Instrument Care Begins Immediately After Use

Linda Spaulding, RN, CIC, is a fixer of sorts. When facilities are having a problem with their infection control practices, they call her in to figure out how to solve it. Based on her experience of observing surgical teams in ORs across the country, she believes treating instruments at the point of use continues to be an issue. "I think it's an area some facilities could improve upon, usually because of a lack of knowledge about the practice," she says.

Scrub techs must keep instruments clean between uses throughout surgery and moist when they're no longer needed for the procedure because dried blood coats surfaces or causes the joints of scissors to stick, factors that impact how well the tools work. Failing to treat tools at the point of use also allows bioburden to dry on surfaces and in crevices, making it harder for reprocessing techs to remove it in decontamination. That means the instruments won't get clean, and instruments that aren't properly cleaned can't be properly sterilized.

Point-of-use preparation removes gross soil and helps to prolong the life of instruments. "Substances such as blood and saline can break down the devices' protective finish," says Ms. Spaulding. "Soil and debris that dry on instruments become harder to remove from lumens and crevices, causing further damage to the instruments."

She suggests keeping soiled instruments moist by spraying them with an enzyme product, soaking them in an enzyme solution or water, or placing a moist towel over them until they're ready to be moved to the decontamination area.

"It's best to begin cleaning instruments within 15 minutes to one hour after a procedure," says Ms. Spaulding. "Prolonged delays can negatively affect the instrumentation. Over time, dried blood and bodily fluids can cause instruments to stain, pit, rust or become dull."

Surgical techs often set up back tables in a variety of ways based on the instrument sets needed for a case, the type of procedure being performed, as well as their training and personal preference. June Van Hoose, RN, CNOR, manager of quality and safety at Parkland Health & Hospital System in Dallas, realized this lack of uniformity ultimately impacted how well — and how efficiently — instruments were handled during and after procedures.

She established a standardized back table set-up to ensure instruments are organized the same way during every case. A tray of basic instruments — the tools needed most often during a case — is lined up along the table's left edge, an open workspace is established next to the tray and a basin of sterile water is positioned at the top of the workspace.

The standardized set-up decreases the number of times procedures need to be paused due to missing instruments, improves overall case efficiencies and lets the team focus more on workflow and patient care than keeping instruments organized.

It also ensures tools are accessible and easily cleaned, regardless of which staff member is working the case. That instruments are kept organized helps to ensure the tools are cared for properly before being sent to sterile processing.

Ms. Van Hoose believes the standardized set-up allows surgical techs to reorganize instruments more easily before placing them in closed carts for transport to the decontamination area. For example, they're able to quickly group sharps together so reprocessing techs know they should take extra care when pulling the instruments out for cleaning.

When instruments arrive in the decontamination area, reprocessing techs get to work, and instruments that have been pre-treated in the OR are easier to clean.

"After cleaning and before being packaged for sterilization, instruments must be carefully inspected for cleanliness, proper functioning and alignment," says Ms. Spaulding. "They should be checked for corrosion, rust, pitting, nicks, cracks and chips. It can be difficult to see bone, tissue or blood wedged in crevices."

Appropriate lighting in the decontamination area reduces worker eye strain and impacts how well instruments are cleaned and inspected, says Ms. Spaulding. She points out that the Illuminating Engineering Society of North America recommends basing lighting levels at reprocessing workstations on the age of the workers: those younger than 40 years require the least amount of illuminance; 40- to 55-year-olds need an average amount; and workers older than 55 years old should have the highest amount.

In the instrument decontamination and inspection areas, where speed and accuracy are paramount, ancillary lighting is also needed. The Association for the Advancement of Medical Instrumentation recommends lighting the space with 1,000 lux to 2,000 lux. Outfitting workstations with individual lighted magnifiers also helps techs inspect instruments for residual bioburden, says Ms. Spaulding. Reprocessing techs should use the lighted magnifiers to examine instruments after they've been manually cleaned and put through an automated washer. Don't assume they always do. "That's one of the first things I look for when I'm called in to find out why a facility has contaminated instruments," says Ms. Spaulding. "I've been to hospitals where the reprocessing staff have asked for magnifiers, but were told they weren't in the budget."

Cleaned instrument sets can be wrapped in blue wrap before being placed in the sterilizer, but rigid sterilization containers are a better option. Ms. Spaulding says they provide an excellent barrier to microorganisms, are easy to use, protect instruments from damage and eliminate the risk of torn blue wrap, which jeopardizes the sterility of the instruments and results in the time-consuming resterilization of trays.

"Rigid containers are definitely the more expensive option, but they make things for staffs in the OR and sterile processing so much easier," says Ms. Spaulding. "They can move and stack instrument trays without having to worry about blue wrap tearing."

Ms. Spaulding believes rigid containers are by far the ideal option for sterilizing and storing instruments, but notes that most facilities use them in combination with blue wrap, often allocating sterilization containers for more complex instrument sets — such as those used for orthopedics — that are used in high-volume cases and therefore must be kept in top condition. Instrument tracking technology could be another valuable addition to your instrument care practices. It can streamline the efficiency of instrument flow, allowing reprocessing managers to track sets as they move between sterile processing and the ORs, and identify and address workflow bottlenecks. They can also track instrument usage to determine when individual tools are due for preventive maintenance.

Larger health systems can afford the tracking technology, but Ms. Spaulding says smaller surgery centers with tighter budgets can manually document which instrument sets were used during a case in order to track their wear and tear and trace them back to a particular procedure.