondents use both, but more than half (54%) of the 255 respondents to last month's poll say they place their sterile packs in rigid container systems at least 50% of the time.

What percentage of your sets do you place in rigid container systems?

• Less than 25%20%
• 25% to 50%15%
• 50% to 75%30%
• 75% to 100%24%
• We use blue wrap exclusively11%

SOURCE: Outpatient Surgery MagazineInstaPoll, February 2016, n=305

STORAGE Rigid containers require significantly more storage space than wrapped sets.

The rap on containers
This is not to say containers are without drawbacks of their own. They're more expensive initially than blue wrap ($300 to $500 per tray, but they can last 10 years). You have to maintain your sterile container system. Then there's storage. One of the nice things about blue wrap is that it's easy to store. Containers take up so much more room. You have to create enough shelving space to store your containers. We had to buy additional wire shelving. Remember, a single knee replacement case will call for as many as 10 instrument pans.

In instrument sterilization, moisture is the enemy. Early on, we were removing instruments too quickly from the hot autoclave and condensation was seeping inside the containers. We noticed the problem and increased the dry time. Our containers have 2 indicators that tell us a set went to 270 ?F and therefore met the standard of the autoclaving. We call it proof of sterility when the dot on the orange plastic padlock changes from blue to black and when a strip on a white ID card changes from white to black.

Finally, a Halyard Health-funded study in the December 2015 American Journal of Infection Control (osmag.net/qWr2WZ) calls into question the widely held assumption that rigid containers, regardless of duration of use, can maintain the sterility of their contents pre-sterilization. When compared to rigid containers, wrapped instrument trays had no detectable contamination while 87% of tested rigid containers allowed bacterial contamination under the test condition used. The study also found that rigid containers may be less effective the longer they are in use: Rigid containers with 5 to 9 years of use were significantly more likely to have bacterial ingress than unused rigid containers. OSM