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Infection Prevention
Are Those Instrument Sets Ready Yet?
Steve Johnson
Publish Date: October 10, 2007   |  Tags:   Infection Prevention

Steve Johnson The OR staff wants all instruments to be available at all times. That's reasonable, but it's not always possible, especially when we in the sterile processing department have to take apart and reassemble multi-part instruments. Here's how the OR team and the central supply staff can work together to ensure quicker turnaround on reprocessed instrument sets.

Steve Johnson\ Communicate.
OR staff can assist central sterile by giving us as much advance notice as possible on surgical schedules and add-on cases. This lets the CSP staff evaluate the equipment inventory and ensure sufficient scheduling so that it has adequate assets on hand. It's also up to CSP staff to maintain an awareness of the day's needs, to monitor the surgical schedule to better plan sterilizer and staff time, and to prioritize instrument processing. In addition, the facility should provide in-services for CSP staff on how devices are used, and in-services for OR staff on handling and delivering the devices for reprocessing.

Soak instruments right away.
You're more likely to get instruments reprocessed quickly if you deliver them to CSP immersed in soaking containers filled with enzymatic cleaner. This begins the cleaning process (the enzyme function removes gross soil and debris, especially in difficult-to-reach areas) and helps speed the rest of the cleaning process. If you don't let gross contamination dry on instruments, it comes off a lot easier during manual or mechanical cleaning.

Designate staff who'll reassemble multi-part instruments.
One key step we took to improve instrument set quality and turnaround time was identifying key staff to assign to assembly. As you know, you must carefully inspect and clean items requiring disassembly, keeping all parts together to avoid loss. It's easier to train just a few staff on each device manufacturers' instructions for cleaning, the approved cleaning agents and proper tools (such as appropriate-sized brushes). In addition, staff need to have an understanding of how each device functions in order to avoid damage during the cleaning process. Specialized staff have less to remember off the tops of their heads, which lessens the possibility they will make a mistake. Even though we minimized the number of staff routinely assigned to instrument assembly, the increase in expertise levels has improved service quality.

Check and track multi-part instruments.
Several multi-part instruments require special attention. For example, you must gently handle and rigorously clean laparoscopic instruments to ensure decontamination.

You can disassemble some newer devices for better cleaning, but this increases the challenges to processing staff. For example, many orthopedic implant sets contain multiple parts that work together as system, and therefore all must be present and functional. In addition, you must also track drill bits and taps to ensure the correct sizes are reprocessed and re-stocked.

Some other crucial checks:

  • Test scissors for sharpness using an approved method or product.
  • Inspect drill bits for sharpness and removal of all bone within the flutes.
  • Check bone-cutting instruments for sharpness and cleanliness.
  • Inspect needle holders for excess wear or cracks in the carbide inserts.

Here's a good tip: Place a repair bin near the assembly area for items in need of repair. Once assembled, supply staff must sterilize and affix load- or device-tracking labels, which would help you locate instruments in the event of a sterilizer malfunction or recall.

Steve Johnso\n Don't overload.
It is counterintuitive, but you can't turn out sterile instruments more quickly simply by doing more at a time. In order to ensure adequate mechanical cleaning, you must avoid excess density in each basket, as well as overstacking many baskets. Even if you've brushed the teeth of a DeBakey tissue forceps, it might not get completely clean if the water and detergent used in the manual washer can't reach the surface of the instrument.

Prepare instrument washer loads by opening instrument box locks, organizing washer baskets to keep sets from being mixed and arranging the baskets to ensure all items come in contact with detergent and spray action. You may need to separate instrument sets into several baskets to allow thorough, proper washing.

Same goes for loads in your sterilizer. You must address such factors as weight and density. Surgical staff tend to lean toward the convenience of having what they need in as few trays as possible. This practice tends to drive up the weights of instrument sets, which may not only inhibit sterilant-instrument contact, but also create safety issues (loads can get heavy quickly). Remember, if instruments aren't clean or sterile and you need to run them through again, you're not saving time.

The AORN, AAMI and IAHCSMM all provide guidelines and recommendations for loading the manual washer, as do manufacturers.

Keep references handy.
Once the cleaning process is complete, the assembly process begins. CSP staff should again follow consistent procedures for assembly of surgical instruments, sets and equipment to ensure the best outcome.

They must prepare all items for the correct method of sterilization based on the device manufacturers' instructions - it is helpful to have these available for staff reference during assembly. Catalogs and instructions for all processed items are invaluable references as well as teaching tools. Assembly technicians should use written instructions or count sheets for items they're processing. CSP staff must inspect all items for functionality and cleanliness before sterilization. There are available aids for staff use in visualizing surgical instruments; these include magnifying glasses, jewelers loupes and commercial video camera/magnifying systems.

All departments these days are measured for productivity against internal financial indicators and external benchmarking sources. CSP is no different. Instead of dreading such comparisons, consider them guideposts to ensure that central sterile performs well.

One area to look at is instrument repairs. A good indicator of CSP's attention to detail is the volume of instruments reprocessing staff are identifying as in need of repair. You should also track the number of items returned by the OR as unusable. That way, you'll know if reprocessing staff are either not inspecting instruments closely enough - or improperly handling or assembling instruments.

The number of items the OR returns should be far lower than the number of items your reprocessing staff identifies as needing repair. You don't want the surgeons and end users to be the primary source of identification for unserviceable surgical instruments. It's not only a service issue, but also one of patient safety. Another area of focus should be sterility assurance. You should be able to validate your processes. Carefully monitor each cycle chemically, biologically and mechanically, and document maintenance and testing of equipment.