Page 79 - JSOM Spring 2024

Sterile Instrument Storage in an Austere Environment

Are Sterile Peel Packaging and Cellulose Wrapping Equivalent?

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Nathan S. Lanham, MD *; Christopher M. Belyea, MD, MBA ;
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David Marcello, BSN, RN ; Allan B. Wataka ; Lillian Musila, PhD 5
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ABSTRACT
Background: Recommendations for optimal temperature and for sterile packaging for smaller, lightweight, low-profile instru-
humidity for sterile instrument storage vary according to dif- ments lack consensus. 6
ferent sources. Furthermore, there are limited data comparing
methods of packing smaller, lightweight, low-profile instru- To date, no direct comparison has been performed between
ments. The purpose of this study was to compare sterile peel methods of packaging sterile instruments in conditions where
packaging and sterile cellulose wrapping for sterile instrument temperature and humidity deviate from recommended values.
storage in an austere environment characterized by elevated Therefore, the purpose of this study was two-fold. The primary
temperature and humidity. Methods: Stainless steel screws aim was to evaluate sterile instrument storage in an austere en-
were sterilized and stored in either sterile peel packaging, vironment with temperatures greater than 24°C and humidity
sterile cellulose wrapping, or no packaging. Four groups were greater than 60%. Secondarily, we sought to compare sterile
evaluated. Group 1 consisted of four screws in a sterile peel- peel packaging and sterile cellulose wrapping in sterilizing and
pack envelope and served as a time-zero control. Group 2 con- storing smaller, lightweight, low-profile instruments. We hy-
sisted of two groups of five screws, each packaged with blue pothesized that sterilized instruments would have no bacterial
sterilization cellulose wrap. Group 3 consisted of two groups growth after 12 weeks of storage in an austere environment
of five screws, each packaged in sterile peel-pack envelopes. characterized by high temperature and humidity. Furthermore,
Group 4 consisted of 10 non-sterile unpackaged screws, which we hypothesized that there would be no difference in sterility
served as controls. Screws from groups 2, 3, and 4 were then maintenance between packaging methods.
cultured for 6 and 12 weeks. Temperature and humidity values
were recorded in the instrument storage area. Results: Average Methods
temperature was 21.3°C (SD 1.2°C; range 18.9°C–27.2°C)
and average humidity was 51.7% (SD 3.9%; range 39%– This quality improvement study was conducted with com-
70%). Groups 1 (time-zero control) and 2 (sterile cellulose mand approval and was reviewed by the Public Affairs Office
wrapping) demonstrated no growth. After 6 and 12 weeks, (PAO) and Judge Advocate General’s Office (JAG) prior to be-
groups 3 (sterile peel packaging) and 4 (control) demonstrated ing submitted for publication. The operating room was located
bacterial growth. Conclusion: The most common culture iso- in a remote, austere setting but had generator power, running
lates were gram-positive rods and two common nosocomial water, and air conditioning units to assist with climate control.
Staphylococcus species. Sterile peel packaging was not found However, there were no dedicated air filters or laminar flow
to be equivalent to sterile cellulose wrapping in austere envi- units. The operating room provided damage-control surgery
ronmental conditions. capability for trauma patients. The air conditioning units were
routinely turned off to deliberately raise the temperature in the
Keywords: instrument sterility; austere environment; peel operating room to assist with the resuscitation of trauma pa-
packing; cellulose wrapping; sterile instrument storage tients. Dust was commonly observed in the instrument storage
area. However, consistent efforts to keep dust to a minimum
and maintain the overall cleanliness of the instrument storage
area were made.
Introduction
Maintenance of instrument sterility during storage is critical Non-sterile stainless steel screws (#8 × 1" 304 Stainless Steel
for infection control in the operating room. Temperature and Phillips Modified Truss Head Wood Screws, BCP1211, BCP
humidity are often closely monitored in areas where sterile Fasteners, USA; https://bcpfasteners.com/) were used to rep-
instruments are stored. Exceeding certain thresholds for tem- resent small, lightweight, low-profile surgical instruments.
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perature and humidity are believed to compromise sterile pack- Some examples of these instruments include forceps, scalpel
aging of instruments. However, recommendations for optimal handles, elevators, iris scissors, small self-retaining retractors,
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temperature and humidity for sterile instrument storage vary and smaller suction tips. Group 1 consisted of four screws
according to different sources. Similarly, recommendations in a sterile peel-pack envelope (Self Seal Sterilization Pouch
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*Correspondence to nathanscottlanham@gmail.com
1 Dr. Nathan S. Lanham and Dr. Christopher M. Belyea are affiliated with the Department of Orthopaedic Surgery and Rehabilitation, Womack
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Army Medical Center, Fayetteville, NC and the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD.
3 David Marcello is in the U.S. Army Reserve Nurse Corps and is affiliated with Tampa General Hospital, Tampa, FL. Allan B. Wataka and
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5 Dr. Lillian Musila are affiliated with the Department of Emerging Infectious Diseases, United States Army Medical Research Directorate–Africa/
Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
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