By Don Sadler
The role of the sterile processing department (SPD) is vital when it comes to ensuring patient safety. The SPD is responsible for ensuring that surgical instruments are cleaned, inspected and reprocessed (including high-level disinfection and sterilization) before being returned to the operating room.
However, many SPD technicians work in less-than-ideal conditions that present ergonomic and other health hazards. This includes working in cramped, inefficient spaces that often aren’t set up to allow for safe ergonomic practices. These conditions jeopardize patient safety and threaten the health and safety of technicians.
Complexity Creates Challenges
“Poorly designed and poorly equipped workspaces in the sterile processing department can be extraordinarily challenging in today’s fast-paced world where medical devices and reusable surgical instruments are becoming more complex,” says Erin Kyle, DNP, RN, CNOR, NEA-BC, editor in chief of Guidelines for Perioperative Practice for the Association of periOperative Registered Nurses (AORN).
Some sterile processing departments just aren’t big enough for all the needed equipment while also allowing space to support the workflow.
“In other words, it’s cramped once you get all the equipment into the space, if you’re lucky enough to get all of equipment you need into it,” says Kyle.
“We wouldn’t expect a surgeon to perform surgery in a tight cramped closet with dim lighting,” notes Amber Wood, MSN, RN, CNOR, CIC, FAPIC, AORN Senior Nursing Practice Specialist. “So, why would we expect sterile processing personnel to perform the critical tasks of endoscope cleaning, inspection and processing in these conditions?”
Wood, who is the lead author of the recently updated Guideline for Processing Flexible Endoscopes, points to research confirming that SPD personnel are uncomfortable when processing endoscopes, especially when using manual cleaning and processing methods.
“This discomfort could lead to shortcuts or human error in processing that is not compliant with the IFU or guidelines and may not ensure the scope is safe for use,” says Wood.
In one survey, three out of four SPD technicians said they experienced fatigue or discomfort as a result of cleaning duodenoscopes. The body areas with the highest discomfort were the lower back, neck and shoulders.
“The researchers discussed that this finding was likely related to responses of uncomfortable work surface height (such as carts, counters and sinks) and small cleaning areas,” says Wood.
Specific SPD Safety Risks
The safety risks posed by unsafe ergonomic working conditions in the SPD are many, including:
- Musculoskeletal (MSK) injuries and muscle strains
- Needle sticks
- Back, shoulder and neck pain
- Falls from slippery floors, especially in decontamination
- Carpal tunnel syndrome
Latisha Newell, BA, CST, CBSPDT, a sterile processing manager with Anmed Health, believes that equipment design and departmental layouts are the leading attributes for injuries among SPD staff.
“Most case carts and racks have shelves that are below the knees, causing staff to bend in order to pull and lift trays,” says Newell. “An 8-by-8 endoscope cleaning room with a stationary three-bay sink is an atmosphere of confinement.”
These conditions can lead not only to the physical safety risks listed above, but they can also affect employees’ mental health.
“SPD staff will eventually grow tiresome of the work conditions and ultimately dread coming to work,” says Newell. “This may lead to decreased productivity, low morale and greater staff turnover.”
David Taylor, MSN, RN, CNOR, president of Resolute Advisory Group LLC, points out that SPD technicians face more than the risk of physical injuries.
“In most cases they are also exposed to cleaning and sterilizing agents such as ethylene oxide, glutaraldehyde and peracetic acid,” says Taylor. “Chronic exposure to these hazardous agents can place SPD technicians at risk for respiratory complications as well as headaches, nausea, vomiting, diarrhea, drowsiness, nosebleeds and even cancer.”
Jane Flowers, MSN, RN, CNOR(E), CRCST, is the former sterile processing manager for the University of Maryland Shore Regional Health. “I’m currently retired but I will never forget how when I would help inspect, count and repackage sterilization instruments, I would go home with a sore back or shoulders from working at a height that did not complement my height,” she says.
Kyle concurs, “One technician may be over six feet tall and performing the same tasks as another one who is under five feet tall,” she says. “It’s unreasonable to expect that a fixed height sink and table will provide for an environment where they can both be safe.”
Taking Ergonomic Safety Seriously
The good news is that an increasing number of SPDs are taking ergonomic safety factors into consideration when designing or updating these workspaces.
“Most SPD leaders and employees understand the benefits to be derived from an ergonomically friendly work environment,” says Deborah Bunn, MS, BS, CRCST, CIS, CER, CHL, ACE, the director of central sterile processing at the UM Medical Center–Downtown Campus, University of Maryland Medical System.
“SPD layout, workflow and equipment setup must always be prioritized, assessed and modified as needed to ensure that equipment, tables, carts and supplies can be accommodated,” adds Damien Berg, BA, BS, CRCST, AAMIF, vice president of strategic initiatives for the Healthcare Sterile Processing Association (HSPA).
“Unfortunately, some SPDs are small and cramped, and even large SPDs can be problematic if their layout and flow aren’t optimal or efficient,” says Berg. “This causes employees to walk great distances for supplies and equipment, or to have to lift, push or pull excessively.”
Beth Israel Deaconess Medical Center in Boston, Mass., has done a tremendous amount of work to minimize hazards to SPD staff, says Ross Simon, senior quality engineer, healthcare quality at BIDMC.
“We have observed that there are many opportunities to reduce ergonomic and other hazards in SPD workspaces, including cramped spaces and outdated equipment,” says Simon. “Involving the staff who do the work and know the hazards is key to understanding and fixing them.”
BIDMC created job safety teams in SPD that meet every other week with specific goals, like reducing injuries by 10% as measured by days away from work.
“Using tools like Job Safety Behavioral Observations (JSBO) and Job Safety Analyses (JSA), we meticulously examined all work performed to identify hazards and a means to prevent injury,” says Simon.
Including a safety department expert on the teams was critical in identifying and developing solutions. “We invested in modern workstations with seats with back support, adjustable table heights and adequate lighting,” says Simon.
Natalie Lind, CRCST, CHL, CIS, the director of education for the HSPA, recommends a worksite analysis to detect conditions and certain aspects of work activities that increase employee injury risks. “This also helps initiate corrective actions to mitigate these risks,” says Lind.
For example, overhead lift systems and transport carts with adjustable height worktables can reduce the risk of back and other MSK injuries.
“Training on good body mechanics when lifting trays or pushing carts is also essential for SPD staff,” says Lind. “Trays should not exceed 25 pounds including the tray, not just the instruments.”
Benefits of an Ergonomically Friendly SPD
Mary Alice Miner, Ph.D., RN, CNOR, AORN Senior Nursing Practice Specialist and lead author of the recent update to the Guideline for Design and Maintenance of the Surgical Suite, says there are numerous benefits to creating an ergonomically friendly SPD workspace.
“Not only is it safer and more joyful for those working in and around the space, but there are fewer risks of workflow inefficiencies and errors negatively affecting others,” says Miner.
Miner points to a study that uncovered inefficiencies in how unprocessed trays were getting to OR shelves. “By working through and improving the different levels of waste, such as poor ergonomics for SPD technicians, there was a reduction in this occurrence,” she says.
Other benefits of improved ergonomics in SPD include improved employee performance and engagement, higher productivity and morale, fewer workplace injuries (including MSK), reduced corporate liability and higher employee retention rates.
“Keeping staff safe so they can go home to their families uninjured is our key objective,” says Simon.
Newell says her team has implemented small changes in the SPD that have yielded big results. For example, they moved empty containers that come through the washer closer to their workstations so staff don’t have to walk halfway across the prep and pack area to get the container for their instruments.
“We also moved the heat-sealing station and wrap station to areas that were wasted space, which opened the floor up by six feet when entering the department,” says Newell. “And we removed mobile carts that were cluttering the isles between the workstations and staged the end of each workstation with stationary racks that are labeled by service line.”
Newell has also added ergonomic sinks and a new cart washer. “I have future plans of adding an ergonomic workstation,” she says.
A spaghetti diagram is one effective tool SPD managers can use to identify items’ movement through various process. “This will track wasted or duplicative steps or actions,” says Lind.
She explains the process: “Draw a floorplan of the existing SPD areas and the various pieces of equipment in each area. Then observe employees working in the area and draw lines to represent their movements with each task they perform.”
For example, suppose an employee must move case carts across the room to unload dirty devices at the computer or scanner and then back for processing in the cart washer. “Work with employees to identify ways to reduce wasted or excessive movement and improve workflow,” says Lind.
Process flow maps can also be used to track steps and movements across each process, Lind adds.
Get SPD Staff Involved
Bunn stresses the importance of getting employees involved in a workplace assessment of the SPD for safe ergonomics. She lists a number of low-cost or no-cost improvements that can be made, including:
- Rotating staff to different tasks.
- Giving staff more breaks, including stretch breaks.
- Creating a “power shift” that will provide assistance when the workload increases.
- Placing the most frequently used items within reach at the workstation.
“On the administrative side, establish more efficient processes and procedures, such as requiring two people to lift heavy items,” says Bunn. “And make sure staff is using personal protective equipment like thermal gloves, gowns and face/eye protection to reduce exposure to hazardous materials.”
Flowers says that while SPD units are frequently retrofitted, they can still only handle so much. “A prime question to ask is whether you have the equipment to sterilize the new instrumentation, or can you handle the increased volume that the new service or procedure will present to the SPD,” she notes.
It’s also important to determine how long it will take to reprocess items because this will mandate how many you need to purchase to do the procedure.
“If the volume projection is to perform six cases needing that instrumentation each day, how many sets will you need to have everything ready to support the OR’s needs? This includes space to store the items,” Flowers explains.
Kyle believes it’s important to conduct an honest evaluation of the current state of equipment, infrastructure, workflows and ergonomics in all sterile processing spaces.
“Be sure to conduct this evaluation with the assistance of trained professionals in ergonomics and occupational health, as well as those who are responsible for maintaining the facility,” she says.
Potential Obstacles to Ergonomic Safety
Not surprisingly, one of the main obstacles to implementing ergonomic safety steps like these in the SPD is cost. “Replacing equipment and redesigning the SPD workspace can be expensive, which is why some departments are behind in making needed improvements,” says Bunn.
“In my mind, the greatest obstacles to improving ergonomics in the SPD are budget and space,” adds Flowers. “When expanding services, the capacity of the SPD in terms of equipment, staff and space to handle the increased volume has to be considered.”
According to Kyle, many SPDs were designed and equipped to handle the processing needs of the organization at a point in time, but that time may now be in the distant past.
“The SPD must evolve with the rest of the organization,” she says.
“If investments aren’t made in the infrastructure and personnel who do the important work of instrument processing, these services can fall behind,” Kyle adds. “And the tipping point to course-correct can be extremely costly.”
