Study Afternoon Report

This study afternoon with about eighty participants started with a paper about the use of custom procedure trays (CPTs) in hospitals by Marc Corthals, product coordinator at Malysse-Sterima.
CPTs have known an enormous evolution within the hospital world during the last three years. They have rightfully gained their position there. About ten hospitals, mainly Flemish ones, exclusively use these sets at present. Others are looking into the possibility of introducing them or are on the verge of doing so.
The use of ready-made, customised sterile packages for certain standardised procedures such as hip and coronary by-pass operations has big implications both on the level of the user and on the level of the whole hospital organisation. At logistics level a number of important advantages have to be pointed out such as the control over the movement of the sterile materials, the traceability, the simplification of the ordering procedures and the stock reduction.
The advantages for hospital management are mainly the accurate identification of the costs that were made. The number of specific surgical operations such as hip or knee protheses are more or less known or can be predicted. This means that costs can be calculated quite accurately.
The user - mostly the operating theatre - makes use of this standardized procedure package which results in a substantial reduction of the preparation time for the nursing staff in the theatre. This gain of time is due to the fact that individual items do not have to be collected, checked and put ready. Moreover manifold manipulations and the opening of the packaging above the sterile area are substantially reduced. This leads automatically to increased sterility.
For the further organisation in the hospital it has to be added that the use of CPTs forces everybody to think carefully about the procedures which are used and leads to standardisation both of the procedures around the surgery and of the composition of the PT. The more unanimity around this, the more efficient and easier the need to standardisation is felt in all levels of the hospital organisation.
A specific point of attention for the CSA concerns the content of such a CPT. It can happen that one wants to resterilize, in a well-intentioned effort to save costs, the content of a package which wasn't used. This should not be done. Disposable items which were in the immediate vicinity of the area of the operation - and this is always the case with a CPT - should be considered as contaminated. Moreover it is very often not worth the trouble as the resterilization cost is too high or unacceptable. If certain items from a set are not used at all or used very seldom and offered for resterilization then it is more advisable to review the composition of the set and to adapt it.

Wim Renders, chairperson of the VSZ, talked in his introduction about the commitment which results from study afternoons and symposiums. The knowledge which is acquired creates responsibility. For the CSA a large amount of energy is devoted to the striving for justified basic procedures. This is necessary in order to avoid constant bickering with the operating theatre about for example the planning of the operations' programme and the minimal resterilization times so that the operations can be carried out in a responsible manner. The professionalization and the emancipation struggle of the sterilisation departments is taking place slowly but surely. The directives of the lawmaker and of industry are of a great help in this regard.
As far as the training and the statute of the members of staff and the managers is concerned, the Society has not been idle. The course for sterilization personnel in cooperation with the KatHo of Roeselare was very successful and at present a similar initiative is running with the collaboration of the Provinciale Hogeschool Limburg in Hasselt. In the autumn a course for managers will be organised.
We are also convinced that the refresher and training evenings organised on 6 May in Roeselare and on 10 June in Antwerp will appeal to quite a few people and meet an existing need. It is high time to inform, sensibilize and convince certain official bodies of the need of a special statute and framework for the CSA. We'll keep you posted.

Ton Boks, expert sterile medical devices of the AZ Rotterdam talked in his presentation about more and better insight into sterilizing and sterility, more specifically for ophthalmologic instruments. He gave an overview of the most important points of attention at reception, cleaning, ultrasoning etc. For these types of instruments the immediate cleaning after use is of the utmost importance (e.g. of delicate canules), the safe storing of the fragile instruments during all treatment phases, and the use and adequate removal of cleaning and disinfecting agents. 70% alcohol without additives is the preferred method.
The mechanical forces exerted during ultrasoning and machine cleaning has to be relative to the delicate construction of the components that have to be cleaned in order to avoid unnecessary deformations or damage. This could result in eye damage during an operation.
For the drying process it was therefore proposed to use filtered compressed air with reduced pressure. Finally it was also stressed that good communications between the operating theatre and the CSA were very important in this regard.
The importance of this attention was demonstrated in an interesting case study. Ton Boks was as an expert involved in an investigation into an endoftalmitis-epidemic (a festering infection of the inside of the eyeball) in Medan, Indonesia. As a result of this infection a number of patients had become permanently blind. After a careful investigation and screening of all the methodologies, amongst others by having a mock operation carried out, the weaknesses were exposed. First of all the general hygienic and aseptic prescriptions in the operating theatre such as the opening of windows and the lax use of mouth masks and aprons were not followed. Furthermore in the recipients with iodine alcohol, which were always re-used, pathogens had formed (pseudomonas cepasia).
In the condensate of the cassette sterilizer endotoxines, which were formed by biofilms, were found. They could easily duplicate in the still and tepid water of the water reservoir. With justification one could in literary wording refer to the cool lakes of death. That's why the important recommendation is given to empty the reservoir each day and to let it dry in the air in order to avoid bacterial growth.
Within a wider framework this case study shows once again that the systematic ignoring of the basic procedures can lead to dangerous situations, also in apparently innocent circumstances or acts. It is not a single weak point in a process that necessarily leads to problems but the accumulation of consecutive 'fails' which results in an unacceptable situation. Translated to the way of working of a CSA: inadequate cleaning, poor checking, resterilization and re-use, the application of an irresponsible sterilization process, bad logistics and poor storing (perforations in the packaging) inevitably lead to problems. It becomes a chronicle of foretold disaster.

Peter Steenwijk provided information on the DataMatrix coding system. This way of coding has a lot of similarities with the well known barcode but the bars here are a pattern of maximally 2335 cells which represent certain data (see picture). This technique is about fifteen years old and is applied in industry (transport, logistics, automating systems, ...) and in space travel. The big advantage is that it can contain much more data than the traditional bar code. The resolution only has to be 20% in order to make scanning possible and this from virtually any angle. Problems with scanning, which so often occur at the checkouts in supermarkets, are nearly impossible.
This system should also be adopted by the sterilization departments, despite the fact that a number of practical questions should still be answered.
First of all there are questions in connection with the technique: the coding could trigger or enhance corrosion of the instrument. On the other hand the set laser quality of the imprinted matrix depends on the quality of the stainless steel, so a good knowledge of materials is necessary.
Another question concerns the practical consequence of individual instrument coding. For most organizations it is at the moment practically impossible to scan each instrument from a set, due to time pressure during the overfull operations programme.
Nonetheless the coding of individual instruments definitely has advantages, think for example of the sometimes numerously circulating individual instruments. Soft ware packages that only register 'the net' as the smallest unit do not provide a solution for individual items.
I was pleasantly surprised by the invention and its application possibilities. It is a beautiful system, but there is the nagging feeling that in the present Belgian hospital context this realisation perhaps is not (yet) a realistic one; I mean the following: there is a big difference between the possibilities of the industry and the limitations of the social sector which has to save more and more. This is a pity, but it is a reality.

Last but not least Luc Van Hoecke gave a flamboyant and interactive speech about motivating and contemporary leadership. He is senior consultant of Athena, a training centre, and advises hospitals on mergers.
With funny but no less real examples he sketched the daily worries of managers and their subordinates. He emphasized that successful leadership never depends on the person one is faced with. Each situation and every individual require their own approach; this is what is meant by situational leadership. The qualities of a manager are all too often specified as technical and are all too seldom defined as his ability to deal with people.
In an exhaustive and systematically elucidating manner each type of subordinate was portrayed on the basis of ability and motivation. With each type the required style was described. It started with authoritarian leadership over supportive 'coaching' and the handling an supporting of a consultation structure to the actual delegation of tasks.
A good manager has these essential qualities and knows how to apply them with ease. He or she consequently has to know the 'maturity' level of each subordinate and realize that every individual requires his or her own approach. From experience I can say that functioning conversations are an ideal way of gauging the temperature and eventual the fever in a department. It provides a wealth of information about all facets of cooperating. Highly recommended!

The daily reality of a CSA is difficult, I don't have to make that clear. The working conditions, the sometimes unrealistic requirements, the increasing responsibilities and the sometimes minimal appreciation form in themselves a problematic basis. It is important - once again - that in this department people are employed who are and competent and motivated. This can only be achieved through special training and education which knows how to value our members of staff.
To finish a quotation:"the secret of an excellent company is not to do ordinary thing with extraordinary people but to do extraordinary things with ordinary people."

Ludwig Van de Voorde