The Importance of Surgical Instrument Maintenance and Patient Safety, part 2
Last issue, we discussed the surgical instrument lifecycle, manually cleaning instruments, and instrument care during transportation and cleaning in the sterile processing department with regard to water type and detergent. This issue, we will examine instrument care during ultrasonic cleaning and sterilization.
Ultrasonic cleaning is considered the follow-up to manual cleaning. While manual cleaning removes most or all of the visible soil from an instrument, it cannot remove small or microscopic particles that are often protected by the texture of an instrument’s surface or the various design features. Ultrasonic cleaning is a powerful tool which works by sound waves that move through water to create many bubbles, a process known as cavitation. When these bubbles implode at a fast rate of speed, they create both heat and energy, allowing instruments to receive a thorough cleaning within the instrument’s serrations, crevices, and lumens.
One of the easiest, yet most effective ways to keep instruments in good condition is to provide lubrication prior to sterilization. Proper lubrication allows all moving parts in instruments to move freely. Moving parts such as ratchets, joints, box locks, and screws should be lubricated on a regular basis and according to each instrument IFU.
How often are the sterilizers cleaned or maintained? Sterilizers also have their own IFUs and sterilizer manufacturers recommend periodic cleaning. To maintain surgical instruments, facilities need a properly cleaned autoclave. If the department area contains hard water or mineral deposits, these deposits can adhere to the chamber walls of the autoclave and affect the surgical instruments. Always refer to the surgical instrument manufacturer’s IFUs regarding autoclave maintenance.
Stainless steel isn’t stainless?
Even though German quality stainless steel instruments are named as such, stainless steel instruments may still experience stains. Unfortunately, improper care and handling may drastically reduce the life of a surgical instrument and instruments may incur damage through a multitude of ways. There are many potential areas that may cause corrosion on stainless steel instruments or cause damage to the passive layer. One area of improper use is staining. Staining is a surface deposit on the instrument and may sometimes be mistaken for rust. True rust on surgical instruments is rare. Stains can certainly occur on instruments and may appear in many different colors and, in most cases, these colors can usually direct us toward the origin of the stain.
Causes of staining and discoloration may include surgical instruments exposed to the following:
- Dried blood and debris
- Water quality
- High acid or high alkaline concentrated detergent
- Chlorine compounds (bleach)
- Mixing dissimilar metals
- Sterilizer or autoclave build-up of deposits
Avoid using harsh chemicals such as bleach to clean any surgical instruments. The high pH of bleach will cause stains and, over time, may cause severe corrosion to the instrument. True rust is quite rare, and we sometimes mistake orange or brown stains for rust. To check for rust, perform the eraser test. If the color rubs off, it usually points toward dried bioburden or blood and may be removed. Some facilities may believe their instruments should be discarded once stained or that they may be damaged beyond repair. It is important to note that if the staining or damage is caught in time, with proper care quality stainless steel surgical instruments may be brought back to life and last for many years.
To IUSS or not to IUSS?
Immediate Use Steam Sterilization (IUSS) is defined as a sterilization method that involves the shortest possible time between a sterilized item’s removal from the sterilizer and its aseptic transfer to the sterile field. Is IUSS being performed as a routine due to unavailable instrument sets to support the surgical volume, or is IUSS used only in emergency situations as recommended? Ideally, facilities should have enough instruments to support their surgical volume and should not become dependent upon IUSS for quick turnovers. According to the CDC, “IUSS should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time.”1
If an instrument is dropped during a procedure and a match is unavailable, the instrument will be placed in IUSS. Depending on the type of instrument and the manufacturer’s IFU parameters, the sterilizer is set to 270° at a range of approximately 3–4 minutes. Once that cycle is complete, staff may bring the item into the OR and pour cold, sterile water over the instrument for cooling to allow the surgeon to grasp for immediate use. Note: The sudden heating and cooling may, over time, cause stress to the surgical instrument.
It’s about maintenance
In addition to these important steps, the manufacturer’s IFU also states that performing ongoing maintenance and repairs ensures that instruments remain in good working order prior to and following each procedure, which contributes to patient safety and a successful surgical outcome. In addition to surgeons depending on surgical instruments that are in good working order, our patients believe and trust that we are monitoring our surgical instruments as safe devices for them.
As with our vehicles, we wouldn’t think to purchase a vehicle and expect it to take care of itself. We understand the importance of proper care and provide our vehicles with periodic maintenance: oil changes, filter changes, new tires, regular cleaning, and repair any dings or scuffs that may occur. We maintain our vehicles to keep them in safe working order and in good appearance to maintain our investment for as long as we can, or until we decide to purchase a new one. It is the same for surgical instruments. Incorporating a preventive maintenance program is crucial to extending the life of our investment.
Qualified and knowledgeable repair technicians have the expertise and technique to keep instruments maintained according to the manufacturer’s specifications. They will sharpen dull scissors, remove burrs, observe metal fatigue and hairline fractures before they become a potential issue, place new inserts within needle holders, tighten or replace loose screws, repair misaligned tips, replace broken springs, recoat cracked insulation to avoid patient burns, remove most stains, and polish instrumentation back to their original state following the form, fit, and function specifications. Confirm the repair company follows ISO 9000 and ISO 13485 guidelines, which address quality systems and processes to ensure repairs, as well as documentation, are being performed according to FDA guidelines and according to the standards. Hospital managers want to ensure the maximum life from their investment and surgeons require instruments to be in optimal condition to support and perform successful procedures; therefore, good repair technicians understand the surgeon’s needs.
Surgical procedures require immense planning. Most procedure complications and delays are commonly related to the quality and readiness of surgical instruments, equipment, and supplies. When the first scheduled surgery of the day begins, how it unfolds will set the tone for the remaining OR cases. If the surgical procedure goes as planned and no issues occur, it will allow the surgeon to remain on time with his or her office schedule and keep the surgery staff on time with the remaining cases scheduled for the day. The importance of the operating room staff and sterile processing staff working as a team greatly influences the success of the operating room protocols.
Next issue, we will examine instrument maintenance in greater detail, including the specific needs of specialized surgical instruments.
- 16 years’ experience in the operating room as a CST
- Clinical specialist for medical device companies
- Product manager for medical device company
- Clinical education manager – Integra LifeScience (Jarit Instruments division)
- Clinical education manager – Northfield Medical
- AS in surgical technology
- BA in business/marketing
- CST, CBSPD, CER certification
- Voting board member AAMI WG84/ST_91 – flexible endoscopes
- Member of AAMI, IAHCSMM
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