TASS: What It Is and How SPD Can Help Prevent It

By Tony Thurmond, CRCST, CIS, CHL, FCS

This article originally appeared in the July-August 2025 issue of Healthcare Hygiene magazine.

Toxic anterior segment syndrome (TASS) is a rare, inflammatory condition of the eye that develops within 12 to 48 hours of an ophthalmic procedure, typically after cataract removals, penetrating keratoplasties, intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections, and vitreoretinal surgeries. The condition affects the eye’s inner lining and presents with or without pain and is marked by a decrease in or blurry vision, extreme sensitivity to light and severe inflammation.

Untreated TASS may lead to permanent eye damage or vision loss. An estimated 28 million cataract procedures are performed each year, with 15 percent (or 4.2 million) completed in the U.S. It is roughly estimated that one in a thousand cataract patients will develop TASS. This article addressed how the condition is believed to develop and Sterile Processing (SP) professionals’ essential role in helping prevent its occurrence.

TASS risk factors

Studies have identified several strong possibilities for the cause or development of TASS. These include patient factors, substances introduced during the procedure, and unsterile medical instruments. As with many surgical post-op complications, patient factors should always be considered. Some patients who develop TASS have poorly controlled type 2 diabetes, hypertension, hyperlipidemia, chronic ischemic cardiovascular disease, or kidney failure. These diagnoses can increase the risk of TASS after an otherwise successful cataract surgery.

Eye surgery involves the use of intraocular viscoelastic materials, gel-like substances used to maintain the depth of the anterior chamber of the eye, manage bleeding and aid in the placement of the intraocular lens (IOL). Some of these materials are sodium hyaluronate (originally derived from rooster combs but now produced in labs); chondroitin sulfate (extracted from the cartilage of sharks, cows and pigs); and hydroxypropyl (extracted from wood pulp or cotton fibers). Each of these products can create side effects that may include inflammatory reactions, corneal edema (swelling) and a rise in intraocular pressure.

Studies have also indicated TASS reactions due to foreign bodies from surgery packs, povidone iodine and other ophthalmic ointments, contaminated balanced salt solutions, improperly manufactured IOLs, and extensive microscopic debris covering surgical drapes and other items. Another concern supported by numerous studies should also be considered: the role of cleaning and care and handling of surgical instruments.

Team-based approach to prevention

Those in the operating room (OR) or procedural areas are responsible for completing proper and thorough point-of-use treatment for instruments, including ophthalmic devices. Instruments should be wiped with a sterile, lint-free sponge or cloth using sterile water and following the manufacturer’s instructions for use (IFU). Without this process and the moisture used to keep viscoelastic and organic material from drying onto the instrument, the risk of biofilm formation increases. Many experts and IFU recommend using non-enzymatic solutions with intraocular instruments. Be sure your OR team is using the correct sprays when performing point-of-use treatment.

Each day, sterile processing (SP) teams process instruments from multiple specialties. Many facilities have one centralized location for the cleaning of these instruments. Both AAMI standards and AORN guidelines recommend having a separate location for the cleaning of ophthalmic instruments. As most departments are limited in design, there is often not enough space or sinks to designate for only one specialty. If a department lacks a separate space, it is recommended to thoroughly clean the sink basins and ultrasonic before processing ophthalmic instruments. After manual cleaning, eye instruments should be run in the ultrasonic. An ultrasonic cycle is capable of breaking free debris that may be impossible to see or remove during the ultrasonic cleaning process. The ultrasonic should be used after manual cleaning, never in place of or as an alternative to it. After cleaning reusable intraocular instruments, lighted magnification should be used to inspect the devices for damage and retained debris.

As with any specialty, the facility must maintain an adequate inventory level of instruments to allow the time necessary to manage the cleaning process effectively. A lack of instrument trays can cause technicians to feel rushed and not able to thoroughly clean the instruments. Any device that is not cleaned properly cannot be sterilized properly.

It is also essential that facilities consider numerous factors before purchasing new ophthalmic. A representative from the sterile processing department (SPD) should be included in the pre-purchasing process and be ready to assess how effectively the SP team will be able to be in the cleaning of exceptionally fine lumens. Many of the cannulas used for injecting and irrigating during ophthalmic procedures are introduced into the surgical incision and may touch and be contaminated by tissue and debris being irrigated out. These small-lumened instruments require extensive flushing with copious amounts of critical water to ensure removal of all debris.

Due to the challenges of processing eye instruments, some facilities have switched to disposable devices or components. When introducing any disposable device, extra care must be taken to remove and properly dispose of it in the procedural area (and not allow it to stay in the tray). All SP team members must be trained to identify the single-use devices used in the facility so they will not reprocess them. It is believed that single-use devices may reduce the risk of TASS.

Prioritize training

Educating staff about what happens to a patient who develops TASS is critical in any discussion or training. While there are several variables associated with TASS, it is everyone’s responsibility to know what it is and how to prevent it.

During SP training, it will be helpful to discuss what happens if an item is not cleaned properly, and how it will affect those in the OR and other procedural areas, as well as the patient. Everyone involved in ophthalmic procedures, including the SP team, must take every step to reduce the risk of TASS. The most critical thing SP professionals can do is increase their awareness of TASS and help provide workable, patient-centered solutions.

Tony Thurmond, CRCST, CIS, CHL, FCS, is the central service manager for Dayton Children’s Hospital.

Resources:

Association for the Advancement of Medical Instrumentation, ANSI/AAMI ST79:2017/(R)2022 Comprehensive guide to steam sterilization and sterility assurance in health care facilities.

Association of periOperative Registered Nurses, Guidelines for Perioperative Practice, 2024.

 

IPs Who Visit SPDs Regularly Can Improve Quality and Safety

By Julie E. Williamson

This article originally appeared in the May-June 2025 issue of Healthcare Hygiene magazine.

Although infection preventionists (IPs) and sterile processing (SP) professionals do not share the same departmental walls, they are nonetheless vital teammates who should work together regularly to ensure standards-based processes, policies and best practices are consistently followed, and challenges are proactively addressed. While such collaborative interdisciplinary relationships are not always prioritized in some healthcare facilities, the Healthcare Sterile Processing Professionals (HSPA) is pleased to see positive changes on the IP-SP collaborative front.

During the 2025 HSPA Annual Conference last month, numerous IPs and executive-level professionals were in attendance, underscoring their commitment to learning more about SP-related topics, advancements and ongoing obstacles regarding instrument design, limited staffing and capital budgets, instructions for use (IFU) concerns, and more. One IP, a first-time attendee, shared with HSPA staff that she “had no idea the problems SPDs face” and vowed to step up her support immediately upon returning to her facility. She shared that she had “about bi-monthly” meetings with the first and second shift managers but planned to engage with SP leaders and technicians across all shifts at least monthly to ensure their voices are heard.

“I now know more questions to ask, and I want to really listen to what is causing them headaches and making it difficult for them to do their jobs consistently, effectively and safely,” she said. “The more I know, the better I can advocate for them.”

Other IPs and managers can attest to the benefits of strengthened departmental partnerships, and that message resonated during numerous educational sessions at the HSPA conference. A primary example was the opening session on April 27. The session, “Everyone’s Dirty Little Secret,” was presented by microbiologist Cori Ofstead, MSPH, President and CEO of Ofstead & Associates, Brandon Gantt, DHSc, CRCST, CHL, CER, LSSGBH, manager of SPD education and training at Emory Healthcare, and Jill Holdsworth, MS, EMT, CRCST, manager of infection prevention at Emory. The trio shared outcomes from their eye-opening Lumens 2.0 study published in the American Journal of Infection Control, which highlighted challenges with device design and cleaning IFU, as well as the importance of using borescopes and swabs to assess device cleanliness.1

For the study, the team used a borescope to inspect lumened instruments used for orthopedic, neurologic and ear, nose and throat (ENT) procedures. When visible debris was identified, the device was recleaned up to three times to assess the cleaning effectiveness. In all, there were 117 inspections involving 40 unique instruments and 77 re-inspections. Debris, discoloration or residues were found inside every device cleaned and inspected, and rust was present in 95% of them. Beyond that, visible soil remained in most lumens after recleaning, and lint or brush fragments were still visible upon repeat inspection.1

Alarming and discouraging observations aside, Ofstead, Gantt and Holdsworth stress that opportunities exist to make powerful improvements—among them interdisciplinary collaboration and the importance of borescope inspection and the pursuit of solutions to address challenges with instrument design and IFU. What’s more, their Lumens 2.0 study serves as a potent reminder of the benefits of having an IP working alongside SP professionals to witness the challenges firsthand—and in the case of Holdsworth, by participating in enhanced visual inspection and other essential steps.

“As an IP, using a horoscope is not something I had done before or knew how to do before I started working with Cori Ofstead and her team,” she told HSPA. “I was so excited to work on this project with our local team so we could learn and grow from our findings.”

Gantt acknowledged the significant benefits of having IP involvement in the process. He noted that using a borescope gave valuable insight into the challenges of biofilm formation, debris retention and cleaning difficulties associated with lumened devices. What’s more, he explained that Holdsworth’s involvement would help educate SP and clinical staff about the risks associated with insufficient cleaning, fostering a culture of accountability and compliance with reprocessing guidelines.

Above all, he said the SP-IP collaboration highlights the correlation between inadequate instrument reprocessing and the risk of healthcare-associated infections. “Infection Prevention and Sterile Processing are inextricably linked,” reminded Gantt, adding that collaboration should be a natural and regular occurrence.

Other studies support that notion. A quality improvement project initiated in 2015, for example, involved the development of an auditing tool, IP-provided education, and participation in SPD meetings to improve IP knowledge and understanding of SP-related processes and compliance with infection control measures.2 The researchers saw a correlation between increasing SPD audit scores and a decline in bioburden events from a yearly average of 3.29 events per 1,000 procedures in 2015 to 1.15 events per 1,000 procedures in 2018.

The project demonstrated how collaboration between IP and SP departments can improve compliance and patient safety, they noted.

Julie E. Williamson is director of communications at the Healthcare Sterile Processing Association (HSPA) and serves as editor-in-chief of HSPA’s publication, PROCESS magazine.

References:

Ofstead CL, Smart AG, Holdsworth JE, Gantt BM, Lamb LA, Bush KM. “Unseen threats: Lumens 2.0 study reveals the hidden challenges of cleaning lumened surgical instruments. AJIC. Vol. 53, Issue 5. Pp. 537– 547. May 2025. https://www.ajicjournal.org/article/S0196-6553(25)00057-4/fulltext.
Evashwick E, Cumplido S, Eleby G, Washington T, Krishna S, et al. “A Tale of Two Departments: How Collaboration Between Infection Prevention and Sterile Processing Departments Can Improve Patient Safety.” AJIC. Vol. 47, Issue 6, Supplement. Page S12. June 2019. A Tale of Two Departments: How Collaboration Between Infection Prevention and Sterile Processing Departments Can Improve Patient Safety - American Journal of Infection Control

 

In SPD Education, Remember ESL Learners

By Debra Sams, BA, AST, CRCST

This article originally appeared in the March-April 2025 issue of Healthcare Hygiene magazine.

High-quality care, service and positive patient outcomes hinge on healthcare employees’ understanding and implementation of policies and procedures, best practices, instructions for use, current standards and guidelines, and more. To facilitate consistent, effective knowledge growth across all employees, sterile processing (SP) educators must be adept at teaching English as a second language (ESL) students in their classrooms and tailoring educational methods to help all students grasp the content and succeed in their new roles.

Every student, regardless of their background and native language, brings valuable and unique experiences to the departments they will serve. Because everyone learns and contributes in their own unique way, educators must learn to adapt and apply teaching methods to benefit all students, while also incorporating each person’s strengths into their learning process whenever possible. Academic Joy M. Reid identified six learning styles —visual, tactile, auditory, group, kinesthetic and individual — and educators should understand those styles and tailor their curriculum to accommodate various learners.

Many ESL students struggle to adapt to the English-language classroom, and this can be especially so given the intensely technical SP-related content. SP education covers many topics; therefore, the curriculum must be presented in a way that makes it simpler for all students to comprehend, all while still communicating essential details so each staff member can function effectively in the department.

Students with limited experience with the English language may lack confidence in their new roles, making them afraid to speak out, even when they know the correct answer. This type of isolation can further affect their learning and practical application of the content being taught. They may also fear making a mistake and embarrassing themselves in front of their classmates, and in some instances, come from a culture that promotes passive participation instead of active engagement. Given these challenges, educators must understand and address such barriers to ensure students are given the opportunity to learn in meaningful ways and successfully integrate within the classroom and department.

Successful integration of ESL students requires educators to provide an inclusive classroom that eases them into a well-constructed, thoughtful learning platform. A practical approach is incorporating visual aids that highlight diverse people and cultures and providing hands-on material to help ensure a sense of belonging for all learners. Educators can also consider adding photos of people of different cultures, genders and countries as well as posting posters and using other resources that translate key English words into students’ native languages. Bilingual glossaries with commonly used words or phrases, for example, can help students better grasp usage, aiding in their understanding and retention of the material being taught.

Additionally, visual aids can help all visual learners conceptualize content. For ESL students in particular, educators can group words by themes or topics to help students learn essential vocabulary relevant to specific settings, such as images of different types of equipment identified in English and other native languages. Creating posterboards with phonetics transcriptions can also help students with correct pronunciation of myriad items and concepts within the department. The purpose is to ensure every student feels supported, respected, accepted and appreciated—all of which will help them become more confident to participate in engaged learning. Peer-to-peer mentorship, tutoring and group work can further enhance communication and learning and create a sense of belonging. Whenever possible, educators should partner ESL students with more experienced peers who speak the same language or come from similar backgrounds and cultures.

Educators may further support ESL students by adopting translating technologies, such as handheld translators, and ensuring students have WiFi access to go online and obtain translations for words they don’t understand. Note: If the school or facility invests in portable translators, ensure they provide good sound quality, support different languages and provide accurate translations. Last but not least, educators can allow ESL students to occasionally teach their classmates in their native language and then ask the students to explain what was taught. Taking tours of the facility to point out equipment and instruments in both English and ESL students’ native language and being sure to enunciate clearly and speak slowly enough to encourage greater understanding are also beneficial approaches.

ESL students are valuable additions to the classroom and SPD and deserve focused, innovative teaching methods to facilitate understanding and engagement and promote confidence in the material and its real-life application. Educators must strive to tap every student’s strengths and encourage active participation, teamwork, comprehension and retention, all while honoring each student’s unique qualities and backgrounds. When this happens, not only will the department benefit but also the healthcare customers it serves.

Debra Sams, BA, AST, CRCST, is a sterile processing educator at Cedars-Sinai.

 

Measuring SPD Productivity is a Vital Task

By Tony Thurmond, CRCST, CHL, CIS, FCS

This article originally appeared in the January/February 2025 issue of Healthcare Hygiene magazine.

In many businesses, including healthcare, productivity is often tied to profit or loss. Focusing on output instead of the demand for products and services poses a challenge, however, because an individual or team can be considered productive, even when they struggle to meet customer demands and needs. In the sterile processing department (SPD), for example, a technician could feel satisfied by their efforts and output but still fail to keep up due heavy procedural volume as well as limited instrumentation and other resources.

Sterile processing (SP) professionals understand the pain of doing their best each shift and still failing to meet daily demands. Equally challenging is that some SP leaders are unaware of how to measure productivity effectively in their departments, especially when there are opposing views about what productivity means. In most basic terms, productivity is the quality or state of being productive, with the effectiveness of productive effort being measured by the rate of output per unit of input. Using that definition, SP productivity will measure the number of products produced, while also taking into consideration all tasks associated with their production.

When assessing SP productivity, surgical volume and each associated task should be measured.

Many organizations measure SPD productivity solely on surgical case volume—an outdated approach that typically leads to inaccurate findings. Instead, a base rate must be factored for each patient and procedure. For example, a minor procedure requiring only two instrument trays will require less productivity than is required to process devices for an open-heart procedure or a total hip revision.

From there, individual tasks should be defined, and a time study should be performed, with the degree of difficulty and the possibility of interruptions factored into the measurement. When timing the decontamination process for robotic instruments, for example, it would be necessary to consider the length of time required to clean and disinfect the device and any attachments according to the instructions for use (IFU). Routine tasks, such as answering phone calls, emptying the cart washer, or delivering an item to the procedural area, also must be factored in, using a time study to determine averages. Certain time requirements will differ, but it is important to capture the true number of minutes spent on various tasks.

Each departmental task should be included to capture the team’s daily efforts. It is helpful to even include breaks and lunches as well as the time spent restocking workstations, answering phone calls, changing detergents, filling supplies, emptying washers, and so on, with each task being measured and recorded. Further, time studies should be performed to determine the length of time needed to process trays from decontamination and preparation to their delivery at the point of use. Tracking productivity metrics also requires consistent input and compliance from all SP staff members. SP leaders should provide data and supportive graphics to all employees to demonstrate actual metrics, improvements, and opportunities for change.

Whenever healthcare organizations aim to control operations costs, it is common for non–revenue-generating departments, such as the SPD, be experience budgetary reductions. SP leaders are often asked to justify their staffing, even when replacing a budgeted position. Additionally, some organizations hire consultants to evaluable labor costs. SP leaders should be prepared to show which tasks their employees perform daily, and the average time and human resource needed to complete each task. Being able to show productivity for each area, from decontamination through distribution and storage will be beneficial for ensuring the SPD doesn’t lose valuable staff members.

Author’s note: Even after demonstrating our productivity to a consultant, they focused on the number of employees staffed in each area of our department. Without considering any of the key metrics we documented and shared, they questioned why we had two or three people working in decontamination. I explained that several items being decontaminated require timed cleaning processes that required far more than just spraying water and running them through the washer. I also explained that each instrument is washed manually and inspected, and the tray must be organized so the washer’s manifold arms can effectively clean what may have been missed during manual cleaning — all steps that require extra time and due diligence. Sharing the IFU was especially effective because it helped justify our resource requirements. The consultants seemed impressed by how we explained our processes and provided specific metrics to support our needs.

In conclusion, developing resource metrics and documenting time studies for each task is a detailed yet valuable undertaking for capturing accurate productivity. SP professionals should be proud of the many critical roles they perform each day, and their leaders should be prepared to consistently document and report productivity findings to justify staffing and other resource needs.

Tony Thurmond, CRCST, CHL, CIS, FCS, is a past-president of the Healthcare Sterile Processing Association (HSPA), as well as a Fellow and columnist for the organization. He serves as sterile processing manager for Dayton Children’s Hospital.