JR Santana, CRCST

Two sterile processing technicians (AI image by Brayden Unger)

The pressure in the sterile processing department (SPD) is constant. They are continually tasked with improving efficiency and reducing turnaround times. When the day runs smoothly, the SPD team, with its daily rhythm of anticipating and overcoming obstacles, makes it all look effortless. But sometimes, even with the best planning, a far greater, unexpected challenge emerges, one that is systemic and threatens patient safety. These unseen threats leave an SPD team navigating a challenge with no easy answers. As an infection preventionist (IP), understanding these hidden struggles is key to becoming their most valuable advocate.

A Critical Connection: The Story of State Hospital

The GI lab at "State Hospital" was ready to revolutionize its workflow with 4 new Automated Endoscope Reprocessors (AERs). These machines were a game-changer, designed to increase throughput from 2 scopes to 8. Months of planning went into ensuring the hospital's water supply could handle the 60 pounds per square inch (psi) required. The SPD team ran successful tests, including running all 4 machines over a weekend to confirm they received adequate water pressure.

However, on a busy Monday morning, everything changed.

Shortly after starting, a "Water inlet low" error flashed on the screens. This critical safety feature immediately aborts a cycle if water flow is insufficient, preventing improper disinfection. "It made no sense," the SPD manager recalled. "We had tested everything, but on a busy Monday morning, the machines wouldn't work." The team, now under immense pressure from the GI lab and facing the real possibility of canceled patient cases, reached out to facilities.

Beyond the Error Code: The IP as a Crucial Advocate

The "Water inlet low" error isn't a simple inconvenience; it's a critical safety alert. AERs are highly sensitive machines with validated cycles. Their ability to achieve high-level disinfection depends on precise and repeatable parameters, including water pressure, temperature, and chemical concentration, all outlined in the manufacturer's instructions for use (IFU). While AERs require between 35 to 87 psi depending on the model, when the water pressure drops below the required psi, the machine cannot guarantee adequate flow. This compromises the entire cleaning and disinfection process, rendering the scope unsafe for patient use. You can’t simply restart the cycle; the scope must be manually reprocessed, costing valuable time and risking patient safety. This technical reality is the foundation of your advocacy.

The answer wasn't a defect in the machines or human error, but a hidden reality in the hospital's plumbing. The successful weekend trials didn't account for a crucial factor: the overall demands on the hospital’s water supply during the week. SPD did not have a dedicated water line, and its supply was subject to the intermittent demands of multiple departments. A temporary decrease in pressure—even from a surge in toilet flushing—could disrupt the delicate flow needed by the AERs and that’s a problem. This event highlighted a critical truth: even the best intentions and most advanced technology can be undermined by invisible infrastructure failures.

When a patient procedure is canceled, a technical issue becomes a crisis. Hospital leadership faces a direct loss of revenue, a damaged reputation, and strained relationships with physicians. As an IP, you understand the urgency, but you also maintain an unwavering commitment to patient safety. You are uniquely positioned to translate SPD's technical challenges into administrative imperatives, ensuring your team is never forced into unsafe, subpar practices. Your role extends beyond adherence; it's about safeguarding both professional integrity and patient outcomes, backed by established guidelines.

Developing a strong relationship with your SPD team encourages them to approach you early when issues occur and ask for your support. As their advocate, you champion their needs and ensure they are not forced into situations that require substandard practices.

The advocacy process involves 3 key steps:

 Ask your SPD team to help you understand the underlying issue and its impact on their processes. Listen carefully and take notes as needed, asking questions to ensure a shared understanding of the problem. Ask detailed questions about recurring issues, workflow bottlenecks, and specific error messages. Document their insights thoroughly.

 Ask what they need to address the problem. This creates a space for them to share their approach and thought process, giving you insight into how best to support them. Clarify what resources (eg, dedicated water line, staff training, new equipment) are needed to address the root cause and ensure a sustainable solution.

 Take what you learn and help create a compelling business case for leadership. Translate their technical needs into terms the C-suite understands revenue loss from canceled cases, the risk of health care-associated infections (HAIs), and reputational damage. By citing specific AAMI, CDC, and other professional guidelines that reinforce the need for validated processes, you provide an evidence-based rationale for your request.

The Solution: A Multi-Departmental Response

The water pressure issue wasn't a quick fix; it required a collaborative, hospital-wide response. The only solution was a complete overhaul, beginning with a joint task force and a deep clean of the main water tank. The initial phase took a whole week to complete, which meant the hospital had to reschedule patients and implement temporary, but safe, workarounds.

This multi-departmental effort was a textbook example of how to tackle a systemic problem. The joint task force, which included members from SPD, IP, Facilities, and hospital administration, was key to success.

 The SPD team provided critical on-the-ground insights. They tracked when and how the pressure dips were occurring, helping the Facilities team pinpoint the source. They also helped devise temporary workflow adjustments that allowed a minimum number of cases to proceed safely.

 The IP served as the vital link and voice of reason. They translated the SPD's technical needs into a compelling case for leadership. By advocating for the necessary time and resources, the IP ensured no corners were cut, and patient safety remained the top priority. They also managed expectations with the GI lab and other stakeholders, maintaining trust.

 The Facilities team became the engineers of the solution. They installed a new dedicated water line and reconfigured the hospital's plumbing to isolate the SPD from other high-demand areas. A deep cleaning of the main water tank was an essential preventative measure.

 Hospital administration provided the financial and logistical support needed. They understood that the short-term revenue loss from canceled procedures was significant, but the long-term cost of damaged reputation and potential patient harm was far greater.

Beyond the Crisis: Proactive Advocacy and Technical Backing

While responding to a crisis is crucial, the most impactful advocacy begins much earlier. Imagine if the water pressure issue at "State Hospital" had been identified before the new AERs were even installed. IPs have a critical role in pre-purchase assessments and facility planning.

 When new equipment like AERs is considered, proactively review manufacturer IFUs for utility requirements (water quality, pressure, dedicated lines, air quality, electrical). Collaborate directly with Facilities to assess infrastructure capacity before purchase.

 Question initial test plans. Weekend trials, as seen at John Doe Hospital, often don't reflect weekday peak demands. Advocate for testing under realistic, high-demand conditions.

Cross-departmental collaboration for infrastructure planning:

Essential Elements of a Reprocessing Program for Flexible Endoscopes

' to advocate for a multidisciplinary team to review not just reprocessing policies but also supporting infrastructure during planning phases. This prevents installing advanced technology into inadequate systems.

A truly successful outcome isn't just about solving a problem; it's about forging a partnership built on trust, technical understanding, and proactive engagement. The "John Doe Hospital" case illustrates that effective advocacy requires a multidisciplinary effort, with the IP as a pivotal voice. This week, empower your SPD team. Don't wait for a crisis to strike. Go to your SPD department, listen to the team, and ask them directly: "What's the one thing that gets in the way of doing your job safely and to standard?" That simple question, backed by your technical insight and advocacy, can uncover the next hidden threat and position you as the indispensable champion for patient safety and professional integrity.

The Technical Case for Advocacy: Citing AAMI and CDC Guidelines

When advocating for a Sterile Processing Department (SPD) team, an IP can cite specific guidelines from organizations, such as the Association for the Advancement of Medical Instrumentation (AAMI) and the CDC to lend technical credibility to their arguments. These guidelines establish the "why" behind the strict requirements for reprocessing.

Here are some specific guidelines that would provide technical support in the scenario described:

Flexible and semi-rigid endoscope processing in healthcare facilities,

 is a key resource. It provides comprehensive guidance for every step of endoscope reprocessing.

 The standard emphasizes that water used in automated endoscope reprocessors (AERs) must meet specific quality criteria. While it doesn't always specify an exact PSI, it mandates that facilities follow the AER manufacturer's instructions for use (IFUs). The IFUs will contain the precise requirements for water pressure, temperature, and quality (eg, filtered, reverse osmosis, etc.). The "Water inlet low" error in this article is documented in the manufacturer's IFUs, which describe the error and the steps to ensure the scope is successfully processed and safe for patient use.

 AAMI ST91 stresses that all reprocessing steps, including the automated high-level disinfection cycle, must be validated to ensure efficacy. Any interruption to the validated process, such as a drop in water pressure that causes a cycle to abort, renders the device unsafe for use. This standard can be shared with leadership to provide strategic communication on why restarting or bypassing a cycle is a direct violation of a validated, patient-safe process.

 The standard recommends a comprehensive quality assurance program. The article's case study of the SPD team tracking the timing of pressure dips is a perfect example of this. An IP can support the SPD by helping to formalize this tracking into a quality monitoring program required by ST91.

The CDC provides several resources that support the IP's position, often in collaboration with other professional organizations.

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

 This document provides the foundational principles for reprocessing. It classifies endoscopes as 

 and states that they must receive high-level disinfection. The guideline also states that all reprocessing steps must be meticulously followed per the manufacturer’s instructions. This broad principle provides a strong defense against any pressure to "cut corners."

 This document, developed by the Healthcare Infection Control Practices Advisory Committee (HICPAC), emphasizes that following manufacturer IFUs is a cornerstone of a safe reprocessing program. It also highlights the need for a multidisciplinary team to review reprocessing policies and procedures, which directly supports the article's recommendation for a joint task force.

Environmental Infection Control Guidelines

 The CDC provides guidance on environmental factors that impact infection control. While not solely focused on AERs, these guidelines acknowledge that poor water quality and compromised water systems can be sources of pathogens, including 

 and nontuberculous mycobacteria (NTM). This provides an IP with technical data to demonstrate that an intermittent water supply is not just an inconvenience but also a potential safety risk.

JR Santana, CRCST

Articles

The Invisible Threats: An IP's Guide to Advocating for Sterile Processing