Does Your SPD Meet Water Quality Standards?

If you’re not sure, find out. Here’s help.

Have you checked on the quality of the water that’s coming into and moving around your facility, particularly the water that your sterile processing department (SPD) uses to reprocess instruments and run its expensive equipment?

If your SPD techs have tools they use to check their water quality regularly, that’s great. But it’s only part of the overall water quality equation. Your SPD staff almost certainly are not water quality experts, which is a science unto itself. And unless you have a water quality expert on staff as many large hospitals do, you don’t necessarily have the full picture of your water’s quality.

The ‘why’ of water quality

Why does SPD water quality matter? The answer lies in your instruments and your SPD equipment. If the water your reprocessing staff uses is substandard, it can degrade or damage instruments more rapidly than they should, or instruments could show up in the OR with nasty film, stains or other issues. While there can be patient safety and infection prevention ramifications involved, circumstances like these indicate another potential problem: Your facility’s return on investment (ROI) in instrumentation — as well as SPD equipment such as automated endoscope reprocessors (AERs), washer-disinfectors, cart washers and sterilizers, which can also be damaged by poor water quality — can shrink.

ASCs typically don’t have a central utility plant run by a facilities department that monitors quality, as hospitals do. Fortunately, many experts and organizations can help provide your facility a fuller picture of your water quality, from associations to consultants to local utilities. And a new standard — ANSI/AAMI ST108, “Water for the processing of medical devices,” published in August 2023 — provides evidence-based recommendations and guidelines for facilities.

One of the country’s leading SPD experts — Damien Berg, BA, BS, CRCST, AAMIF, vice president of strategic initiatives with the Healthcare Sterile Processing Association (HSPA) — represents his organization’s 54,000 members on the Association for the Advancement of Medical Instrumentation (AAMI) standards board and was intimately involved in the development of ST108. He spoke with us about how outpatient surgical facilities, especially those not connected to larger hospital systems, can better ensure that the quality of the various types of water they use for reprocessing is safe for not only patients, but also your instruments and equipment.

ROI on instrumentation and equipment

Mr. Berg says knowledge gaps exist about water quality at many facilities but doesn’t necessarily chalk those gaps up to ignorance or lax practices. Many outpatient centers, and the people who work at them, simply don’t know much about water. “There is a lack of awareness of this issue,” he says. “I don’t know if there’s a big problem out there, and that’s also the problem.” The longtime dynamic, he says, is more reactive than proactive. “We don’t know where we stand with water quality until something happens,” he says.

You might think that “something” means patients suffering infections from poor water quality. “But honestly, nothing has been directly tied to water quality and negative outcomes,” replies Mr. Berg. “It’s when our instruments have black flakes or corrosion or staining and our surgical teams ask, ‘Whoa, what’s going on here?’ while our financial teams ask, ‘Why am I replacing these instruments and this equipment so quickly? What's the problem?’ And then we start chasing our tails because we don’t know.” Issues with diminished ROI for instrumentation should get the attention of your center’s C-suite, governing board and ownership. “And don’t forget water quality’s impact on your sterile processing equipment, which is extremely expensive,” says Mr. Berg, who notes that while SPD gear isn’t directly attached to revenue, damage and downtime associated with them can cost a center hundreds of thousands of dollars in repairs, replacements and lost SPD staff productivity.

If you find that water quality is accelerating the deterioration of your instruments and equipment, let your higher-ups know that the resulting instrument shortages can lead to delayed or canceled cases, as well as potential patient safety and infection prevention issues.“That’s ROI you can show them,” says Mr. Berg. “As far as canceling cases, that’s even more about brand image. There are reports of hospitals stopping surgeries for a day or two days because of some question about water. Doctors pay attention. They have a choice on where they want to take certain patients, and patients are seeing that too.”

Establish a baseline

The most important thing you can do to get your arms around water quality at your center is to establish a baseline. “Your water may be fine, but if you don’t know where you’re at, how do you know where you’re going?” says Mr. Berg. “Get your baseline. It’s not that hard. What’s scary is you don’t know what result you’ll get until you see it. Then look at the [ST108] standard. You might find you’re not out of range and just need to set up a routine monitoring system. Or you might find you’re out of the recommended range, and now you need to consult a water expert who can zero in on the problem.”

In these cases, you’ll want to bring together the people who run your building’s infrastructure with the C-suite and other surgery center leadership, including sterile processing and infection prevention, to establish awareness of the water problem and develop a plan to correct it.

Mr. Berg stresses getting leadership involved early on so they know you’re investigating an issue that might require funding to fix. “Let them know you don’t know what the problem is yet, you’re testing the water, and you’ll come back to them with results and recommendations,” he says. “That way, when you have those results and recommendations, it’s not the first time they’re hearing it.” Mr. Berg also suggests connecting with your local water department, which can help you develop a monitoring plan. “Every state is different, every water source is different, and during different times of the year, your water could be different,” he says. “I’m from Colorado, so we have good water at certain times of the year that’s perfect. Then we hit the summer drought time, when they pull water from different areas and change things.

“Understanding where you get your water is crucial, so ask them about when you will have challenges with changes in the water supply,” he says. “You’ll find that maybe you should test at this or that challenging time. And once you see the results over time, you’ll be able to predict through data if you don’t need to test as frequently, or need to test more. Document all of this in your water plan and then, going forward, if you experience water quality problems, you have the structure to better identify exactly what the problems are.”

Mr. Berg says the ability to digitally monitor water quality is still developing, with some systems in place at larger facilities. “I don’t think it’s as fully automated and smart as I’d like it to be, where you can basically set it and then get a notification via email or text that says your water is out of range and you’d better do something,” he says. “I think we're getting there, because now that this is a standard, a lot more attention is being placed on how to comply with it.”

Four monitoring sites

Mr. Berg says once your baseline is established, you’ll be better equipped to investigate issues with reprocessed instruments. He employs a process of deduction in the SPD, where distinct areas of the department could be the culprit(s).

“Instead of trying to play Whack-a-Mole with which area it is, I remove all the areas one at a time to find out what the cause is,” he says. “I’ll grab brand-new instruments and only wash them in the sink under the final rinse and see what that water does. Then only through the washer, then only through the sterilizer. Then I can narrow it down. Once you know your results, you can start making changes through your water experts and hopefully resolve your problem.”

Four distinct types of water supplies should fuel your SPD, and any or all of them could be in or out of range. “It’s about knowing where you’re at in these four areas and understanding where you might have problems in each,” says Mr. Berg.

• Initial rinse water. This is your “tap water” used to remove visually apparent bioburden, debris and chemicals from instruments to prepare them for reprocessing.

• Final rinse at sink, sonic or AER. This is where highly purified “critical water” should be present. “If you’re hand-washing an item like a battery or light cord that can’t run through the washer-disinfector, you should be rinsing it with critical water, as defined by AAMI,” says Mr. Berg, who warns that facilities that use deionized (DI) or reverse osmosis (RO) water and regard it as critical water aren’t necessarily correct in that assumption.

“Critical water is its own definition,” he says. “Is your DI or RO water in the range of what the standards say they should be? I’ve seen people who never test their water say, ‘I have this beautiful tank that’s giving us all that critical water.’ Well, it’s an RO system, and when was the last time you tested it?”

• Final rinse at washers. Critical water should be used here, too. “It helps remove any impurities that are left,” says Mr. Berg. “You don’t want any of those impurities to keep transferring through the process.”

• Steam. “A lot of people will blame the steam for causing problems with instrument staining, when it’s really maybe your final rinse at your washer leaving mineral deposits on them that get activated by the steam, and you don’t see it until it gets autoclaved,” says Mr. Berg, who recalls a case of an OR team opening instrument sets to find a rusty orange tint on them. “It turned out it was iron and phosphate from the final rinse, where there was bad water quality. The washers weren’t getting descaled, so the final rinse was transferring these hard solids onto the instruments. You couldn’t see it or smell it when you inspected it, but when an instrument went to the steam cycle, it had this orange patina to it. It wasn’t a steam problem. They weren’t monitoring water.”

Remember that all water is not created equal. Water considered safe for drinking, for example, might not necessarily be conducive to reprocessing surgical instruments. “A good example is water hardness and metals,” says Mr. Berg. “You can have phosphate and iron and sodium in your water at the correct levels that is totally safe to drink and use. But if it changes one or two percentage points in one direction or the other, what’s that doing for our sterile processing machines? You might still be in range, but that’s a big jump. You may have more mineral or hard water deposits on your coils, which then will transfer to instruments and can react with steam and other chemistries. It can impact the quality of your instruments and their longevity, which then could lead to detrimental patient care.”

Tap resources

Mr. Berg says HSPA is aligned with associations such as AAMI, the Association of periOperative Nurses (AORN), the Association for Professionals in Infection Control and Epidemiology (APIC) and others on the water quality issue and collaborated on the standard. As such, says Mr. Berg, organizations like HSPA can help you find your footing with water quality.

“You’re not on your own,” he says. “A ton of resources and education is out there online — webinars, podcasts, articles, conferences, chapter meetings — through trusted associations like APIC, AORN, HSPA, SGNA and others. Make sure it’s not commercial where you’re just listening to someone trying to sell you a water system.”

Water quality fixes often aren’t too expensive or difficult, and might not require any replacement of capital equipment. “Maybe you need a stronger prefilter or some ultraviolet lights. Maybe you need to change the loop system that sends your water wherever it’s going and where it returns,” says Mr. Berg. “I’ve had some people install the wrong plumbing. Critical water is very corrosive to copper, and could produce a lot of bad issues in your instruments. Know where the problems are and how your water quality stands, and that will direct you to the fixes.” OSM