CRCST Self-Study Lesson Plan

Lesson No. CRCST 136 (Technical Continuing Education - TCE) by Susan Klacik, ACE, BS, CIS, CRCST, FCS
CSS Manager, St. Elizabeth Health Center,
Sponsored by: Youngstown, OH

THE FLASH DANCE IS OVER!

IUSS IS OUR NEW PARTNER
T
LEARNING OBJECTIVES HE BEGINNING OF THE END OF THE “FLASH DANCE,” WHICH
1. Define “flash sterilization” and moved our profession from flash sterilization to immediate-use steam ster-
explain why it was replaced with the ilization (IUSS), resulted from a 2010 meeting of numerous healthcare orga-
term “immediate-use steam nization and regulatory and accreditation agency personnel. Organizations
sterilization” (IUSS) represented included the International Association of Healthcare Central Service Mate-
2. Describe IUSS and discuss its riel Management (IAHCSMM); the Association of periOperative Registered Nurses
proper use (AORN); the Association for Professionals in Infection Control and Epidemiology Inc.
3. Review steam sterilization methods for (APIC); The Joint Commission (TJC); the Centers for Medicare and Medicaid Services
IUSS processing (CMS); the Centers for Disease Control and Prevention (CDC); the Accreditation
4. Explain that IUSS training and Association for Ambulatory Health Care (AAAHC); the American Dental Association
education is critical (ADA); and the U.S. Food and Drug Administration (FDA).
5. Identify inappropriate medical devices Concerns were voiced about poor flash sterilization practices used by some facilities,
for IUSS processing and the need for process improvements to sterilize medical devices in surgery and
6. Explain the basics for an immediate- other areas requiring quick instrument turnaround. Originally, flash sterilization was
use steam sterilization policy designed for single instrumentation that may have become contaminated during the
surgical procedure; however, the process had evolved to become an all too common
“remedy” for challenges, such as inadequate instrument inventories, untimely receipt of
loaner instrumentation, and so on.

OBJECTIVE 1: DEFINE “FLASH process of sterilizing an item that is not

STERILIZATION” AND EXPLAIN WHY packaged.”1 Its replacement was necessary
IT WAS REPLACED WITH “IMMEDI- because, in many instances, the process
ATE-USE STERILIZATION” (IUSS) was uncontrolled and critical steps were
Flash sterilization was defined as “the not correctly performed. For example,
process by which unwrapped instru- cleaning was inadequate, and sterilization
ments are sterilized for immediate use was based on a gravity cycle with a 3- or
when an emergency situation arises; the 10-minute exposure, based on whether

This series of self-study lessons on CS topics was de- Mail: For written grading of individual lessons, send the IAHCSMM provides online grading service for any of
veloped by the International Association of Healthcare completed 20-question quiz and $15 to: PEC Business the Lesson Plan varieties. Purdue University provides
Central Service Materiel Management (IAHCSMM). Office, Purdue University, Stewart Center Room 110, grading services solely for CRCST and CIS lesson plans.
Purdue University’s Extended Campus and IAHCSMM 128 Memorial Mall, West Lafayette, IN 47907-2034.
both offer grading opportunities. Each 20 question quiz with a passing score of 70% or For More Information:
higher is worth two points (2 contact hours) toward your Direct any questions about online grading to IAHCSMM
Earn Continuing Education Credits CRCST re-certification of 12 CE. at 312.440.0078, and questions about written grading
Online: You can use these lessons as an in-service with to Purdue University at 800.830.0269. To print any
your staff, or visit www.iahcsmm.org for online grading Subscription Series: From January 1 to June 30 each current valid lesson for grading or review, visit
at a nominal fee. Each 20 question online quiz with a year, Purdue Extended Campus offers an annual mail-in www.distance.purdue.edu/training/cssp/lessons/.
passing score of 70% or higher is worth two points or online self-study lesson subscription for $75 (six
(2 contact hours) toward your CRCST re-certification specific lessons worth 2 points each toward your CRCST
of 12 CEs. re-certification of 12 CE). Call 800.830.0269 for details.
 CRCST Self-Study Lesson Plan

the item being sterilized was porous or (IFU), and by adherence to best practices. and distilled). Drying requires the use of
non-porous. Devices were sometimes Instrumentation must be disassembled, lint-free cloths or medical-grade air.
placed in open baskets for sterilization thoroughly cleaned, processed through After decontamination, devices are
and, when the cycle was completed, they the automated washing process (if moved to the preparation and packaging
were removed and transported to the permitted), and inspected. Personnel per- area. It’s here where they are inspected
point of use unprotected, which contami- forming this task must wear the appropri- for cleanliness and functionality, and
nated the contents. ate personal protective equipment (PPE). prepared for sterilization following best
Note: required PPE for decontaminating practices and the manufacturer’s IFU.
OBJECTIVE 2: DESCRIBE IUSS AND medical devices are general-purpose utility The purpose of packaging is to ensure
DISCUSS ITS PROPER USE gloves and a liquid-resistant covering gown that sterilization occurs and then to
A position paper2 addressing the correct with sleeves (example: a backless gown, maintain item sterility as it is transported
method to reprocess instrumentation be- jumpsuit, or surgical gown), liquid-resis- to the point of use and presented to the
tween cases was endorsed by IAHCSMM, tant shoe covers, fluid-resistant facemask, sterile field. Instruments are packaged for
AORN, APIC, AAAHC, and the ASC and eye protection. IUSS sterilization with a Class 5 chem-
Quality Collaboration (ASCQC). Note: Central Service (CS) personnel have ical indicator in the package. Note: the
the ASCQC brings together leaders from the expertise to correctly and consistently packaging process should provide an easy
the ambulatory surgery center industry perform instrument cleaning tasks. When method to identify that the containerized
and organizations that focus on healthcare surgical personnel performed cleaning set is intended for IUSS, so the set will not
quality and safety. tasks for flash sterilization, their time was be used for a later surgery case.
The position paper is applicable to all inefficiently used, and instrumentation Sterilization will occur near the point
healthcare facilities that perform steriliza- was not processed in a dedicated decon- of use in an IUSS process, typically in the
tion (not just hospitals) in the same way tamination room. Instead, it was hastily surgical department. Since the imple-
that ANSI/AAMI ST79 is directed to all cleaned in a surgical area, often without mentation of IUSS, most sterilization
healthcare facilities, including hospitals, the appropriate cleaning implements, container manufacturers have performed
nursing homes, extended-care facilities, PPE, water quality, decontamination validation testing on their containers
free-standing surgical centers, clinics, and equipment, and expertise. to enable their use in the IUSS process;
medical and dental offices.2 Instrument cleaning is an extremely however, some require new types of
The importance of following the IUSS important step in instrument steriliza- container filters. Before using steriliza-
position paper is demonstrated by the tion, and there can be no shortcuts or tion containers for IUSS, the IFU must be
fact that surveying organization person- missed steps. Thorough cleaning requires carefully reviewed to ensure that they can
nel, including those representing TJC, the use of an ultrasonic washer, medical be used for this purpose and will indicate
have been trained on IUSS techniques grade air, and detergents designed for the proper sterilization cycle. Note: one
and may review logs to assess whether cleaning medical devices. As well, there benefit to using sterilization containers
the process is appropriately used. For are specific water quality requirements, is that instrumentation can be complete-
example, IUSS sterilization logs can be and the correct size and type of brushes, ly prepared in CS. The instrument set is
reviewed to determine if the same instru- among other cleaning tools and supplies, thoroughly cleaned, inspected, assembled,
ment or set is frequently undergoing IUSS are also essential. and packaged, just as is done for sets
due to inadequate instrument inventories. All critical steps must be performed. undergoing terminal sterilization, and the
IUSS is also addressed in TJC’s National For example, the correct type of detergent container provides aseptic transportation
Patient Safety Goal NPSG 07.05.01: must be used with the correct cleaning and presentation.
Implement evidence-based practices for solution preparation, and lumened devic- After use, the instruments and contain-
preventing surgical site infec- tions.3 This es must be properly brushed and flushed. er should be returned to CS for cleaning.
is an important goal because a risk For thorough cleaning, instruments must Cleaning instrument containers before
assessment to determine the reason(s) for be disassembled, and instruments requir- each use is recommended by AAMI ST
IUSS may show ways to reduce it. ing ultrasonic cleaning must be processed 79.2 Therefore, sterilization containers
All instrumentation must be thor- with this equipment. Also, the final for IUSS must also be cleaned in the CS
oughly cleaned according to applicable rinse should be done with treated water department in-between uses.
manufacturer’s Instructions for Use (examples: deionized, reverse osmosis,
 CRCST SELF-STUDY LESSON PLAN

OBJECTIVE 3: REVIEW STEAM s .AMEOFPERSONINITIATINGTHESTERILIZA tion-related topics. Candidates must also

STERILIZATION METHODS FOR tion cycle and unloading the sterilizer. successfully demonstrate skills through
IUSS PROCESSING s 4HEREASONFOR)533 completion of hands-on work experience,
The use of several critical steps is and those holding the CRCST designa-
required to produce a product that is OBJECTIVE 4: EXPLAIN THAT IUSS tion must recertify annually by complet-
sterile and safe for patient care. First, the TRAINING AND EDUCATION IS ing continuing education requirements
sterilization cycle used in the IUSS pro- CRITICAL In addition, Certified Instrument
cess must be based on the medical device Training and education is vital to ensure Specialist (CIS) technicians ensure that
manufacturer’s IFU, just as when steriliza- effective IUSS. Personnel performing all instruments, including those used for
tion is done in the CS department. the reprocessing must be knowledgeable IUSS, are thoroughly cleaned and prop-
With IUSS processing, the manufactur- about all details and be able to demon- erly packaged and sterile. They also learn
er’s IFU will dictate the cycle to be used. strate competencies, including: how to examine equipment for defects
For example, the IFU for most medical s $ECONTAMINATIONOFINSTRUMENTATION and report problems, test autoclaves and
devices requires a dynamic air removal to prepare it for sterilization record the results, order supplies, assem-
cycle, and instruments requiring extend- s 3TEAMSTERILIZATIONBESTPRACTICES ble instrument trays, distribute supplies,
ed sterilization cycles in CS departments s /BTAININGANDCOMPLYINGWITHTHE and ensure that sterile supplies are within
also need these cycles with IUSS. Since manufacturers’ IFU their expiration date.
there will be little to no dry time with s 0ACKAGINGITEMSFOR)533
IUSS processing, the items may be hot s 3ELECTINGCORRECTQUALITYMONITORS OBJECTIVE 5: IDENTIFY INAPPRO-
and wet after sterilization, and caution is s $ECONTAMINATINGRIGIDSTERILIZATION PRIATE MEDICAL DEVICES FOR
required. Also, since the package contains containers, if used IUSS PROCESSING
moisture, it cannot be stored or used for a s 4RANSPORTINGSTERILIZEDITEMSFROMTHE Disposable items and instrumentation
later surgical case, and must be returned sterilizer to the point of use used on Creutzfeldt-Jakob disease (CJD)
to CS for reprocessing. cases are not recommended for IUSS.
Upon completion of the sterilization Certification is a demonstration of Further, non-emergency implants should
cycle, the sterilization parameters must be competency. Continuing education on not be subjected to IUSS when any other
reviewed to ensure they were met. Also, medical device processing further assures option is available.
the sterilizer printout must be signed that the required competencies are met. AAMI ST79 addresses IUSS for
to indicate that the parameters were re- In addition, processing personnel must implants in section 10.3: IUSS of im-
viewed and attained. All healthcare steam possess critical thinking skills. IAHCSMM plantable devices is not recommended;
sterilizers must be tested weekly (prefer- provides a comprehensive training however, if it is unavoidable, full trace-
ably daily, as is done in most hospitals) program for all aspects of medical device ability to the patient should be main-
with a biological spore of Geobacillus processing. The Certified Registered tained. Sterilizing implants increases the
stearothermophilus in a process challenge Central Service Technician (CRCST) risk of a surgical site infection because
device (“test pack”). The processing cycle training program prepares personnel to they are considered a foreign body. When
used is the one to be tested. If a facility effectively reprocess medical instrumen- sterilizing implants, a biological monitor
uses gravity and dynamic air removal tation, and CRCST certification demon- and Class 5 chemical indicator must be
cycles, both must be tested. Test results strates the required competencies. CRCST included. To ensure it is safe, the implant
must be recorded and the records should personnel are integral members of the should not used until the final result
be retained. healthcare team that is responsible for is available showing negative growth.
As with all sterilization processes, decontaminating, inspecting, assembling, Should an implant be used and the
record-keeping is required, and the follow- disassembling, packaging, and sterilizing biological monitor show positive growth,
ing information should be maintained: reusable surgical instruments or devices the surgeon and the facility’s infection
s 4HEITEMS PROCESSEDANDDATEAND in a healthcare facility. IAHCSMM offers prevention committee must be contacted
time of processing a course that prepares candidates for the immediately.
s 0ATIENTSNAME CRCST certification exam. This course is Record-keeping for implants should
s 4YPEOFCYCLEUSED designed to measure the understanding include the patient’s and surgeon’s name,
s -ONITORINGRESULTS of general CS- and infection preven- date, and the reason IUSS was required.
 CRCST Self-Study Lesson Plan

Reviewing and analyzing this information s $ECONTAMINATION IAHCSMM acknowledges the assistance of the
can identify patterns to help prevent fur- s 0REPARATION following two CSSD professionals who reviewed
ther occurrences. For example, records s 0ACKAGINGSELECTIONANDUSE this quiz:
may show a pattern of IUSS on a specific s 3ELECTIONOFSTERILITYMONITOR LISA HUBER, BA, CRCST, ACE, FCS; Sterile
day, identify instrument shortages, reveal s 3ELECTIONOFSTERILIZATIONCYCLE Processing Manager, Anderson Hospital,
the overscheduling of cases that are not s 4RANSPORTTOPOINTOFUSE Maryville, IL
supported with current instrumentation, s $OCUMENTATION
and identify late-to-arrive loaner sets. s 'UIDELINESFOREMERGENCYIMPLANT PAULA VANDIVER, CRCST, CIS, CS Technician;
If late-arriving loaners create the need sterilization using IUSS Orthopedic Specialist, Anderson Hospital,
for IUSS, the loaner policy and appli- Maryville, IL
cable procedures must be reviewed and IN CONCLUSION
revised. If the facility does not have a IUSS has replaced flash sterilization,
loaner policy, one must be developed and and all critical instrument cleaning,
implemented. All stakeholders should be inspection, preparation, packaging, and
involved in policy development, including sterilization steps must now be followed.
ADVISORY COMMITTEE FOR
infection prevention, quality, CS, safety IUSS should be minimized and not used
SELF-STUDY LESSONS
committees, administration, and surgery for implants, unless in an emergency sit-
(including the department’s manager). uation. Personnel should be trained and
Policy support must be provided by competent to perform IUSS according SCOTT DAVIS, CMRP, CRCST, CHMMC
administrative personnel and the Supply to the applicable policy and procedures, Materials Manager, Surgical Services
Chain Director. The loaner policy must and record-keeping is needed to yield Las Vegas, NV
be shared with vendor representatives information about its use. SUSAN KLACIK, ACE, CHL,
to ensure that they know about and CRCST, FCS
realize the consequence of not comply- REFERENCES CSS Manager, St. Elizabeth Health
ing with it. Note: IAHCSMM developed 1. International Association of Healthcare Central Center, Youngstown, OH
a position paper and policy template on Service Materiel Management. CSSD Dictionary
PATTI KONCUR, CRCST,
loaner instrumentation.4 It is available on and Reference Guide, 2010. CHMMC, ACE
IAHCSMM’s website (under “News” and 2. Association for the Advancement of Medical Educational Specialist, IAHCSMM
2011 archives). In March 2014, IAHCSMM Instrumentation. ANSI/AAMI ST79: 2010 &
NATALIE LIND, FCS, CRCST, CHL
also released a Loaner Instrument Receipt A1:2010 & A2:2011 & A3:2012 & A4:2013.
Educational Director, IAHCSMM
Document, a template form facilities can Comprehensive Guide to Steam Sterilization
use to better manage and document the and Sterility Assurance in Health Care Facilities. DAVID NARANCE, RN, BSN, CRCST
receipt of loaner instrumentation. This Arlington, VA: Association for the Advancement Reprocessing Manager/Clinician
MedCentral Health System,
is also available in the News section of of Medical Instrumentation, 2010.
Mansfield, OH
IAHCSMM’s website. 3. The Joint Commission Edition, January 1, 2014.
4. International Association of Healthcare Central CAROL PETRO, RN, BSN, CNOR,
OBJECTIVE 6: EXPLAIN THE BASICS Service Materiel Management. Loaner Position CRCST, CIS
OR Educator and Sterile Processing
FOR AN IUSS POLICY Paper and Sample Policy, 2011.
Educator, Indiana University Health
Each facility using IUSS should have an North Hospital, Carmel, IN
applicable policy with a statement of
purpose and procedures that are consis- TECHNICAL EDITOR
CARLA MCDERMOTT, RN, CRCST
tently followed. The procedures should Clinical Nurse III, South Florida Baptist
be clearly stated and must be understood Hospital, Plant City, FL
by all applicable personnel. The policy
should be reviewed by the infection pre- SERIES WRITER/EDITOR
JACK D. NINEMEIER, PH.D.
vention and surgical safety committees, Michigan State University
and should address all critical IUSS steps, East Lansing, MI
including:
 Sponsored by:

CRCST Self-Study Lesson Plan Quiz - Benchmarking

,ESSON.O#2#344ECHNICAL#ONTINUING%DUCATION 4#% s,ESSONEXPIRES-AY

OBJECTIVE 1 7. Instruments should be inspected for OBJECTIVE 4

1. Which is true about flash sterilization? functionality ________ decontamination. 14. Which is a demonstration of competency
a. It is the same as immediate-use steam a. Before in instrument processing?
sterilization b. After a. Number of years of Central Service
b. It prevents problems when loaner experience
instruments arrive later than scheduled 8. Instruments are packaged for IUSS b. Certification
c. It involves sterilizing unpackaged sterilization with a class ________ c. Attendance at vendor presentations
instruments chemical indicator in the package. d. Membership in applicable professional
d. It is acceptable when there are inad a. One associations
equate instrument inventories b. Two
c. Three 15. Which is true about IAHCSMM’s CRCST
2. The original purpose of flash sterilization d. Four certification?
was to sterilize single instrumentation that e. Five a. The certification exam focuses on
may have become contaminated during general Central Service and infection
surgical procedures. 9. Sterilization containers that have passed prevention topics
a. True validation testing can be used in IUSS b. Candidates must demonstrate skills
b. False procedures. with hands-on experience
a. True c. Those with the CRCST designation
OBJECTIVE 2 b. False must recertify annually
3. Which is true about The Joint Commission d. All of the above
and use of IUSS techniques? OBJECTIVE 3
a. The Joint Commission personnel have 10. Sterilization cycles used in the IUSS OBJECTIVE 5
been trained on IUSS techniques process do not need to be based on the 16. Non-emergency implants should not be
b. The Joint Commission personnel may medical device manufacturer’s IFU when subjected to IUSS when any other option
review logs to assess whether the there is not time to do so. is available.
process is appropriately used a. True a. True
c. The Joint Commission has no position b. False b. False
on the use of IUSS techniques
d. A and B above 11. Which is true about IUSS processing? 17. Which are not recommended for IUSS?
e. All the above a. The manufacturer’s IFU dictate the a. Disposable instruments
cycle to be used b. Instrumentation used on CJD cases
4. All instrumentation must be thoroughly b. Instruments needing extending c. Both of the above
cleaned following: sterilization cycles when processed d. Neither of the above
a. Recommendations issued by The Joint in Central Service departments require
Commission them when IUSS is used 18. Which is required when sterilizing
b. Requirements of the Centers for c. Significant dry time is required with implants?
Disease Control & Prevention (CDC) IUSS processing a. A biological monitor
c. Instructions for use (IFU) developed by d. A and B above b. Class 4 monitor
applicable instrument manufacturers e. All the above c. A class 5 monitor
d. The loaner representatives’ verbal d. A and C above
instructions. 12. Instruments that have been sterilized with
the IUSS process cannot be stored or 19. Implants should not be used until the
5. Which was not usually available when used for a later surgical case. final test results indicating negative
previous flash sterilization was done by a. True growth are available.
operating room personnel? b. False a. True
a. Appropriate cleaning implements b. False
b. PPE 13. IUSS record keeping must provide infor-
c. Appropriate water quality mation about all of the following except: OBJECTIVE 6
d. None of the above were available a. Patient’s name 20. Which does not need to be addressed in
b. Reason for IUSS an IUSS policy?
6. Which is/are examples of treated water c. Date of original instrument processing a. The selection of sterilization cycle
required for the final rinse in instrument d. Instrument cycle used b. Transport to point of use
cleaning? c. Guidelines for emergency implant
a. Deionized sterilization with IUSS
b. Reverse osmosis d. All of the above must be included in
c. Tap the policy
d. A and B above
e. All the above

REQUEST FOR ONLINE SCORING (payment and scoring made directly online at www.iahcsmm.org)
REQUEST FOR PAPER/PENCIL SCORING (please print or type information below)
❍ I have enclosed the scoring fee of $15. (please make checks
_______________________________________________________________________________
payable to Purdue University. We regret that no refunds can Name
be given)
❍ Check here if you have a change of address _______________________________________________________________________________
Mailing Address (be sure to include apartment numbers or post office boxes)
❍ Check here if you wish to have your results emailed to you
_______________________________________________________________________________
DETACH QUIZ, FOLD, AND RETURN TO: City State Zip Code
Purdue University
PEC Business Office (_______________________________________________________________________________
)
Stewart Center, Room 110 Daytime telephone IAHCSMM Membership Number
128 Memorial Mall _______________________________________________________________________________
West Lafayette, IN 47907-2034 Email Address
800.830.0269 If your name has changed in the last 12 months, please provide your former name
Purdue University is an equal access/equal opportunity institution