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Understanding Wet Pack & Wet Load Investigations

What is a wet pack?

So, what does it mean to have a wet pack in your sterile processing department? We know that wet packs result from a variety of sources, during, or after the steam sterilization process. A wet pack can be defined as identifying visible moisture on the inside or outside of the item or package after it’s been exposed to a steam sterilization process. A wet load can be defined, as multiple wet items stemming from one autoclaved load. Here at Belimed, Inc. we also know that wet loads can cause patient delays, frustrating team members and ultimately poor outcomes. We want to help you through the troubleshooting steps and investigation methods it requires to identify the source of a wet pack issue.


A Multi-variable obstacle 

The most important variable in having a successful outcome during the assessment of moisture is understanding how to approach the issue. Because there are so many factors to consider; equipment, utilities, placement, load capacity and environmental controls, not to mention the entire operational workflow, it is critical to have a dedicated and educated team. Communication and collaboration can make or break your success when it comes to having heightened stressful situations. Those involved in this process must understand how to look at all aspects of the problem. It is possible that you might see the issue recurring, but it could be caused by an entirely different source. The investigation process itself requires a variety of members to be present at the collaboration table and to be included and speaking the same language.

Creating an Activation Team

  • SPD Representative – drives and manages the investigation process, handles documentation and communication among the activation team and hosts routine huddles to share information
  • Infection Control Representative – manages and handles the patient record, tracers, and necessary patient related communications only as necessary when and if a wet pack reaches a patient without resolution, and sterility is in question
  • OR Personnel- focuses on proper documentation when applicable, helps streamline the investigation, helps educates the teams involved and keep their OR room calms during the investigation process, makes sure items do not reach the patient, through investigation for  moisture at time of opening packs
  • Quality & Education- focuses on reviewing the investigation, shares education and knowledge with the team, ensures the process is sticking to protocol, uses every occurrence as a training opportunity to avoid recurrences
    Sterilization Equipment Representation- provides support during investigation, verifies the issue is not from steam lines, autoclave malfunctions, checks for leaks, checks all functions of the equipment to rule out causes
  • Biomedical Engineer- helps with the investigation as needed, organizes communication with the equipment manufacturer, handles internal management of maintenance on equipment, checks all internal causes or equipment failures
  • Maintenance or Facilities Engineer- completes an entire investigation into possible utility causes, water main lines, steam generators, steam piping, insulation and all utilities that are involved with the equipment in the SPD

A Thorough Investigation

The objective of a wet pack investigation is to locate the source of the moisture itself. While this can be challenging, the less variables that are altered during the process, the better and faster a resolution can be identified. The investigation ultimately begins when the first sign of moisture is seen, this could be in the sterile processing department or in the operating room. The dedicated team should be alerted through an “activation” method of communication. This will help streamline the investigation in a systemic way. Each dedicated representative as listed above will complete their set responsibilities to help determine the root cause of the issue. The investigation timeline is different in each situation, and there isn’t a definitive agenda, sometimes the solution can be located immediately, while other times it takes much longer.

 

  • Identify the location of the moisture, verify if it is an internal or external issue
  • Activate your “investigation team” , begin documentation preparations
  • If 1 wet pack is identified, the investigation will include proper steps in locating a variety of items from the same load to determine if further moisture is found in other packs, this will determine the recall initiation
  • Communicate promptly, calmly and provide information to the activation team and SPD staff so troubleshooting can begin
  • Ensure all reprocessing professionals are allows sets to cool properly, checking temperature of sets before release, and confirm the environmental controls of the cooling area is within set parameters

Documentation 101

Anytime there is an investigation in sterile processing it should be well documented and kept in safe keeping for future referencing if needed, to help analyze trends. Each occurrence should be well written, and in a clear method that is easy to follow and understand. This is when the collaboration between departments is critical. If sterile processing is using a logbook make sure to allow them to complete the necessary steps, and the operating room personnel should be providing useful information as quickly as possible. The recall documentation can help to identify trends and help pinpoint the root cause of the issue. 

  • Include digital photos of the processed load, the wet pack item, and location of the moisture If your department has a quality system in place or tracking system of some kind, it is important to feed the information into that system especially if a recall takes place.
  • Document the cycle parameters, location, weight of the set, packaging material, and cooling temperature & time
  • Ensure the documentation also includes the entire recall, if the whole load is recalled back
  • Ensure to complete the documentation with the resolution once it is determined


Contact Belimed
Please contact our education and training team with questions or comments at clinicaledu.us@belimed.com