Objective: To reduce the number of immediate-use steam sterilization (IUSS) cycles performed to below 2% to increase patient safety and decrease surgical site infections (SSIs). Methods: The facility decide to make a “hard stop” date at which IUSS cycles were no longer going to be allowed without operating room (OR) and Sterile Processing Department (SPD) leadership approval, based on standardized indications for IUSS cycles. Before the start date, extensive education was given to surgeons, OR clinical teams, and SPD team members to ensure understanding of the process and risk of infection due to IUSS. The facility also recognized that workflow was a large part of why instruments were being sent through IUSS cycles, due to a backup of sets in the department and because some items could not be processed before the next day. Many items were purchased to increase workflow capabilities: such as a new washer, sonic, adding a pass-through window, a low-temperature sterilizer, Also, 3 sterilizers were replaced with newer, more efficient models. The facility also purchased a large number of instruments to create new and additional trays to accommodate the surgical volume. The SPD also underwent LEAN Kaizen events on both the clean and dirty sides to improve workflow and efficiency to prevent further IUSS. Project Results: The facility saw immediately results in reduction of IUSS cycles being performed and were the department was able to drop below the goal of 2% after the first month of using the new process. The rate has continued to be <2% for >5 months. Communication and partnership between the OR, infection prevention staff, and SPD were beneficial and will continue to move the facility forward in a shared decision-making model as improvement continues in the future.

Funding: None

Disclosures: None