Caring for Surgical Instruments and Medical Devices

Tools of the Trade
Caring for Surgical Instruments and Medical Devices 

By Kris Ellis

Every ambulatory surgery center (ASC) must make a significant investment in the instrumentation that is necessary for it to function. In order to best protect this investment, and its patients, a facility should become intimately familiar with best practices for surgical instrument and device handling, cleaning, sterilization, maintenance, and repair.

Instrument damage can occur anywhere in an ASC. This includes in the operating room (OR), while an instrument is being used. Keeping instruments free of blood and debris whenever possible can be a helpful practice, according to Patti Koncur, CRCST, CHMMC, ACE, director of clinical operations for Integrated Medical Systems International, Inc. “Blood should be wiped from the instrument as soon as it’s handed back to the scrub. Sterile water should be used because there’s chlorine in blood, and it can start to eat away at your instrument. The other reason is that once the blood starts drying, it becomes much more difficult to get off, and much harder to present a clean instrument for assembly. The main thing is that it starts degrading your instruments, so you don’t get the full life out of them; you start to get pitted instruments.”

The Association for periOperative Registered Nurses (AORN’s) Recommended Practices for Cleaning and Caring for Surgical Instruments and Powered Equipment specify that instruments should be kept free of gross soil during surgical procedures.¹ AORN also notes that instruments should be wiped with sponges that are moistened with sterile water since corrosion, rusting, and pitting can occur when blood and debris are allowed to dry in or on surgical instruments. Cannulated or lumened instruments may become obstructed with organic material; irrigating instruments with sterile water helps remove residue. Saline causes deterioration of instrument surfaces and should not be used.

Healthcare workers (HCWs) should also be cautious about what they use instruments to do. “Many times you’ll see people use instruments inappropriately,” Koncur points out. “They’ll use a tissue scissor to cut a suture, which will ruin your scissor. They’ll also use a kocker to help pull out pins and screws on orthopedic cases. Obviously if you’re using instruments to pull out orthopedic screws, it will cause the instrument to come out of alignment, if it doesn’t snap at the box locks or the ratchet. At the very least there’s a repair cost involved.”

Other examples of improper instrument use include:²

• Hemostats are designed to clamp blood vessels and should not be used as towel clips or medicine vial cap removers; this can cause cracking in box-lock areas 
• Scissors that are designed for cutting tissue should not be used to cut sutures or wire, which can cause the blades to chip and misalign 
• Needle holders should be used only for holding and driving the appropriate-sized needles, not for pin or wire removal. This can cause the jaws to become deformed and misaligned 
• Microsurgical instrumentation can be damaged very easily and should only be used for delicate procedures 

The most common way that instruments become damaged or worn is through normal use, contends Alex Vrancich, vice president/general manager, Spectrum Surgical Instruments. “Similar to the tires or brakes on our cars, the more you use them, the more you need to service or replace them. However, one trend that we see over and over again is the need to increase inventory levels. If we notice a particular scope, piece of power equipment, or instrument set is in constant need of service, it tells us that it’s usually being used too frequently. The best way to offset this problem is to increase your inventory of those items which break most often. It’s sometimes a difficult decision, because it requires dollars up front, but in the long run it will pay off.”

Due to the fast pace of most ASCs, instruments that are coming from the surgical field to the decontamination area are oftentimes thrown on top of each other into pans or baskets, causing damage to some of the more delicate instruments and devices, notes Mark Paquette, surgical equipment specialist and territory manager for Michigan at Mobile Instrument Service. “It’s the most common source of abuse and damage,” he says. “Also, a high staff turnover rate often results in a higher volume of broken instruments.”

To avoid damage to instruments, ASCs should set up a procedure for certain tray types to be put in multiple pans after surgery, suggests Paquette. “Put delicate instruments in one pan, and place heavy instruments in a separate pan. It’s so simple, but effective. Washers should be inspected regularly and in-services should be performed on a regular basis to help maintain the life of all instruments and care and handling of scopes, cameras, and power equipment.”

Koncur also asserts that the manner in which instruments are handled is critical. “On the field, they’re usually handled very gently, but when the case is over, you see people start to pick instruments up and throw them or drop them in the pan, which causes damage.” When damaged instruments are kept in service, they can cause unnecessary stress to the patient. “If you have scissors that don’t cut properly, the suture line takes longer to heal and there’s more chance for infection.” When a case is done, some kind of enzymatic spray should be used, or a moist towel to cover the instruments, Koncur adds. “They shouldn’t be left in water; that will start the rust process.”

When instruments reach the decontamination area, they need to be cleaned and inspected as soon as possible, Koncur emphasizes. “It does come in floods; you never get one tray at a time, but you should get to it as soon as you can, especially if the gross blood isn’t getting cleaned off using an enzymatic spray solution, or using a moist towel. Again, you don’t dump the instruments into anything; you treat them like they’re delicate. Just because something is stainless steel doesn’t mean it’s not going to break.”

Each instrument needs to be disassembled as much as possible, according to the manufacturer’s recommendations. “The appropriate cleaning chemicals must be used — usually a multipurpose enzyme in decontam,” Koncur continues. For lumens, proper-sized cleaning brushes are a must. “You need an array of brushes to be able to clean the crevices of the various instruments. Putting a couple dollars more into the proper cleaning brushes will save you a lot of dollars down the road because it will increase the life of your instruments.”

One aspect of cleaning that is frequently overlooked is what type of solution is being used, Koncur says. “A disinfectant may be used instead of an enzyme. The instrument needs to be cleaned before it’s disinfected, or else you’re deactivating the disinfectant. Again, be careful what you use — any abrasive cleansers should not be in there, such as hydrogen peroxide, bleach, and steel wool pads. You should be using items that are approved for instrument cleaning, and you can get those from multiple manufacturers. If you’re using the wrong chemicals, they can eat through the chromium oxide layer on the instrument; that’s called the passivation layer. That actually protects the instrument against rusting and pitting, and if you’re using the wrong chemicals they’re going to eat through that layer and ruin the instrument.”

Cynthia Spry, RN, MS, an international clinical consultant for Advanced Sterilization Products, suspects that there’s not always an appreciation for the fact that cleaning is the most important step in instrument processing. “If you can’t clean it, you cannot ever guarantee the sterility,” she says. “The sterilization machinery will work fine, but if instruments haven’t been properly cleaned, they won’t become sterile.”

Spry says automated decontamination systems are always preferred, because they offer a consistent process. Many ASCs don’t have automated systems, however, in which case it’s done manually. “One of the most important and simplest things that can be overlooked is actually following the instructions on the detergent label,” she comments. “For example, if it says one ounce of detergent to one liter of water, people sometimes just put a squirt in the sink, or if it’s really dirty they might put in a couple extra squirts, or they may not have the exact concentration mix specified. That concentration is very important.

“You also need to look very carefully at the kinds of procedures that you’re doing and what kind of bio-burden is generated,” Spry continues. “If it’s a facility that does all kinds of surgery, they may want a detergent that’s geared toward that, but if it’s strictly vascular or strictly orthopedic, those procedures will generate different kinds of bioburden, and you need to look at the enzymatic detergent, because there are detergents that are specifically intended for those types of bioburden, whether it’s blood or fat, etc.”

Spry also emphasizes the importance of rinsing. “Sometimes people just run it under the faucet and think it’s rinsed, but it may need to be immersed, or it may need more than one rinse; it’s very important to read the instructions and follow them. In ASCs you might have a nurse who is well-educated doing these things, but if it’s a large facility you may have technicians who are strictly responsible for instrument processing or decontamination. I think it’s important to make sure that they can read and understand those labels. Not that they’re ignorant, but English might not be their first language.”

The types of procedures performed at a surgery center may also impact the types of cleaning errors that are made. “Many surgery centers that perform ophthalmic cases tend to have problems with instruments,” Vrancich points out. “Because there is such a rush to get the sets turned around faster, we often find that steps are missed during the decontamination and sterilization processes. In addition, improper solutions are sometimes used (such as saline) that cause the instruments to rust prematurely. This is why education is so important. Your repair vendor should be able and willing to conduct staff training to help address such concerns.”

Koncur also advises caution when using an acid-based cleaner or rust remover; in these cases, an instrument should not soak for a long period of time. “That can remove not only the rust, but also the passivation layer, and degrade the instrument very quickly. With power equipment, your chords or batteries should be in place when you’re cleaning it. That keeps water from getting into the unit. When the piece of equipment is clean, then you remove the chord and finish cleaning that. If a manufacturer recommends that an item should be lubricated, then it needs to be done. You shouldn’t immerse power equipment at all, because water can get inside and you can get calcium deposits in there that will necessitate a major repair.”

With endoscopic equipment, HCWs should take great care to follow all the manufacturers’ recommendations. “Make sure they’re flushed properly, or else you’re going to have blood left down in the lumens,” Koncur says. “If you don’t have an automatic machine to do that, you need to spend a lot of time on that and make sure all the blood is out. With mechanical cleaning methods, again you want to make sure you have a good quality detergent that won’t hurt your instrument. There are products on the market that they say will clean it faster, but if it’s acid-based or very neutral, you need to have another chemical to counter-balance that. Make sure your chemicals are compatible.” 

After instruments are disassembled in the decontamination area, they need to be assembled again to make sure no parts or pieces are missing, and that the instruments work as they should. “They should be disassembled again after that for sterilization,” Koncur states. “Some instruments can be sterilized while assembled, some cannot — you must check the manufacturers’ recommendations. Many of them cannot; things as simple as a Frazier suction with a stylette, the inner lumen isn’t sterile, so you have the stylette in place; there’s no way to get the sterilant into the instrument.”

In terms of guidance and standards that address the decontamination and sterilization processes, excellent resources do exist. “It’s really important to look at the AAMI (Association for the Advancement of Medical Instrumentation) guidelines,” Spry notes. “Every facility should be following those. There are also guidelines from the International Association of Healthcare Central Service Materiel Management (IAHCSMM), and from the American Society of Healthcare Central Service Professionals (ASHCSP). AORN also has guidelines, and they’re all fairly congruent. If you’re doing flexible endoscopy procedures, you must follow the SGNA (Society of Gastroenterology Nurses and Associates) guidelines or the Multi-society Guideline for Reprocessing Flexible Gastrointestinal Endoscopes. That’s critical.”

After sterilization, instruments must be stored correctly. “If instruments are wrapped, you need to avoid stacking,” Koncur advises. “When you stack a tray, the weight of the upper tray is compressing the tray below it. When you lift that tray up, it’s going to suck air into it, so you may be contaminating the tray. The storage area needs to be kept clean as well. Every area needs to be as surgically clean as the OR. Dust is a contaminant; you need to keep the whole area as dust-free as possible.”

In order for ASCs to maintain their instruments in the best possible condition, Vrancich strongly recommends preventative maintenance. “I can’t stress this enough,” he says. “I will draw again on the car analogy; we don’t drive our cars until the engine blows up. We preventatively maintain the vehicle through oil changes, tuneups, etc. When it comes to surgical instruments, whether it’s an expensive piece of power equipment, or a scissor, the best thing you can do is put it on a regular service plan. This allows us to find small problems before they become big problems. Once again, this is a difficult decision to make, as it requires spending money up front.”

Koncur also promotes this idea. “If instruments are not checked periodically and sharpened or tightened, etc. as they need to be, then they start to work out of their designed parameters and need to be replaced pretty quickly. If you take care of your instruments they should be with you for 20 years to 30 years easily.”

1. Association of periOperative Registered Nurses. Recommended practices for cleaning and caring for surgical instruments and powered equipment. AORN J. 2002 Mar;75(3):627-30, 633-6, 638 passim.

2. IAHCSMM self-study series: Care and Maintenance of Surgical Instrumentation. https://www.continuinged.purdue.edu/iahcsmm/pdf/Lesson87.pdf