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(Not) Gone Like a “Flash”: 5 Years Later in the IUSS Debate and We’re Still Confused

A number of industry organizations gathered together in 2011 and made a bold statement: “flash sterilization” is dead, long live IUSS (immediate-use steam sterilization).1 While the 2011 position paper arguing the need to cease using the term flash sterilization had an impact on the sterile processing and operating room industry, it wasn’t until August 2014 when the Centers for Medicaid & Medicare Services (CMS) sent out their Change in Terminology and Update of S&C (Survey and Certification) Memorandum 09-55 Regarding Standards for Immediate Use Sterilization (IUSS) in Surgical Settings that the entire hospital world took notice2.

Or did it?

We are now a little more than five years out from the CMS memorandum 09-55 that states, “IUSS is now the preferred term, because ‘flash’ does not adequately convey the fact that sufficient time and a number of steps and safeguards are required to accomplish pre-cleaning procedures that are necessary to ensure sterilization.”2 The reality is large portions of the industry are still using the term flash to describe immediate-use sterilization. For a number of reasons discussed below, the top-down approach to changing an industry’s language and terminology has never actually stuck.

Who reads CMS memorandums?
When I began my career in sterile processing, it was the spring of 2009. At that time, my training and orientation to the department included education around immediate needs in the OR that required our team to prioritize the washing, inspection, (flash) packaging, and transport of certain instrumentation to the OR for sterilization in their “flash autoclaves.” When the initial position paper was released in 2011 by organizations such as AAMI, AORN, IAHCSMM, APIC, and others, most technicians like me didn’t even hear a peep about it. As frontline technicians at a hospital in the middle of Kentucky, our primary concern was ensuring we kept up with today’s surgical volume, wore our PPE correctly, and documented our sterilization loads consistently. Some collaborative statement about the particular words we used in our hospital to describe various processes never made it into our native vocabulary.

That is one of the primary reasons I believe this attempt at a redefining the language of flash sterilization has ultimately failed in our industry. It does not appear that there has ever been any concerted effort to get this information into the trenches of the operating room and sterile processing departments. After all, who reads CMS memorandums on their lunch break? If there was an attempt to bring this information down to the department level, the conversations heard daily in departments across the country tell the tale—the attempt was not successful. The shear scope of such a monumental shift in vocabulary is hard to measure, but it would have to include things such as changing verbiage in:

  • Orientation checklists
  • Facility training manuals
  • Documentation forms
  • Product names and marketing materials
  • Existing industry literature
  • Multidepartment policies
  • Facility signage and labels

Those would have been the easy steps. Much more difficult (and perhaps the reason for the failure of this directive) is actually educating and requesting individuals to change the way they speak about these processes, day in and day out.

No one to police the language law breakers
As we know, people hate change. The only thing people hate more than change is change that makes their lives more difficult, even if it’s only a little and would last a short time. The challenge for implementing such a multidisciplinary shift in clinical vocabulary has some roots in the proverbial chicken and the egg scenario. Who is going to stop using the flash term first? If the sterile processing team begins referring to this process as IUSS, their team members in the operating room may misunderstand. If operating room staff use flash language in the trenches but report the data as IUSS to their partners in infection control, what real progress is being made?

At the end of it all, there arose no real industry police to enforce the new language requirements being sent down from CMS. And with no stick, the carrot of familiarity and convenience has led many (if not most) perioperative professionals to stick with what they know. Yes, the processes of rinsing something in a scrub sink then popping it into an autoclave has almost universally ended (thankfully). But the language of flash has simply taken on a new, albeit more compliant, meaning. What we are left with are two terms (flash and IUSS) that have substantial, if not identical, meanings today—and an entire industry full of intentional or unintentional misuse of them in various clinical contexts.

A surveyor’s favorite question: What’s your flash rate?
As if all this were not enough, the supposed paragons of industry best practice—accreditation surveyors—are often found to use these terms interchangeably as well. I have heard numerous surveyors ask me about my department’s flash rate during their accreditation visits, and I have been told by many other sterile processing leaders that I am not alone in that experience. In our onsite consulting visits both before and after department surveyors, hospital staff regularly share that their surveyors have used the language of flashing to describe department documentation and policies. While this is not a universal claim, it is undeniable that we have accreditation surveyors in the field today who aren’t even following the language of CMS and the other collaborative bodies. If this is the case, how can we ever expect a holistic change to ever take place?

Ultimately, the position paper of 2011 and CMS memorandum of 2014 did prompt real, positive change in the practice of short-circuiting a full decontamination and assembly process for immediately needed surgical trays. We are much closer to patient safety in those areas today than we were five years ago.

What it did not do is change the way most of us talk about the process.

I guess if we had to choose between the two, we chose the right one.


  1. http://s3.amazonaws.com/rdcms-aami/files/production/public/FileDownloads/Products/ST79_Immediate_Use_Statement.pdf
  2. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-44.pdf

Feature articles exclusively for Ultra Clean Systems by Weston “Hank” Balch, BS, MDiv, CRCST, CER, CIS, CHL

Weapon of Mass Microbial Destruction * Professional Clean Freak * Podcast Host * Safety Addict * CS/SPD Consultant

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