Prevention of Surgical Site Infections (SSI)

1
Prevention of Surgical Site Infections (SSI)

• MSIPC Fundamentals of Infection Prevention
  Control
• October 2015
• Karen Hoover, RN
• Infection Prevention Coordinator
• St. Marys of Michigan, Saginaw

2
SSI A Complication of Surgical Care

• gt 51.4 million surgical procedures/year in US
• 31 of all HAIs due to SSI, second only to UTI
• gt 91,000 readmissions for SSI Rx
• 1 million additional inpatient days
• 1.6 billion excess costs
• Associated mortality rate of 3
• Cost Pay for performance patient safety
• CDCs Guideline for Prevention of Surgical Site
  Infection, 1999.8
• Jan 2014 CDC

3
Common Surgeries/Procedures

• 719,000/year Total knee
• 498,000 Hysterectomy
• 395,000 CABG
• 332,000 Total Hip
• 1.3 million Cesarean sections
• Ambulatory
• 1.3 million cataracts
• 923,000 Lens implants
• 499,000 Endoscopies of lg. intestine 1.1
  million of sm. intestine
• 735,000 Injections of spine
• Approx. 40 have more than 1 procedure
• CDC http//www.cdc.gov/nchs/fastats/inpatient-surg
  ery.htm (2010)
• CDC www.cdc.gov/nchs/data/nhsr/nhsr011.pdf

4
Risk Factors for SSI identification
opportunities for intervention

• Risk factor variable with significant,
  independent association with development of SSI
• Patient age, nutrition, diabetes, smoking,
  obesity, immunocompromised, pre-op LOS,
  micro-flora, other infection
• SSI prevention measure action(s) to reduce SSI
  risk, antibiotic prophylaxis, skin
  prep/antisepsis
• Operation patient peri-op personnel, duration,
  ATB re-dosing, surgical asepsis, traffic flow,
  surgical technique (robotic), hair removal,
  immediate use sterilization, glove/instrument
  change
• Environmental cleaning, disinfectant contact
  time, UV light, OR environment-HVAC
• Risk of SSI after receipt of blood products 3.5

5
Principles for Prevention of SSI

• Minimize access of bacteria to the surgical site
• Measures to neutralize that do gain access to
  site
• Reduce that which is conducive to infection
• Enhance the host defenses - look at risk factors
• Follow established guidelines

6
Pathogenesis of Surgical Site Infection (SSI)

• Dose x virulence
• Resistance of Host
• risk of SSI
• gt 105 / gm tissue ?risk with foreign body only
  100/gm is needed to cause SSI
• Pathogens
• Endogenous flora normally contained
• Exogenous healthcare personnel, environment,
  devices/materials used

7
Key Concepts on Source of SSI Pathogen OR
personnel or patient?

• Every surgical site has bacteria by the end of
  the procedure!
• Four Clinical variables determine infection
• Inoculum of bacteria
• Virulence of bacteria
• Microenvironment
• Host defenses
• Endogenous flora normally contained

8
Distribution of Pathogens Causing SSIs
Mangram AJ. AJIC 19992797-134
9
Risk Classification for SSI

• CLASS III/CONTAMINATED WOUNDS--open, fresh,
  accidental wounds. In addition, surgical
  procedures in which a major break in sterile
  technique occurs (eg, open cardiac massage) or
  there is gross spillage from the gastrointestinal
  tract and incisions in which acute, nonpurulent
  inflammation is encountered are included in this
  category.
• Class IV/Dirty-Infected
• Old traumatic wounds with retained devitalized
  tissue and those that involve existing clinical
  infection or perforatedviscera. This definition
  suggests that the organisms causing postoperative
  infection were present in the operative field
  before the operation.

• CLASS I/CLEAN WOUNDS--an uninfected surgical
  wound in which no inflammation is encountered and
  the respiratory, alimentary, genital, or
  uninfected urinary tracts are not entered.
• CLASS II/CLEAN-CONTAMINATED WOUNDS--a surgical
  wound in which the respiratory, alimentary,
  genital, or urinary tracts are entered under
  controlled conditions and without unusual
  contamination.

http//www.cdc.gov/hicpac/SSI/table7-8-9-10-SSI.ht
ml
10
Smoking Surgery Bad combination

• Randomized, controlled trial 48 smokers(S) vs 30
  never smoked (NS)
• 228 wounds evaluated
• SSI rate 12 S vs 2 in NS
• SSI rate significantly less for S if abstain for
  4wks (27 vs.1.1)
• Wound rupture 12 S vs. 0 NS
• Smokers nearly 40 more likely to die
• (within
  30 days)
• When to stop 30 days?
• 2-6months? at least 1 yr?

http//health.clevelandclinic.org/2013/08/facing-s
urgery-kick-cigarettes-now
11
Preoperative Patient Shower with Antimicrobial
Soap

• Bacterial counts on skin are 9-fold lower after
  shower - chlorhexidine
• CDC SSI Guidelines Require patients to bathe
  with antiseptic on at least the night before
  their operation
• CHG cloth use night before day of surgery

12
Intranasal De-colonization Prevention of SSI

• Orthopedic cardiothoracic patients -
  significant reduction in SSI among treated1-3
• However these were retrospective used
  historical controls
• Another randomized trial in ortho.surg found less
  S. aureus nasal carriage but no signif. Reduction
  in SSI rate4

Mupirocin decolonization of nasal Staphylococcus
aureus prior to surgery decreases surgical site
infections, however, treatment requires 5 days,
compliance is low and resistance occurs.
13
Preventing Surgical Site Infection System-level
success Usry GH, et al. AJIC 200230434-6.
Intervention Intranasal mupirocin 48 hrs prior
to through 5 days post op Results 94 of
patients Rx Rate of SSI dropped by 53
overall 55 for deep sternal
Rate Per 100 CABGs
14
New Study (2015) Povidone-Iodine Solution 5

• Assurance - Reduces bacterial counts in the
  nares, including S. aureus by 99.5, so you know
  you're helping address another variable in the
  fight against surgical site infectionsControl -
  Works within one hour
• One at a time, the foam-tipped applicators are
  saturated with the appropriate solution using a
  vigorous stirring motion for at least 10 seconds.
  The subjects nostrils are prepped for 30 seconds
  each using separate applicators. This process was
  then repeated using two additional applicators
  for a total application time of 1 minute per nare
  (2 minutes total).

15
Surgical Care Improvement Project (SCIP)

• Antibiotic Timing - lt60min
• Antibiotic Selection type/body location
• of procedure
• - dosing for body wt.
• - duration of procedure
• - PCN allergy?
• - cost of antibiotic

• 2006
• http//www.medscape.org/viewarticle/531895_2
• Ancef
• Vancomycin or Clindamycin

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Surgical Care Improvement Project (SCIP)
within 24 hours surgery end time Stop ATB 24
Hours of OR end time 48 for Cardiac
Surgery Blood sugar lt200 POD 1 2 S Controlled
_at_ lt 200 by 6STTTTTTGKLBLK a.m. POD 1 2
Appropriate Hair removal no razors DVT
Prophylaxis Beta-blocker given before OR and
after unless contraindicated ICD (Int.
Compression Device), TEDs, Heparin, Warfarin
Foley cath remove by POD 2 or physician note
why not
17
Centers for Medicare Medicaid Services (CMS)
Actions

• Payment reforms for inpatient hospital services
  in 2008
• ensure that Medicare no longer pays for the
  additional costs of certain preventable
  conditions (including certain infections)
  acquired in the hospital
• Serious preventable events Object left in
  during surgery air embolism Delivering
  ABO-incompatible blood or blood products
• 2) catheter-associated urinary tract infections
• 3) pressure ulcers
• 4) Vascular catheter associated infection
• 5) Mediastinitis after CABG surgery
• 6) Patient falls
• 7) VAE
• 8) Influenza vaccination rates
• 9) Future MRSA, S. aureus BSI, CDAD (C. diff)

18
Impact of SSI Occurring After Discharge

• Many/Most SSI not identified until after
  discharge
• Cost for care with SSI were 2.9 times greater
• 19.5 of readmits 18 of ER visit some at
  other facilities
• Post discharge SSIs can impair physical mental
  health
• Surveillance (PDS) is inconsistent phone/paper
  honest
• Education - ? enough/consistent/updated
• Host defense acute and chronic medical
  conditions
• Effective management to minimize consequences
• http//www.hfma.org/Content.aspx?id28199 Feb 2015

19
.
Stitch/ Stitch/ Superficial Deep
Pt. DOB Surg Class Room Procedure Description Staple Staple Incisional Incisional
J 5/22/63 3/7 1 OR 12 DECOMPRESSIVE LAMINECTOMY L4-5, L5-S1, NEURO FORAMOTOMY L4-5, L5-S1        
J 4/8/54 3/7 1 OR 12 KNEE ARTHROSCOPY LEFT        
J 7/29/59 3/30 1 OR 12 KNEE ARTHROSCOPY RIGHT, PARTIAL MENISCECTOMY,        
J 6/20/62 3/14 1 OR 12 KNEE ARTHROSCOPY LEFT, PARTIAL MENISECTOMY, PARTIAL CHONDROPLASTY        
J 11/19/68 3/21 1 OR 12 KNEE ARTHROSCOPY RIGHT, PARTIAL CHONDROPLASTY, RELEASE PLICA        
J 1/28/32 3/28 1 OR 12 KNEE TOTAL ARTHROPLASTY LEFT        
J 8/31/91 3/28 1 OR 12 left KNEE ARTHROSCOPY with fixation of osteochondyle fx, debridement of        
J 8/18/40 3/21 1 OR 12 LEFT TOTAL HIP REPLACEMENT        
J 9/10/30 3/11 1 OR 10 OPEN REDUCTION, PINNING RIGHT FEMORAL NECK        
J 1/29/05 3/15 1 OR 8 REALINEMENT WITH PINNING AND CASTING LEFT ELBOW        
J 9/16/60 3/14 1 OR 12 RELEASE OF ACHILLES TENDON RIGHT        
J 2/24/32 3/7 1 OR 12 REMOVAL OF FOREIGN BODY RIGHT THIGH ANTIBIOTIC BEADS        
J 5/14/59 3/30 1 OR 12 REVISION LEFT TOTAL KNEE ARTHROPLASTY, EXTENSIVE SYNOVECTOMY        
J 11/1/44 3/28 1 OR 12 REVISION, POLY LEFT KNEE, DEBRIDMENT, LATERAL RELEASE        
J 1/13/25 3/21 1 OR 12 RIGHT KNEE ARTHROSCOPY, CHONDROPLASTY, PARTIAL MENISCECTOMY        
J 12/1/38 3/28 1 OR 12 RIGHT OPEN QUADRICEPS REPAIR WITH AFLEX GRAFT        
       
Stitch/staple Stitch/staple   minimal inflammation and discharge confined to the points of suture penetration minimal inflammation and discharge confined to the points of suture penetration        
   
Superficial Incisional Superficial Incisional Superficial Incisional Purlent drainage from the superficial incision or pain or tenderness, localized swelling, redness, or Purlent drainage from the superficial incision or pain or tenderness, localized swelling, redness, or Purlent drainage from the superficial incision or pain or tenderness, localized swelling, redness, or Purlent drainage from the superficial incision or pain or tenderness, localized swelling, redness, or Purlent drainage from the superficial incision or pain or tenderness, localized swelling, redness, or  
heat, and superficial incision is deliberately opened by surgeon, and is culture-positive or not cultured heat, and superficial incision is deliberately opened by surgeon, and is culture-positive or not cultured heat, and superficial incision is deliberately opened by surgeon, and is culture-positive or not cultured heat, and superficial incision is deliberately opened by surgeon, and is culture-positive or not cultured heat, and superficial incision is deliberately opened by surgeon, and is culture-positive or not cultured  
If from secondary incison (e.g., donor site leg incision for CABG), please note Y- SIS If from secondary incison (e.g., donor site leg incision for CABG), please note Y- SIS        
 
Deep incisional Deep incisional Deep incisional a. purulent drainage from the deep incision but not from the organ/space a. purulent drainage from the deep incision but not from the organ/space        
b. incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured b. incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured b. incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured b. incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured b. incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured b. incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured
a. purulent drainage from the deep incision but not from the organ/space a. purulent drainage from the deep incision but not from the organ/space        
during reoperation, or by histopathologic or radiologic examination during reoperation, or by histopathologic or radiologic examination        

• ICD 9 CM codes

20
The Challenge of Surveillance of SSIs expanding
universe of health care delivery

• Major trend towards delivery in wide range of
  settings
• Short lengths of stay inter-facility transfer
  is common
• NEW PACE (Program of All-inclusive Care for the
  Elderly) Home care for 55yr who met Medicaids
  LTC eligibility with 24 hr call line, respite
  care
• http//www.michigan.gov/mdch/0,4612,7-132-2945_425
  42_42543_42549-87437--,00.html

Networking!
21
Ambulatory Surgery Risk Free?
Cluster of Endoph-thalmitis after cataract
surg. Acremonium kiliense 4 patients Risk Factor
1st case, Mondays Humidified air in ventilation
likely source Fridkin SK. Clin Infect Dis
1996 Steroid Injection Outbreak

• Cluster of fungal contamination of saline breast
  implant
• Saline bottle stored under water-damaged ceiling
  
• OR in negative pressure
• Kainer MA. 40th IDSA (abstr)

22
CMS for Ambulatory Care

• 42 CFR Part 416 Medicare and Medicaid Programs
  Ambulatory Surgical Centers (ASC), Conditions for
  Coverage
• require the ASC to designate a qualified
  professional, such as a registered nurse, as the
  infection control officer
• The infection control condition places
  accountability on ASCs to prevent, control, and
• investigate infections and communicable diseases,
  and take action that result in improvements

23
Waterless Alcohol-based Hand Rub for Surgical
Hand Antisepsis

• Randomized trial, 4387 pts.
• Hand rub vs scrub with antimicrobial soap water
• SSI rate in hand rub (2.4) vs scrub (2.5) not
  signif.
• Better compliance, less skin irritation/dryness
  with hand rub in personnel

Parienti JJ. JAMA 2002 288722-77
WHO
24
Possible SSI Prevention Measures

• Subcuticular suturing vs skin stapling technique,
  CABG - 2 studies no consistent results (Mullen
  JC. Can J Cardiol 19991565- Chughtai T. Can J
  Cardiol 2000161403-)
• Quill Suturing? expensive
• Anemia leukocyte-depleted red blood cell
  transfusion - studies have had mixed results
  more study needed(Jensen LS. Transfusion
  199535719- Titlestad IL. Int J Colorectal Dis
  200116147-van de Watering LM. Circulation
  199897562-)
• Laminar Airflow Orthopedic Surgery - Mixed
  results difficult to demonstrate clear cost
  effectiveness (Berbari EF. Clin Infect Dis
  1998271247-)
• UV light vs Xenon gas

25
Possible SSI Prevention Measures

• Supplemental perioperative oxygen- randomized
  trial found lower SSI with 80 O2 among 500
  colorectal surgery pts.however-high SSI rate
  risk index in control population - Need
  confirmation (Grief R. N Engl J Med
  2000342161-7)
• Periop. normothermia - randomized trial of 200
  patients, colorectal surgery pts. lower SSI
  rate with additional warming(forced air IV
  fluids) vs those with regular care more
  investigation needed for wider application (Kurz
  A. N Engl J Med 19963341209-15)
• Changing Gloves/equipment - before
  closure(spillage)
• Invanz/Ertapenem new studies suggesting not as
  effective
• More patients who received ertapenem developed
  Clostridium difficile infection
• http//dicon.medicine.duke.edu/sites/dicon.medicin
  e.duke.edu/files/documents/October20201320DICON
  20newsletter--Avoiding20Ertapenem.pdf

26
Category IA SSI Prevention Recommendations

• Patient-focus
• treat existing infections first before OR
• avoid hair removal but if needed use clippers
• Asepsis technique
• aseptic principles IV, inserting catheters,
  administering medications

AJIC 19992797-132
27
Category IB SSI Prevention Recommendations

• Patient-focus
• control serum blood glucose
• encourage tobacco cessation
• preop shower
• clean skin incision site apply antiseptics
• Surgical Team
• no artificial nails
• surgical hand antisepsis

AJIC 19992797-132
28
Category IB SSI Prevention Recommendations

• Intraoperative
• Positive pressure in OR
• Min. 15 air changes/hour
• Filter supply air
• Keep OR doors closed as much as possible
• sterilize surgical instruments limit flash
  sterilization
• Surgical Team
• surgical mask, hair cover
• gown sterile gloves
• Gentle handling of tissue

AJIC 19992797-132
29
Category IB SSI Prevention Recommendations

• Surveillance
• Use CDC definitions
• Apply risk index
• Periodically calculate risk stratified SSI rates
• Report SSI rates to surgical personnel
• Use standard case finding methods

AJIC 19992797-132
30
Surgical Site Infection Criteria

• Superficial incisional SSI
• Infection occurs within 30 days after any NHSN
  operative procedure and
• involves only skin and subcutaneous tissue of the
  incision and
• patient has at least one of the following
• a. purulent drainage from the superficial
  incision.
• b. organisms isolated from an aseptically-obtained
  culture of fluid or tissue from the superficial
  incision.
• c. superficial incision that is deliberately
  opened by a surgeon and is culture-positive or
  not cultured
• and patient has at least one of the following
  signs or symptoms pain or tenderness localized
  swelling
• redness or heat. A culture negative finding
  does not meet this criterion.
• d. diagnosis of a superficial incisional SSI by
  the surgeon or attending
• physician or other designee (see reporting
  instructions).

31
Two specific types of superficial
incisional SSIs

• Superficial Incisional Primary (SIP)
• superficial incisional SSI that is
  identified in the primary incision in a patient
• that has had an operation with one or more
  incisions
• (e.g., C-section incision or chest incision
  for CABG)
• Superficial Incisional Secondary (SIS)
• superficial incisional SSI that is
  identified in the secondary incision in a
• patient that has had an operation with more
  than one incision
• (e.g., donor site incision for CBGB)
• Do not report a stitch abscess, stab wound or pin
  site infection as SSI
• Diagnosis of cellulitis, by itself, does not
  meet criterion for superficial incisional SSI.

32
Deep incisional SSI

• Infection occurs within 30 (most) or 90 days
  (implant) after the NHSN operative
• procedure and involves deep soft tissues of
  the incision (e.g., fascial and muscle
• layers) and patient has at least one of the
  following
• a. purulent drainage from the deep incision.
• b. a deep incision that spontaneously dehisces or
  is deliberately opened by a surgeon
• and is culture-positive or not cultured
  and patient has at least one of the following
• S/S
• -fever (gt38C) localized pain
  or tenderness.
• c. an abscess or other evidence of infection
  involving the deep incision
• d. diagnosis of a deep incisional SSI by a
  surgeon or attending physician
• or other designee

33
Organ/Space SSI

• Infection occurs within 30 or 90 days after the
  NHSN operative procedure and
• infection involves any part of the body,
  excluding the skin incision, fascia, or muscle
  layers, that is opened or manipulated during the
  operative procedure and
• patient has at least one of the following
• a. purulent drainage from a drain that is placed
  into the organ/space
• b. organisms isolated from an aseptically-obtained
  culture of
• fluid or tissue in the organ/space
• c. an abscess or other evidence of infection
  involving the
• organ/space

34
Special Comments

• Occasionally an organ/space infection drains
  through the incision and is considered a
  complication of the incision. Therefore, classify
  it as a deep incisional SSI.
• Report mediastinitis following cardiac surgery
  that is accompanied
• byosteomyelitis as SSI-MED rather than
  SSI-BONE.
• If meningitis (MEN) and a brain abscess (IC)
  are present together
• after operation, report as SSI-IC.
• Report CSF shunt infection as SSI-MEN if it
  occurs within 90 days
• of placement if later or after
  manipulation/access, it is
• considered CNS-MEN
• Report spinal abscess with meningitis as SSI-MEN
  following spinal
• surgery.

35
Environmental Infection Control Guidelines, 2003

• HVAC
• Positive pressure ventilation
• Filtration
• Environmental Cleaning
• Preventing water-associated illness
• Preventive maintenance

MMWR 200352RR-10
36
A Surgeons Perspective on Prevention of SSI

• The most critical factors in the prevention of
  postoperative infections, although difficult to
  quantify, are the sound judgment and proper
  technique of the surgeon and surgical team, as
  well as the general health and disease state of
  the patient
• -Nichols RL. Emerg Infect Dis
  20017(No.2)220-4.

37
How to Display SSI data

• Target state in IP Plan
• Just ? what if 1 of 2 procedures develop SSI?
• Denominator numerator?
• Graphs
• Previous year 2 years?
• Scorecards
• Compare with NNIS vs Standard Infection Ratio
  (SIR)
• Special Investigations
• High volume surgery
• Surgeon specific?
• Tell them/show them what they need to see

38
Sample of displaying SSIs
2013 2014
Surgery Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
Total hip     1             1 1   3 1       1       1       3
done 10 12 7 12 11 10 17 19 8 13 10 12 141 11 9 9 10 8 8 5 16 14 19 7 8 124
SSI rate/month 14.3 7.7 10.0 2.1 9.1 12.5 7.1 2.42

Total knee     2               1   3     1   1 1 1   1       5
done 20 12 16 16 18 18 21 15 19 20 21 14 210 24 20 17 19 16 23 20 20 12 22 20 19 232
SSI rate/month 12.5 4.8 1.4 5.9 6.3 4.3 5.0 8.3 2.16

Vascular 1         1             2         1               1
done 4 4 8 4 1 3 4 2 0 3 2 3 38 4 5 4 2 2 6 0 2 1 4 3 4 37
SSI rate/month 25.0 33.3 5.3 50.0 2.7
39
Post discharge Data Surveillance
Patient Name DOB Surgery Class Room
Procedure Description Name of hospital __________
_______ Education New surgeons/Annually
(definitions) Skin/staple related? dont count
Incisional skin or sub-Q , drainage,
dehisence, ID Any cultures? Readmit? Within 30
days vs NEW 2013 90 days (implants)
40
SSI Surveillance Prevention Intervention

• Feedback surgeon/surgical personnel or committee
  (s)
• Result Overall SSI rate/SIR for given (targeted)
  surgeries
• Action Plan Quality Improvement education,
  equipment, timing, etc.

41
Summary Aspects of Surveillance Program for
Prevention of SSIs

• SSIs cause considerable morbidity and mortality
  and are expensive complications to treat -
  prevention therefore is cost effective
• Surveillance Interventional Epidemiology is an
  effective component of a facilitys patient
  safety/performance improvement program
• Feedback of process outcome data is helpful but
  broad partnership involving multiple disciplines
  is likely key to success

42
Skin Soft Tissue Infections

• Changing Pattern of Community- Associated Skin
  and Soft-Tissue Infection with methicillin-Resista
  nt Staphylococcus aureus (CA-MRSA)
• Almost three quarters of the soft-tissue
  infections were caused by CA-MRSA (N389
  patients)
• King MD, et al. Ann Intern Med 2006 144309-317.

43
Example of Surgeon-Specific data
44
Conclusions

• SSIs will always be with us
• MDROs will challenge us
• New techniques and technology will evolve
• Government agencies will change how we measure
  quality performance (NHSN)
• Reimbursement can effect our process, advancing
  to new equipment or products, how we stay in
  business

45
Sterile Processing

• From Acquisition to Reuse

46
Sterilization of Equipment

• Certified technicians
• Cleaning ultrasonic (5 to 10 min) open
  instruments DRY/inspect
• Wrapping trays

47
Sterilization

• - Steam 121oC (250oF) and 132oC (270oF).
  Manufacturers recommendation.
• Bowie-Dick test is used to detect air leaks
  and inadequate air removal
• Biological monitor Geobacillus
  stearothermophilus (formerly Bacillus
  stearothermophilus)
• Monitored using a printout (or graphically)
  by measuring
• temperature, the time at the temperature,
  and pressure
• - Sterrad
• -Portable (table-top) steam sterilizers
• - Immediate use
• www.roboz.com/catalog20pdfs/Sterilization_and_Mai
  ntenance.pdf quick chart
• www.cdc.gov/hicpac/Disinfection_Sterilization/13_0
  Sterilization.html

48
Correct loading /unloading

• Sufficient space must occur around the packages
• place items on edge and no chamber wall touching
• do not stack packages or cassettes one upon the
  other
• paper of one pouch next to the plastic of the
  adjacent pouch
• Basins, bowls or other devices on their sides
• running a load with both linens and medical
  instruments, place the linen packs on the top
  shelf
• heavy medical items or large trays flat on the
  bottom shelves
• Some steam sterilizers have an automatic dry
  cycle
• opening the door about ½ inch after the pressure
  equalizes and let items sit inside the chamber
  for 30 to 60 minutes
• Wet packages that exist at the end of
  steam-sterilization cycles should not be handled

49
Steam Sterilizer recall

• Recalls due mechanical, chemical and biological
• -Who you going to call?
• Retrieval of processed items
• Notify your sterilizer service representative
• Re-validated with three consecutive negative
  biological monitors in three consecutive cycles
• AAMI recommends that sterilizers be biologically
  monitored at least once a week, preferably daily,
  when normal cycles are used, in each flash
  sterilization load and in any load containing an
  implantable device.
• http//www.spdceus.com/recalls.htm for online
  info quiz