PROTECTING YOUR INVESTMENT:
Why Instrument Care is So Important to Today’s ASCs
By Jennifer Schraag
“Instruments, like other tools, will last a long time if they are cared for properly and receive regular maintenance,” says Natalie Lind, educational director for the International Association of Healthcare Central Service Materiel Management (IAHCSMM). “When they are handled roughly, used improperly, or exposed to harsh chemicals, they may be damaged, or their life may be shortened, which will require more frequent replacement.”
Lind advises that all staff who come in contact with a center’s instruments be briefed about the cost of those instruments and the proper handling procedures. In addition, she recommends providing adequate time for processing and operating room (OR) turnaround so that staff has the time to handle instruments carefully and perform proper inspections. “Incorporate the use of digital cameras to aid in the training of instrument assembly and decontamination technicians,” she adds.
Cory S. Nestman, senior professional service consultant for SterilTek Inc., a wholly-owned subsidiary of STERIS Corporation, says, “An ounce of prevention is worth thousands in the world of surgical instrument reprocessing.”
“Effective care and handling of instruments has a huge impact on repair and replacement budgets,” she explains. “Some hospitals spend anywhere from $250,000 to $1,000,000 on instrument replacement and repair — annually.”
She offers the following tips for the regular, proper care of instruments:
- Always consider an instrument contaminated if it’s been to a patient care area or was used in a procedure. Decontamination begins at the point of use, so during the procedure, wipe, and flush or suction instruments so that gross contaminate does not accumulate and dry on its surfaces. Place soiled instruments back into their original basket or container and apply either a moistening agent or spray/foam enzyme to start the pre-cleaning process pending transportation to the decontamination area in central sterile (CS).
- In the decontamination area, instruments are pre-cleaned to remove soils in any tough-to-clean places (such as lumens) before they are processed in automated washers. Make sure that instruments are in an open position to go through any automated washer, and baskets are arranged on washer manifolds to allow maximum washing effectiveness. Run automated washers with the correct cleaning chemistries and water treatments to avoid staining and damaging instruments. Manually clean instruments that are not designed to be processed through mechanical washers according to the manufacturer’s directions, including the use of the right chemicals, copious rinsing, thorough drying and safe pass-through into the assembly side of the CS department. With the exception of implants, process instruments with a lubricant as part of the automated washing cycle.
- After the washing/disinfection process, inspect all instruments and test them prior to packaging for sterilization. The use of a magnification light is helpful for micro/delicate instruments. Test and prepare the instruments for sterilization according to the manufacturer’s recommendations (some power instruments require lubricant). In addition, dry the instruments to avoid rust or other deposits that can cause staining. Test all cutting instruments by actually cutting with them, since chips, barbs or uneven surfaces can cause tearing of tissue. Test instruments with retracting or other action to ensure a smooth action and freedom from contaminates such as bone. Inspect instruments with tips and jaws for proper alignment and intact tips. Test instruments that grip or clamp for holding strength and inspect jaws for serrations or inserts that are in proper working order and are free from any visible soils.
- Arrange instruments according to their order of use in the OR and place them with enough space to avoid damage from crushing down a container lid or having other trays stacked on top.
- Steam used for sterilization must be pure, so use the recommended water filters to ensure that instruments are not stained. Check all linens placed in or used to wrap instrument trays for detergent or chemical residue that could stain the instruments.
- In general, disassemble all instruments as much as possible for cleaning, then reassemble and test them for full function before sterilization.
- Instruments should always be used for their intended purpose only.
“The key to proper instrument care is to ensure that OR and CS staffs are well trained in, and compliant to, the policies and procedures for proper use, care, handling, inspection and testing of surgical instruments,” Nestman adds.
She continues, “The most common mistakes come from a lack of standardization and control of the instrument process flow. This relates to the old ‘squeezing the balloon’ analogy. The pressure on surgical staff to turn rooms over results in rushing to get instruments out of the OR and on their way to the CS department. OR staff thinks CS staff has more time to sort, straighten and clean. On the other side, CS personnel receive many cases of mixed-up instruments and are expected to sort, decontaminate, and reprocess everything quickly. In many cases, the CS staff does not have the time they need to inspect and test every instrument to ensure its proper function and still meet the customer demand for instruments and supplies. In many cases instrument abuse occurs in the CS department from a lack of adequate supervision, space, equipment and/or people to assemble the trays. It is very common to see instrument sets stacked and baskets overcrowded and mistreated.”
As Lind points out, improperly processed instruments not only increase the risk of infection, but if their function is impeded, they may also pose other threats to the patient. “For example, a cracked instrument may break when pressure is applied during a procedure. Incomplete instrument sets or nonfunctional instruments may cause procedures to be canceled or worse yet, if they go unnoticed, they could cause serious problems during a procedure.”
Nestman adds that there is potential for a foreign body (i.e. screw or tip from an instrument) to be left in a patient as a result of a damaged surgical instrument, and she says this incidence has increased. “This is one of the primary focuses of the JCAHO patient safety goals,” she explains, adding, “If the surgical nurses must search for and inspect instruments due to lack of attention during the reprocessing cycle, their focus is taken away from their surgical patients. In general, surgical departments (that) pay attention to the care and handling of all surgical instruments lower the risk for the patients at their facility.”
Automating the cleaning and instrument tracking process, and standardizing employee work practices is an effective way to improve efficiency and capacity in the CS department. Nestman advises that if hospitals want to reduce risks to patients and reduce costs for instruments, time and money must be devoted to staff education and training, validation of competency, and standardization of work practices in each phase of the instrument process. Furthermore, the procedures should follow all device and equipment manufacturers’ recommendations for the processing of devices and the use of the disinfection and sterilization equipment. “Surgical instruments and their integrity are the responsibility of everyone in the CS department and the surgical suite, and all policies, procedures and training should emphasize this,” she asserts.
According to Jack Kinville, marketing manager at Ruhof Healthcare, an important factor in reducing the risk of cross-contamination to patients and damage to the instruments is the enzymatic detergent used to clean the instruments. Kinville says the most common detergents used today are single- and dual-enzyme detergents which are designed to remove only blood and protein. “Other components of bioburden such as fats and starches are left on the instruments leaving them contaminated and unsafe to use,” he shares. “Also, bioburden left on an instrument breaks down and turns to salt which will cause rust and corrosion on the instruments. By choosing a multi-tiered enzymatic detergent, all components of bioburden are removed, leaving instruments and scopes free of contaminants and safe to use.”
Nestman offers that some use a third-party vendor for routine maintenance of instruments (i.e. sharpening, polishing, alignments, etc.) and, she says, this has proven to prolong the life of instruments and increase surgeon satisfaction.
“However, the facility should have a systematic approach to tracking these maintenance and repair activities so that money is not wasted and all instruments needing attention are rotated appropriately.”
Nestman adds that automated tray and instrument-level tracking systems are an effective way to get the most “bang for the buck” on instrument repairs. “Also, the use of instrument repair tags (usually red plastic tags that are affixed to a non-functioning or damaged instrument at the point-of-use) helps to increase the life of the instrument and reduces the risk to the patient from a malfunctioning instrument that is put back into a tray for reprocessing. These tags must be readily available to the OR staff and a policy for their use must be clearly specified.”
Kathy Dix contributed to this article.
PATIENCE, CARE, AND ACCOUNTABILITY:
Extending The Life Of Your Surgical Instruments
By Robert Edelstein
With procedural volume on the increase at most outpatient centers, a rushed approach to surgical instrument set processing has become more the rule than the exception. Although maintaining surgical instruments at their optimal condition requires significant time and resources, the price pales in comparison to costly repairs and replacements as well as the potential damage of a decline in patient safety.
Preserving your instrumentation is a savings measure in itself, since replacement of worn and damaged surgical instruments can cost hundreds or thousands of dollars per month. Poorly-maintained equipment jeopardizes not only surgeon satisfaction but patient care as well. Rushed processes invite lawsuits and a compromised JCAHO accreditation, which no facility can afford.
If a surgical hospital or ASC expends time, effort and experience to proactively handle, clean, decontaminate, service (as necessary) and sterilize its surgical instruments, the investment will yield greater surgeon satisfaction, fewer purchases and repairs, and increased patient safety. Some practical suggestions:
Organization, Prevention and Accountability
The edges of scissors and other sharp devices can degrade through contact with other instruments. Organize your instruments, using stringers when possible.
Lubrication (or “milking”) is a similarly proactive approach that provides a veil of protection from the metal-upon-metal friction of moving joints. The Association of periOperative Registered Nurses (AORN) recommends that all decontaminated instruments with moving parts be bathed in a water-soluble lubricant after each mechanical processing, unless the manufacturer advises otherwise.
Efficient instrument sets can also extend the life of equipment. Know your inventory: Catalog the facility’s instruments and track those that are most frequently used. Increase inventory of high-use items, spreading wear-and-tear over a wider supply. Streamlined instrument sets can be created using in-demand instruments, making favorites more accessible while devoting fewer resources to seldom-used items.
Cleaning, Inspection and Testing
When the bioburden is not completely removed, the box lock and hinge areas of needle holders and forceps can function poorly, becoming stiff and/or cracking during autoclaving. Use instrument cleaning brushes to remove organic material and stringers to keep instruments in open positions during washing and sterilization.
“The most important thing would be to get instruments cleaned as soon after the procedure as possible,” says Joan Blanchard, RN, MSS, CNOR, CCI, and a perioperative nurse specialist at the AORN’s Center for Nursing Practice. “This means taking instruments apart and making sure all the surfaces and parts are exposed to the cleaning process. Blood can be corrosive.”
Disassembling or flushing reusable laparoscopic graspers, needle holders and forceps is another way to divest this material. Each insulated instrument needs to be tested before including it on a tray. Implement a testing system, and consider assigning more than one person to this task when building such complex trays.
Micro surgical instruments are particularly vulnerable to damage. Examine the tips of micro forceps before adding them to a tray to make sure they are intact. A lighted magnifying glass is suggested for these and other inspections.
In addition to function, instruments in general should be examined for pitting, corrosion, etc. If pitting or corrosion is evident, examine the cleaning and sterilization process and water quality as well as the quality of the instruments. Instruments that are sold for $5 to $7 are low-grade, no matter what the vendor claims.
Avoiding Flash Sterilization
Flash sterilization was originally meant to immediately sterilize an irreplaceable device that has been contaminated in the operating room. Today, however, the process is employed more as a standard procedure due to insufficient inventory. This is especially common in orthopedics and ophthalmology cases.
The rapid heating and cooling cycles in flash sterilization cause stress and harm to stainless steel. Repetition of this process will significantly decrease the lifespan of an instrument. For that reason (and due to an increased risk of infection), flash sterilization should be applied only when there is no time to process an instrument by the preferred wrapped or container method. It’s not an acceptable solution to deficient inventory.
Since this method may still be necessary in certain instances, establish guidelines defining which situations are appropriate. Have someone of authority acknowledge when the method is used. Many facilities report that rules are followed more diligently when personnel are aware they are being observed.
In the end, the application of patience, accountability and expertise in handling surgical instruments will prevail over corner-cutting and rushed or sloppy management. As with any crucial investment — a car, a home — surgical instruments will cost you more if you neglect them. And in the life-or-death OR, the consequences can be far more dire than breaking down on the highway.
Robert Edelstein, president of Millennium Surgical Corp., has close to two decades of experience equipping new centers with surgical instruments through both Millennium and his equipment consulting firm, Streamline Surgical Solutions.
INSTRUMENT CARE BEGINS AT POINT-OF-USE
By Susie McDonald, RN, FCSP
Instrument care is a collaborative effort and should be a shared responsibility between the operating room (OR) and the central sterile/sterile processing department (CS/SPD). Everyone involved needs to be aware of what steps can be taken to keep the instruments in optimum condition.
Even though the central processing staff may ultimately be the eyes of the final inspection of surgical instruments, reducing instrument damage and costly repairs can begin at the surgical site.
Surgical technology instructors and nurse educators in the ORs not only teach their staff the proper way to handle and set up instruments for procedures, they also teach them the proper way to care for them during and after a surgical procedure. Keeping the instruments clean and free from gross blood, tissue, bone, etc., during a surgical procedure can play a vital role in instrument maintenance. Keeping instruments free of gross blood during a surgical procedure can help reduce the pitting of the instruments.
The CS/SPD department in turn, needs to be aware of the urgency to remove blood as soon as they receive the instruments. Immediate attention to instruments grossly contaminated with blood can greatly reduce the effect the blood will have on the instruments. It is the responsibility of the CS/SPD technician in decontamination to process instruments as soon as possible, but sometimes they may need to prioritize which instruments need immediate attention based on the amount of visible bioburden.
Another important aspect of instrument handling at the surgical site is careful disassembly and arrangement of used instruments at the end of the procedure. Large incisional retractors should be disassembled and placed at the bottom of the tray or basin used to transport instruments to the decontamination area. Very heavy instruments and mallets should also be placed at the bottom of the tray or basin. Taking the time and effort to arrange the instruments appropriately after a procedure will also help the facility avoid needless damage and repair expenses.
CS/SPD plays a vital role by properly handling instruments. Proper instrument disassembly and decontamination must be thoroughly taught to all CS/SPD technicians. This is one more reason it is vital to have your CS/SPD technicians trained and certified.
After the surgical procedure is complete, the OR staff should use the wall suction to run water or alcohol through any reusable suction, especially very delicate suctions. This simple flushing can expedite the cleaning process in the decontamination area. There have been many instances that an entire tray of instruments is held in the decontamination area of CS/SPD because the suctions are hopelessly clogged and endless time is spent trying to find a way to clear the lumens.
Last, but certainly not least, there is a great deal of time spent opening all the instruments in each instrument tray that is returned to CS/SPD’s decontamination area. Instruments cannot be cleaned if they are closed; therefore each instrument has to be handled by the decontamination staff to make sure they are in the open position. Unused instruments as well as used instruments should be fully opened and carefully placed in the tray or basin by the OR staff before they send the instruments to CS/SPD.
Susie McDonald, RN, FCSP, is the past president of the American Society for Healthcare Central Service Professionals (ASHCSP), and currently serves as sterile processing department manager at Winter Park Memorial Hospital, a division of Florida Hospital.