By Don Sadler
Safe patient care is the responsibility of every person and department in the health care facility. Three departments in particular – the operating room, sterile processing department and infection prevention department – have a unique relationship when it comes to ensuring safe processing of surgical instruments.
All three departments are crucial in making sure that surgical processes, products and devices are safe for use with every patient, every time.
“Each department plays a critical role in safe instrument reprocessing,” says Julie Gorog RN, BSN, CNOR, clinical education consultant, Advanced Sterilization Products. “Therefore, it is essential that staff members have an understanding of the expectations and barriers faced by their counterparts to assure quality and safe patient care.”
Promoting a Culture of Patient Safety
Amanda Heitman, BSN, RN, CNOR, clinical nurse educator and Qlicksmart perioperative educational consultant with Periop Anew, points out that while these three departments are separate and unique, they should work together to promote a culture of patient safety.
“This helps protect both patients and health care workers,” she says.
“Each discipline possesses subject matter expertise that optimizes patient safety for instrument processing,” says Addy Bell, BBA, CSPDT infection preventionist, infection control and prevention at Lehigh Valley Health Network. “The OR focuses on management of the instruments in the surgical environment, including inspection, and initiates the cleaning process at the point of use.”
“SP continues the cleaning, disinfecting and sterilization of the instruments according to manufacturer’s instructions for use,” adds Bell. “And IP lends their expertise with knowledge of current guidelines and trends while performing audits to make sure that protocols are being followed to prevent infections.”
IP notification is necessary when breaches in processing are identified, notes Bell.
Karen Reiter, RN, CNOR, RNFA, CASC, vice president of operations for DISC Surgery Centers, likens SP to the heart of the health care organization.
“The sterile processing department must be finely tuned and work the same way every time,” she says. “Strict processes and absolute adherence to policies trickle down to the safety of the patient.”
The OR, meanwhile, is like an orchestra.
“Everything in the OR must be in perfect order, synchronized and working together,” says Reiter. “The patient is the beat of the orchestra. And the infection preventionist is the person who constantly stretches these teams to achieve best practices. Together, these three teams write the music for patient safety.”
Farrah Marsh, BSN, RN, CNOR, director of surgical services for Sanford Health, calls SP “the foundation of the patient’s surgical experience.” Meanwhile, the OR must be well-versed in standards and able to support the work of the surgeon to provide patients with great surgical outcomes.
“IP is seen as the expert voice when decisions regarding patient safety are required,” says Marsh.
According to Rebecca B. Roe, MSN-Ed, RN, NPD-BC, CNOR, the OR is the “start and end” of instrument inspection related to direct patient care.
“I say it is the end of instrument inspection because the scrub personnel must keep the instruments clean and free of debris to the best of their ability,” says Roe.
“The decontamination process starts in the OR,” Roe explains. “This means flushing lumens, wiping down drills of blood and other organic material, and keeping instruments wet until official decontamination begins in the SP department. Inspection alerts also require tagging of any broken, dull or non-functioning instrumentation found. This helps prevent use in subsequent trays and allows for proper repair or disposal of the equipment.”
Infection prevention’s influence in the OR has increased with special attention to SP and OR quality inspections and observations.
“IP personnel in surgical services provide an objective view of work activities, along with a deeper understanding of cases involving surgical site infections,” says Roe. “This department has taken on a pivotal role in monitoring surgical cases for readmissions at 30 to 90 days or longer for cases where implants are utilized.”
“Infection control needs to be behind the scenes advocating in their organizations for better safety measures,” says Heitman.
Heitman emphasizes the importance of these three departments working together to improve patient safety by implementing administrative controls. “These measures help support higher levels of controls by ensuring that people are working within safe systems,” she says. Examples include writing policies for sharps safety, ensuring compliance with safe work practices and implementing sharps injury reporting and investigation processes.
Communication and Collaboration are Key
Ensuring patient safety requires that the OR, SP and IP departments collaborate and work closely together at all times.
“It can be tempting to assume that because our work is complimentary, we are all experts in each area,” says Marsh. “But this usually isn’t the case.”
For example, an OR nurse may believe the standards that guide the work of the OR team are the same as those that guide SP practices, but they aren’t. “So, it’s important to listen with a willingness to be influenced when working collaboratively,” says Marsh.
It’s vital that staff in each area educate themselves on the standards, workflows and challenges of each specialty.
“Meeting regularly to develop relationships and maintaining open lines of communication is a great way to begin,” says Marsh.
This includes providing opportunities to shadow staff in each area.
“Shadowing is a great way to debunk myths about processes and influence attitudes,” says Marsh. “In my health system, we encourage IP auditing to bring fresh eyes into the OR. We also welcome SP staff to observe cases so they can learn and develop an understanding of their role in each case. I believe patients benefit from this type of collaboration and transparency.”
Gorog agrees.
“It’s essential that staff in all three departments maintain an understanding of the expectations, struggles and barriers faced by their counterparts,” she says. “Providing them with the ability to shadow roles in real time is one way to accomplish this.”
Roe recommends job sharing as a way for team members in the different departments to better understand each other’s roles and responsibilities.
“This helps lessen the silo effect of thinking one department is to blame for things not working well,” she says.
Reiter says that her facility often hires skilled teams trained in hospitals who are used to working in silos.
“So, blurring the lines between departments, cross-training and working together as one team can sometimes be challenging in the beginning and involve a learning curve,” she says.
“Communication between the departments is key so always keep the lines of communication open,” says Kia Parker, MACPR, CRCST, CER, CHL, a-IPC, CIC, infection preventionist with the department of clinical epidemiology at the James Comprehensive Cancer Center. “For example, OR teams can invite SP personnel to participate in their huddles and SP teams can invite surgical techs, nurses and IP personnel to tour their department during orientation.”
“IP personnel can round in the OR with their SP partners and round in SP with OR partners,” adds Parker. “And SP staff can opt to observe a surgical case. This will facilitate conversations and help break down barriers between departments.”
According to Gorog, collaboration depends on strong communication between each department to build a sense of teamwork.
“Establishing an inter-departmental group with regularly scheduled meetings gives each department the opportunity to provide feedback on process improvements and policy development,” she says.
Bell believes that transparency between the departments, along with communication, is critical to ensuring patient safety. She recommends conducting regular meetings together and creating a feedback system so each department can report any issues or concerns they might have.
“The patient safety trifecta team should conduct audits and round in the OR and SP monthly,” she says.
At Lehigh Valley Health Network, there are monthly collaborative IP/OR/SP meetings covering a range of topics, with a focus on IP.
“I think getting this group together once a month has helped increase communication across disciplines and created relationships by connecting people who might not normally have gotten together,” says Bell.
Obstacles to the Patient Safety Partnership
While everyone agrees that open communication and collaboration are the keys to an effective patient safety partnership, there are some common obstacles that often make this difficult. One of the biggest obstacles Bell sees is competing goals between departments.
“For example, if the volume of surgical cases in the OR increases but surgical instrumentation does not increase proportionately, this may put pressure on SP to turn over instruments faster,” says Bell. “If SP is not allocated additional staff, this could have adverse consequences.”
Resources can also be an obstacle.
“If there are many cases of the same type scheduled on the same day, instrument turnover is required to have instruments ready for subsequent cases,” says Roe. “This calls for meticulous coordination and communication to ensure equipment has been through standard cleaning and sterilizing processes specific for that instrumentation.”
There may be pressure to cut corners and speed up the process if funds are lacking for this level of turnover.
“If facilities are required to limit turnover, budget allocations for more instrumentation may become necessary,” says Roe.
Parker warns against falling into the ‘blame game’ trap.
“Infection prevention is everyone’s responsibility,” she says.
She also warns against what she calls the six most dreaded words in health care: ‘We’ve always done it this way.’ “This helps no one,” she says.
According to Marsh, Sanford Health has implemented SSI drilldowns led by the IP team.
“These meetings have a multidisciplinary approach and include multiple players who impact the patient experience,” she says. “OR team members research the procedure and patient condition while SP reviews any potential opportunities in their processes that could have impacted the outcome.”
Marsh says conversations that arise in these meetings give everyone the opportunity to look through the lens of each other’s expertise and offer different perspectives as they seek to improve.
“I have found this collaboration to be both informative and useful,” she says. “Taking time to debrief together has inspired new ideas and improved patient outcomes.”
“It’s important to approach our work with a curiosity about the contributions of others,” Marsh adds. “We must never stop asking questions of our partners as we seek to improve. The relationships cultivated by curiosity and respect will improve the working environment for each of us, which will positively impact our patients as well.”
A Culture of Patient Safety
Many of these obstacles can be overcome when the OR, SP and IP departments function collaboratively and share resources, which helps create a culture of patient safety. “It’s important for these departments to recognize that their objectives are intertwined,” says Bell. “The OR needs to have sterile instruments, SP needs resources to function effectively and IP needs information that enables them to detect trends or outbreaks.”
To improve collaboration in DISC surgery centers, Reiter says the departments start and end each day with a short huddle.
“Everybody talks about what was good, what was great and what could be improved on that day,” she says.
The departments then review the next few days coming up and how everyone will be educated about any new implants to be used, including how to sterilize them properly.
“The huddles focus not only on what cases we have the next day, but also what trays need to be sterilized and turned over between cases,” says Reiter. “This guarantees that SP remains in the loop, which ensures that work is completed and managed with accountability.”
Sharing Best Practices
The need for the OR, SP and IP departments to work closely together cannot be overstated. “Opportunities remain to strengthen these relationships in most organizations,” says Bell. “I believe that more emphasis on this is needed from professional organizations to highlight facilities that have strong relationships between these departments and share best practices.”
