Major article An evaluation of immediate-use steam sterilization practices in adult knee and hip arthroplasty procedures Scott L. Zuckerman BS a , Ravi Parikh BS a , David C. Moore BA a , Thomas R. Talbot MD, MPH b, * a Vanderbilt University School of Medicine, Nashville, TN b Departments of Medicine and Preventive Medicine, Vanderbilt University School of Medicine, Nashville, TN Key Words: Flash sterilization Quality assurance Surgical site infection Perioperative Operating room Patient safety Checklist Background: Immediate-use steam sterilization (IUSS) is a safe method to sterilize emergently contaminated instruments, but inappropriate use may lead to an increased risk for surgical site infection. This study aimed to identify risk factors, rationale, and variability in procedural adherence in cases of IUSS. Methods: This retrospective, case-control study compared adult patients undergoing hip and knee arthroplasty in which IUSS was (n ¼ 104) and was not (n ¼ 81) performed. Results: Multivariate analysis revealed 4 predictive risk factors for IUSS: history of malignancy (odds ratio [OR], 3.2 [95% confidence interval (CI) 1.1-9.3]), obesity (OR, 2.3 [95% CI: 1.02-5.2]), procedure performed in operating room 13 (OR, 2.5 [95% CI: 1.2-5.4]), and Monday procedure (OR, 3.6 [95% CI: 1.4- 9.1]). The only factor that protected against IUSS was performing the procedure in the morning (OR, 0.4 [95% CI: 0.2-0.96]). Only 9.5% of cases of IUSS involved an acceptable indication. Documented adherence to core practices was also variable. Conclusion: Several patient- and case-specific factors can help predict the incidence of IUSS. Further- more, practices should be hardwired to ensure IUSS is utilized for the correct indication. Documentation must be improved to allow institutions to accurately track IUSS. Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. Over 40 million surgical procedures are performed in US hospitals each year, 1 resulting in nearly 300,000 surgical site infections (SSI). 2 Identifying perioperative practices that may increase a patient’s risk for such morbidity is an important step in reducing SSIs. One practice that, if not performed correctly, has potential to increase risk of infection is flash sterilization, recently termed immediate-use steam sterilization (IUSS). The Association for the Advancement of Medical Instrumenta- tion defines IUSS as, “the process designated for the steam sterili- zation of patient care items for immediate use.” 3 This is performed on an as-needed basis when instruments designated for a proce- dure become contaminated or sterile instruments are not imme- diately available. 4 When performed correctly, immediate-use, or flash, sterilization is a safe means to sterilize contaminated instruments for urgent use, only to be used in carefully selected clinical situations. 5 The Centers for Disease Control and Prevention (CDC), 6 the Joint Commission, 7 and the Association of periOperative Registered Nurses (AORN) 8 all concur that IUSS should be reserved for emergent situations and never utilized for implantable hard- ware or devices. Additionally, detailed procedures for safe IUSS practices have been published. 6,9-11 A major concern regarding IUSS is that its convenience may lead to nonemergent, inappropriate use. This abuse of IUSS has the potential to increase risk for development of SSI, increased health care costs, and even direct thermal injury to the patient. 5,12,13 Even if utilized appropriately, the stresses associated with an urgent need for the instrument may lead to skipped steps in the sterili- zation process and wide variability in practices. 8 Minimizing the use of IUSS has been integral in efforts to reduce infection rates following both cardiothoracic 14 and orthopedic procedures. 15 Some institutions have even discontinued IUSS almost entirely. 16 Despite the growing literature outlining the risks of IUSS, there is limited published information about the variability of IUSS practices in an operative setting. It is important to determine what patient and procedural factors are associated with increased rates of IUSS to allow for targeted * Address correspondence to Thomas R. Talbot, MD, MPH, Associate Professor of Medicine & Preventive Medicine, Vanderbilt University School of Medicine, A2200 Medical Center North,1161 21st Avenue South, Nashville, TN 37232. E-mail address: tom.talbot@vanderbilt.edu (T.R. Talbot). S.L.Z. and R.P. contributed equally to this work. Conflicts of interest: None to report. Contents lists available at ScienceDirect American Journal of Infection Control journal homepage: www.ajicjournal.org American Journal of Infection Control 0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2011.11.006 American Journal of Infection Control xxx (2012) 1-6