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What’s the Point? Point-of-Care Treatment Position Statement

Recently, I was invited to work on a project for our healthcare system involving standards for point-of-care treatment practices. The mission of our work group was to establish minimal expectations as a prevention effort to further reduce the risk of infections and improve overall quality for patients. During the project, I wrote a position statement to share my perspective on why, in my professional opinion, point-of-care treatment is a critical area for healthcare facilities to focus improvement initiatives.

Healthcare systems pride themselves on being leaders in best practice. Organizations influence one another on a national level and should operate in a way that promotes others to view them as an entity that exudes expertise, quality, and safety.

The evidence for the value of point-of-care treatment as a prevention effort is high and well documented. According to the Association of periOperative Registered Nurses (AORN) 2019 Guidelines for Perioperative Practice: Guideline for Cleaning and Care of Surgical Instruments, Recommendation III, instruments should be cleaned and decontaminated as soon as possible after use, “Instruments should be kept free of gross soil during the procedure. [2: High Evidence] Periodically during the procedure, the scrub person should use sterile water to irrigate instruments with lumens. [1: Strong Evidence].”1

For context, the statements of “High Evidence” and “Strong Evidence” in the AORN publication cited above is provided in the guidelines to demonstrate the quality of evidence for the recommendation, according to Appendix C: AORN Research and Evidence Appraisal Tool Summary.2 A reviewer can then go to the reference section to read the original sources numbered in the subtext.

Point-of-care treatment is not a new concept and has been recommended as a best practice standard of care for many years. Surgical technological schools implement this training into their programs by following Association of Surgical Technologists (AST) Guidelines for Decontamination of Surgical Instruments, Standards of Practice for the Decontamination of Surgical Instruments, Effective April 16, 2009, which states in Standard of Practice I that, “The cleaning of instruments should begin during the surgical procedure to prevent drying of blood, soil, and debris on the surfaces and within lumens.”3

In addition, AST’s publication entitled Guidelines for Best Practices for Breaking Down the Sterile Field, approved October 20, 2008, and revised June 1, 2018, provides further support for consistent point-of-care treatment practices but also discusses rationale for continuing education and overall responsibilities of the scrub. Guideline II, Section C states, “The principles of ‘point-of-use (POU) decontamination’ of instruments should be applied by the CST; POU decontamination is the beginning of the cleaning process of instruments. POU decontamination is important because it assists in lengthening the life of instruments by preventing blood and saline from corroding the finish on instruments. Additionally, blood and body fluids that are allowed to dry on instruments are difficult to remove versus when they are kept moist. The CST should try to handle the contaminated instruments as little as possible while breaking down the sterile field.”4

Should we only elevate our expectations when accreditation surveyors are looking to score against a particular area? Absolutely not! Having the backing and support of any accreditation survey organization is helpful in holding facilities accountable to best practice; however, it is not necessary. Who is to say we as healthcare systems should not go above and beyond to ensure that we are following the evidence outlined in the standards and guidelines that are recommended by AORN, AST, AAMI, etc.?

There is a lack of consistency among manufacturer’s instructions for use (IFUs). While some OR staff may monitor IFUs, most do not and it is difficult to expect clinical staff to remember which devices state point-of-care treatment and which ones do not without much more sophisticated systems in place for data delivery. The idea of limiting point-of-care treatment only to manufacturers who have specifically mentioned to do so is setting ourselves up for undue risk. As manufacturers catch up and revise their IFUs, we will find that more and more outline this expectation. Similarly to Universal Precautions, implementing a standard precaution into work instructions for point-of-care treatment can allow facilities to remain ahead of the curve.

We can be certain that there is a movement going toward point-of-care treatment as an expectation in the future, as more awareness is generated from the public through incidents that make media attention. We must prevent our facilities from being exposed to this vulnerability by creating interventions in our practice that promote the safest outcomes for our patients. Examples of current IFU statements on point-of-care treatment include:

  • Smith & Nephew Orthopaedics, “Coarse contaminants must be removed from the instruments directly after use (within a maximum of 2 hours).”5
  • Stryker Spine, point-of-use, “After use (within a maximum of 2 hours post-operatively) remove gross soil using absorbent paper wipes. Intensive rinsing of the reusable device with fluent water or transfer of the medical devices into a bath with an aldehyde-free disinfectant solution is highly recommended.”6
  • Zimmer, “For optimal results, instruments should be cleaned within 30 minutes of use or after removal from solution to minimize the potential for drying prior to cleaning”7

The main obstacle to feasibility in point-of-care treatment is the current culture in the OR for case turnovers and scheduling. Transitioning to more efficient means of OR turnovers and scheduling caseloads would have an additional impact on the surgical services value stream related to instrument availability, instrument-processing time, and the reduction of immediate use steam sterilization (IUSS), which ultimately drives surgical site infection (SSI) rates. The argument of time as a limitation can be overcome with the adoption of creative solutions such as surgical turnover kits, which can significantly reduce the time it takes for turnovers. In addition, if surgical scrubs are proficient in wiping as they go, the practice is built in and hardwired into their day-to-day practice.

I will share a story to illustrate the importance of this discussion. In the same timeframe that our workgroup was involved in this project, my facility started having incidents of bioburden making it to the OR with a very specific loaner instrument that a spine surgeon had started using. In each instance, the instrument did not contaminate the sterile field; however, our radar was heightened to address the risk. Surgical start time was delayed in each instance to reprocess the contaminated instrument along with the entire tray of instruments it was sterilized with. Focusing on education, we called the manufacturer to schedule in-services with our team, evaluated the efficacy of the cleaning brushes used on the instrument in question, and increased team awareness.

On a particular Friday, toward the end of his shift, one of our technicians was packaging this same system of loaner trays and paid particular attention to inspect the problematic instrument. The loaner trays had just been washed after being dropped off from the rep for a case on that following Monday. Noticing that it was still dirty, he sent the entire set back to the decontamination room and communicated with the team before he left for the evening. He was scheduled to work over the weekend and had been worrying about the instrument, so he performed an audit and opened the tray that it was kept in. He discovered it was still dirty, so he took the set again back to decontam and rewashed the tray. He then took an additional measure and peel packed the problematic instrument separately from the rest of the tray just in case there were any further issues so it would not contaminate the entire set. After this, we addressed the OR and reviewed the section of the IFU that clearly stated that the manufacturer recommended point-of-care treatment within two hours of use. Many spine procedures run longer than that minimum timeframe, and after collaborating with the OR staff the issue ceased. Consider how much cost went into the rework from just this one example. Working together with the staff at the point-of-care can help make the process safer and more cost-effective.   

We understand that it is a collaborative effort and commitment between all stakeholders to ensure that our system is delivering on our promise to our communities. We must do everything within our power to create an environment that fosters healing by ensuring that we maintain conditions that are conducive to reducing the risk of infection. Healthcare associated infections (HAIs) are preventable, and point-of-care treatment is one piece of the whole picture that contributes to a prevention effort that reduces the opportunity for harm.

Developing guardrails that are approved by a multidisciplinary risk assessment team, perioperative administrative council, and sterile processing leadership committee for healthcare settings can ensure that appropriate measures are taken. The standard that we set forth is to prevent Immediate Jeopardy and establish a benchmark of excellence. According to Centers for Medicare and Medicaid Services, “Immediate Jeopardy means a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident.”8 Organizations can take a stand with the support of executive leadership and shape the future of infection prevention from a collaborative and comprehensive approach.

References

  1. AORN; (2019). Guidelines for Perioperative Practice Edition 2018: AORN Guideline for Cleaning and Care of Surgical Instruments. Published by AORN. Denver, CO. 
  2. AORN; (2019). Appendix C: AORN Research and Evidence Appraisal Tool Summary. Published by AORN. Denver, CO. 
  3. AST; (2019). Guidelines for Best practices for Breaking Down the Sterile Field. Retrieved January 4, 2019. http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Guidelines%20Breaking%20Down%20Sterile%20Field.pdf
  4. AST; (2019). Standards of Practice for the Decontamination of Surgical Instruments. Retrieved January 4, 2019. http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard_Decontamination_%20Surgical_Instruments_.pdf
  5. Smith & Nephew; (2020). Processing (cleaning, disinfection and sterilization) of instruments from Smith & Nephew Orthopaedics AG. Page 5. Retrieved January 25, 2020. https://www.smith-nephew.com/global/assets/pdf/corporate/03389-en%20v3%20sterilisations%20flyer%20(1363)%201119.pdf
  6. Stryker; (2020). Cleaning, sterilization, inspection, and maintenance of reusable medical devices: Instructions for Stryker Spine. Retrieved January 25, 2020. Page 6. http://az621074.vo.msecnd.net/syk-mobile-content-cdn/global-content-system/SYKGCSDOC-2-47315/E2OtjfBeKppWbYOTg23AHtufNhCMFA/NSRDEV_RG_1.pdf
  7. Zimmer; (2020). Orthopaedic Reusable Devices: Instructions for Care, Cleaning, Maintenance and Sterilization. Retrieved January 25, 2020. Page 8. https://www.zimmerbiomet.com/content/dam/zimmer-biomet/medical-professionals/support/reusable-device-reprocessing-instructions/orthopaedic-reusable-devices.pdf
  8. CMS; (2019). State Operations Manual: Appendix Q — Core Guidelines for Determining Immediate Jeopardy.Retrieved December 9, 2019. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_q_immedjeopardy.pdf

Lisa M. McKown (Wakeman), MBA, CRCST, CIS, CHL, MBTI, is a manager of research and development for Beyond Clean. She graduated with a Bachelor of Science degree in Integrative Leadership and an MBA from Anderson University. Lisa is a doctoral student in the Richard Fairbanks School of Public Health: Global Health Leadership program through IUPUI in Indianapolis, IN. She also holds a certification as a Meyers-Briggs Practitioner, specializing in interpersonal communication. Lisa contributes as an SME volunteer for standards development and other industry-related projects that promote the sterile processing profession, including writing workshops focused on creating and revising questions for the IAHCSMM certification exams. As a healthcare professional driven to influence positive change for patient safety initiatives, Lisa is a catalyst for the advancement of infection prevention within sterile processing. Her passion is education and she is energized when she can use her experience to develop people.

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