295 - Using A-3 Thinking to Manage Immediate Use Steam Sterilization (IUSS)
Our Team: Los Angeles County Harbor-UCLA Medical Center is a Level 1 trauma center, with about 1000 surgical cases per month in 16 surgical suites. Our team consists of the Perioperative Clinical Nurse Specialist, Central Sterile Processing Nurse Manager, and three OR registered nurses, including the leader and members of our orthopedic team.
Assessment: Three months of IUSS indicator results recorded in the instrument tracking system were reviewed, demonstrating that 11% (7/64) of results were documented, while 89% (57/64) were not. Ortho service was responsible for 94% (60/64) of the IUSS loads and 93% (41/44) of the undocumented integrating indicators.
Preparation and Planning: A-3 Thinking is an 8-step process similar to Plan-Do-Check-Act (PDCA). The team went into the OR and observed the IUSS process, talked with staff, and discussed observations. The initial focus of the project was improving documentation of Type 5 integrating indicator results, however, our root cause analysis led to identification of additional issues and development of countermeasures to resolve them. Root cause analysis distributed the issues into four categories using A-3 thinking.
Manpower issues include time, redundant records, and multiple duties of the RN.
Machine issues include a lack of hard stop in the instrument tracking system to remind staff to save information.
Materials issues are holes in sterilization wrappers leading to IUSS.
Method includes confusion regarding two parallel systems of recording (paper and electronic); long and intimidating IUSS instructions; not handing off the IUSS process; and lack of knowledge of IUSS documentation.
Implementation: OR staff were educated stressing the importance of documenting indicator results. Paper IUSS logs were removed to eliminate redundancy. The list of IUSS load reasons was modified to streamline documentation. Standardized work was developed, trialed, modified, finalized and posted as reference for staff. Staff were encouraged to involve the charge nurse when needing to run an IUSS load in order to get help. CSP staff were educated on correct use of the tray belts to prevent damage to wrapped trays and avoid the need for reprocessing.
Outcomes: Documentation of indicator results improved dramatically to 90% (9/10), then 93% (27/29), followed by 100% for the following months.The IUSS process and documentation were standardized. Monitoring of IUSS load reasons and contents justified purchase of additional instrumentation.
Implications for Perioperative Nursing: Use of IUSS must be limited, however, when used, must be done correctly and documented completely in order to provide patients with the assurance that surgical instruments are sterilized properly. A-3 thinking provides a framework for managing this issue.
Co-Authors: Aileen Cabatan-Almazan, Lailani Manimbo-Esmilla, Ana Cadena, Arnel Virtusio