By Don Sadler
Communication is key to extending instrument life and promoting patient safety
Of all the different kinds of medical instruments found in a hospital setting, surgical instruments are among the most sensitive and delicate. To prevent damage to the instruments and promote patient safety, it is critical that OR nurses and technicians exercise the utmost care and precaution when handling, cleaning and sterilizing surgical instruments.
“The importance of proper care and handling of surgical instruments cannot be understated,” says Natalie Lind, educational director for the International Association of Healthcare Central Service Materiel Management (IAHCSMM). “Patient safety depends on sterile, functional instrumentation.”
“Delicate care must be taken when handling and cleaning surgical instruments,” adds Ron Runyon, CRCST, supply chain manager at St. Vincent Hospital in Indianapolis, Ind. “This requires both knowledge and understanding of the complexities involved. An instrument can be ruined before it ever makes it back to sterile processing.”
The Cornerstone of SSI Prevention
Ramona L. Conner, MSN, RN, CNOR, manager of Standards and Recommended Practices for the Association of perioperative Registered Nurses (AORN) and co-chair of ST79, AAMI standards committee, says that improper handling and cleaning of surgical instruments can cause many problems. “This includes potentially leading to surgical site infections.” “Sterility is the cornerstone of SSI prevention,” adds Ann Marie Pettis, RN, BSN, CIC, the director of infection prevention at the University of Rochester Medical Center in Rochester, N.Y. and the chair of the APIC’s Communications Committee.
Surgical instrument damage can take two forms, notes Lind: immediate damage, which immediately impairs the instrument’s function, and long-term damage, which shortens the instrument’s useful life.
“Immediate damage, such as bending forceps tips or dulling scissors, can render an instrument unusable or impact its performance, and this can lead to frustration and delays in the OR. Meanwhile, longer term damage, such as long-term exposure to saline, can break down an instrument’s surface and cause pitting and corrosion, which shorten the life of the instrument.”
Due to their many parts and crevices, not to mention techno- logical advancements, today’s surgical instruments have become harder to clean and sterilize. “Surgical instruments today are very complex and difficult to clean,” says Conner. “Hundreds of instruments are processed in hospitals every day, so proper sterilization and decontamination is a big challenge.”
According to Rose Seavey, an independent consultant on surgical services and sterile processing and member of the AAMI Steam Sterilization Hospital Practices Working Group, AAMI ST79, the “Comprehensive guide to steam sterilization and sterility assurance in health care facilities,” provides best practice recommendations built on sound principles, scien- tific data and expert opinions. “ST79 is a consensus document that gives us step-by-step procedures for cleaning and reprocessing reusable devices for health care facilities,” says Seavey.
“ST79 also details the training needed for reprocessing personnel and provides best practices for quality control, risk management and process monitoring,” she adds. “Following these proven, state-of-the-art practices helps ensure that devices are clean and sterile, promotes safe patient care, and protects health care workers from exposures.”
Because ST79 essentially consolidates five AAMI steam sterilization standards, it is a comprehensive guideline for all steam sterilization activities in health care facilities, regardless of the size of the sterilizer or the size of the facility. “It provides a resource for all health care personnel who use steam for sterilization,” says Seavey.
According to Sharon Greene- Golden, CRCST, FCS, SPD manager of BON SECOURS–Mary Immaculate Hospital in Newport News, Va., and IAHCSMM’s president-elect, proper procedures for surgical instrument cleaning are also included in the IAHCSMM Central Service Technical Manual, 7th Edition. “This states that instrument decontamination begins at point-of-use and is then contin- ued in the Central Service decontamination area.”
Greene-Golden adds that in AORN’s 2011 Recommended Practices, Recommendation IV states that instruments should be kept free of gross soil during surgical procedures. “This is called ‘point-of-use cleaning.’ Blood and body fluids can cause pitting of instruments and can be difficult to remove if left to dry, so we need the OR team to remove gross soil and body fluids from the instruments before they return them to the SPD. Then the instruments should be kept moist, either with a wet towel or some type of enzymatic spray that continues the breakdown of the bioburden.”
Conner notes that AORN’s Recommended Practices for OR instrument care and handling have been open for public com- ment, and updated Recommended Practices are expected to be published on June 1, 2012. “These RPs address instrument care and cleaning, packaging, high-level disinfection (or sterilization), and care and handling of flexible endoscopes. They’re all critical; if there’s a breakdown in any part of the process, this can result in a failure.”
Teamwork and Communication
All of the experts stress that teamwork and communication between the OR and SPD staff is critical to safe instrument care and handling. “This relationship is critical because they can’t function without each other,” says Greene-Golden.
“Teamwork is essential, as is the recognition that SPD is, in fact, part of the team,” adds David Jagrosse, CRCST, Central Service Department manager at Middle- sex Hospital in Middletown, Conn. “Care and cleaning of the instruments begins in the operat- ing room, which is often over- looked due to time constraints and sometimes a lack of knowledge in regard to what is required for proper instrument care and handling. But the SPD should be part of any preplanning and post-case evaluation of procedures to determine better outcomes.”
Pettis adds that the SPD and OR staff should come together after each case to plan ahead for future cases. “Team and cross- training can be helpful, like in the airline industry. Can hospital systems and processes be redefined for better workflow, like is done in the manufacturing industry via lean manufacturing process improvements and kaizen?”
In addition to proper cleaning and sterilization, Jagrosse also urges proper sorting and handling of instruments, which includes segregation of heavy instruments from lighter, more delicate instruments. “Set count sheets can be reviewed to deter- mine proper utilization of instruments, and properly prepping and sorting of used medical devices also facilitates faster instrument turnover, as does tagging and identifying STAT turnover items.”
“After point-of-use cleaning, all instruments should be accounted for on the instrument tray before the instrument set is sent back to the SPD,” adds Greene-Golden. “This will help ensure that the instruments are returned in an orderly manner and help SPD process them for the next use.”
Runyon encourages OR staff to return soiled instruments to the SPD as quickly as possible. “And be aware of any specific handling needs as they relate to varied instrumentation. A water rinse (not saline) and/or cursory wipe-down of soiled instrumentation is always appreciated—this really should be considered a standard of care.”
Follow Manufacturer’s Guidelines
Following the instrument manufacturer’s guidelines for handling, care and sterilization is also critical, say the experts. “The manufacturer of the medical device is ultimately the one who determines proper cleaning and sterilization though the Instructions For Use,” says Jagrosse.
“OR personnel should always follow the manufacturer’s guidelines in terms of how to clean and sterilize instruments,” adds Pettis. “And instruments should only be used for their intended purpose. Also, OR staff should not stack items on top of each other when they come out of the sterilizer unless they are placed in a rigid container.”
Ultimately, the care of instrumentation is the responsibility of all members of the surgical team, Greene-Golden stresses. “Proper care and handling from the OR to the SPD provides continuity from one patient to the next.”