When Good Intentions in Facilities Created Trouble in Sterile Processing
It began with stains. Not debris. Not bacteria. No visible contamination in the water.
Stains. A faint discoloration on surgical instruments – A brownish tinge. SPD did what any department would do. They reviewed their process. Checked their detergents. Inspected their washers. Everything appeared normal. But the staining persisted. That’s when Len Sparks was called.
The First Suspicion
When discoloration appears on instruments, water is often the first suspect. And in this case, water was involved. But not in the way anyone expected.
“The facility thought they were solving one problem,” Len explains. “But they were creating another one.”
Clue #1: The Overcorrection
Facilities management had been working to reduce bacteria levels in incoming municipal water. A responsible goal. In one case, chlorine or chloramine injection was being heavily dosed into the system. In another, copper and silver ionization was being used as a disinfectant strategy. The idea was simple: More disinfectant = less bacteria.
But in sterile processing, water isn’t just about killing bacteria. It’s about balance.
The Copper Problem
In this particular hospital, copper levels were elevated throughout the building. Not from pipes. Not from fixtures. From deliberate copper injection upstream.
The result? Copper concentrations exceeded the recommended levels outlined in ANSI/AAMI ST108 — both for Utility Water and beyond what the Critical Water system could effectively remove. Reverse osmosis removes a high percentage of metals. Deionization removes more. But if the incoming concentration is too high, those systems can be overwhelmed.
“RO systems work great. DI systems work great,” Len says. “But if there’s too much to start off with, it’s not going to bring it down to the low levels you need.”
The hospital didn’t know. Every fixture tested high. Every location. The disinfectant strategy had quietly become a contamination source.
The Symptoms in SPD
What did SPD see? Staining. Discoloration. Surface changes that looked like chemical residue. They were correct that it was water-related. They just didn’t realize they were contributing to the condition indirectly.
The Temperature Trap
Copper wasn’t the only example. Len describes another common “good intention” gone wrong: raising hot water temperature to control bacteria.
Facilities sometimes push hot water systems to 140°F… even 150°F… believing it will reduce microbial growth. But in Sterile Processing? That can create a different issue entirely.
“If it comes into SPD that hot, it’s the worst thing for washing off blood. You’re almost baking it onto the instruments.”
Anyone who has tried removing blood from fabric knows this principle. Hot water coagulates blood. It fixes proteins to surfaces.
And enzymatic detergents? Many are designed to operate below certain thresholds — often 120°F to 130°F. Too hot, and enzymes denature. Too cold, and they underperform.
Water quality is not about extremes. It’s about parameters.
The Pressure Illusion
Then there’s water pressure.
A gauge reads 60 PSI. Looks fine. But what if pressure dips to 40 PSI for brief periods throughout the day?
Without real-time monitoring, you’d never know.
“You look at the gauge and think, ‘We’ve got 60 PSI. I don’t see the problem.’ But that’s just a single data point.”
Intermittent pressure drops can fault out washers, disrupt cycles, or create inconsistent results. But unless someone is monitoring continuously, the cause remains hidden.
The Bigger Lesson: ST108 Isn’t Just Six Numbers
Many facilities focus on the “heavy hitters” in ST108:
Bacteria
Endotoxin
Hardness
Alkalinity
pH
Conductivity
Those matter. But there’s another table. Eighteen additional parameters – Copper included. And while those may not have prescribed monthly frequencies, they still require awareness.
“If you’re barely passing on those, you may need to add that to your monthly testing. If you only test it once a year, you don’t really know.”
The problem isn’t ignorance.
It’s assumption. Assuming that solving bacteria upstream won’t affect SPD. Assuming that more disinfectant is always better. Assuming that higher temperature always improves sanitation.
Water is chemistry. Chemistry is balance.
The Detective Mindset
What made this case unusual wasn’t that water was the issue. It was that the hospital was causing its own problem — unintentionally. No one meant to harm instrument integrity. No one meant to exceed copper thresholds. No one meant to denature detergents. But Sterile Processing wasn’t part of the Facilities conversation. And that gap created the mystery.
Closing the Case
Once copper injection levels were adjusted… Once temperature parameters were reviewed… Once monitoring became more than a glance at a gauge… The staining resolved. Not because the water system was replaced. But because it was recalibrated.
Final Question
Is your facility solving one water problem while quietly creating another?
Water quality in sterile processing isn’t just about removing contaminants. It’s about understanding how upstream decisions impact downstream performance. Sometimes the issue isn’t contamination. It’s overcorrection. And the clues are hiding in the numbers you’re not watching.
If you need detective-level help solving SPD water quality issues, Contact Us
