Infection Control Today - 09/2001: Instrumental Knowledge

Surgical Instrument Organization

By R. Michael Appleby

Organizing surgical instruments can enhance productivity, simplify the process of replacing missing or damaged instruments, and help to maintain complete instrument sets in service.

The Pick List

The organization of surgical instruments begins with complete instrument set lists. "Pick lists," as they are commonly referred to, come in a variety of configurations. They may be manually typed, be part of a scheduling program, or be prepared from an instrument company's computerized instrument inventory software. Regardless of the set's form, anyone who handles the instrument set benefits if some basic information is included in the pick list.

The pick list can be organized by the manner in which the set is built in the processing department. A complete description should include a manufacturer's catalog number for easy replacement ordering, as well as quantity and unit of measure. The description also should provide the length in inches and inform as to whether the instrument is straight, curved, sharp, or blunt. An example of a complete description would be: 8 ea SU2702 forceps, Mosquito, curved, 5."

Tray Organization

Instrument sets should be organized to minimize damage to the instruments and to assist surgical personnel as they place sets into service in the operating suite. Place double-ringed instruments, such as hemostatic forceps, scissors, and needle holders, on stringers or instrument racks; this will keep the jaws of the instruments open for sterilization and allow for easier handling by the surgical staff. Hooks, thumb forceps, knife handles, dilators, chisels, gouges, and osteotomes can be stored in peel pouches or multiple inner-pouch products to protect delicate items or sharp edges and to aid in their overall handling.

Take care when designing your instrument sets by segregating delicate instruments from larger, heavier patterns. Using an adequately sized tray for the handling of instruments allows healthcare workers (HCWs) to place heavier items at the bottom and leave delicate items toward the top. Many rigid container companies offer dividers, pins, clamps, cradles, and silicone mats that can be utilized to organize the instrument tray into instrument handling systems. By dividing the tray into compartments and using pins for double-ring instruments or cradles and clamps for telescopes or other delicate endoscopic or gynecologic instruments, HCWs can preplan instrument trays to avoid damage caused by the random placement of instruments into these trays.

Instrument companies also offer a variety of racks, cassettes, and cradles that are designed specifically for chisels, osteotomes, gouges, ENT picks, endoscopic instruments, and other delicate items. These products not only protect the instruments during processing, but also while in storage and during transport within the tray. In addition, these products can be transferred directly to the back table or Mayo stand for use during the surgical procedure. They make it easier to tell when an instrument is missing.

Containers

Most healthcare institutions currently utilize hard sterilization containers for their instrument sets. Containers lend themselves to the process of organization through the use of identification tags both outside the container and on the inner basket.

Containers' labels should identify their institution and department of origin so that loaned instrument sets can be returned to the appropriate department after use. In addition, each container's label should correspond to the instrument contained within as well as to the consecutive set number. A label might read: "City General Hospital--Operating Room" and "Minor Tray 1." Labeling the specific instrument set by name and consecutive number allows for the proper identification of the instrument set in use and establishes an efficient method to track any instrument set for routine maintenance and repair. In addition to exterior container labeling, each instrument basket should also list the same instrument set name and consecutive number on a permanent basket tag.

Many healthcare institutions utilize "on-site" surgical instrument repair services to perform routine refurbishing maintenance on their instrument sets. By labeling instrument sets with their names and consecutive numbers, your repair service can easily set up a maintenance schedule to refurbish each set on a routine basis. The numbering of instrument sets prevents delays in routine maintenance and eliminates the chance of overlooking some sets or inspecting the same set repeatedly.

Instrument Pegboard

Another important part of surgical instrument organization in the processing department involves the "instrument pegboard." This consists of a pegboard where commonly replaced instruments are hung under labels reflecting the catalog number and name of the instrument. Instruments that cannot be hung on the board's hooks could be placed in labeled plastic bins and stored in a cabinet near the board. Par levels should be established and replacements ordered in the event that an instrument falls below the required level. Implementation of an instrument pegboard facilitates the preparation of a complete instrument set during processing, in contrast to such methods as the inclusion of a note concerning missing instruments, or the removal of an instrument set from service until replacements can be ordered.

Surgical Suite Organization

Instrument organization in the surgical suite is critical to the smooth flow of instruments to and from the operating field during the procedure. Incorporate back tables and/or Mayo stands to organize the instruments needed for the procedure, depending on the quantity of instruments required.

Position a rolled Huck towel on the back table or Mayo stand to stabilize double-ringed hemostats and scissors. If racks, cassettes, or cradles are utilized, transfer them from the instrument tray directly to the back table. Instruments should be organized in similar patterns and in their order of use during the procedure. As instruments are no longer required on the field, transfer them to a basin of sterile water. This will keep the bioburden wet and facilitate cleaning during the decontamination process. An enzymatic solution may also be utilized in this step to help remove the bioburden prior to cleaning in SPD. Avoid placing heavy items on smaller, more delicate patterns to prevent potential damage to these instruments.

As instruments are passed on and off the field, use a moist 4"x4" towel to wipe off gross bioburden during the procedure. This will insure the proper functioning of the surgical instruments when they are returned to the field as well as prevent pitting of the instruments from drying blood or tissue.

Damaged Instrument Organization

Everyone, from the processing and nursing staffs to the physicians who handle surgical instruments, should watch for nonfunctioning items. When a tip is broken or a box lock is cracked, tag the instrument so that it can be removed from service and placed in the "repair box." Likewise, when a surgeon mentions that a scissors or rongeur is not cutting or a hemostat or clamp is not functioning correctly, that instrument, too, should be tagged. Many instrument repair services will provide plastic locking tags for placement on instruments in need of repair.

The processing department should promptly remove all tagged instruments from each set as the set is processed and assembled. The damaged instrument should be placed in the repair box and a replacement instrument taken from the instrument pegboard and placed in the set. Processing personnel should be responsible for inspecting each instrument in the set and for replacing all instruments needing service. In addition, they can identify an instrument set in need of refurbishing prior to its routine scheduled service by set name and number so that it can be refurbished at its next scheduled repair service.

Missing Instruments

Instrument counts represent an important part of total instrument organization. The processing department should take and record a count on the pick list to assure that the instrument set has been assembled with all the required surgical instruments. Surgical suite personnel are responsible for taking a count both prior to the procedure to verify the pick list count's accuracy as well as after the patient has been closed to confirm that all instruments have been returned to the tray. The processing department also should count the instruments after decontamination to ensure that all instruments have been returned from the surgical suite. This represents the only way to keep track of surgical instruments and prevents instruments from being thrown away with the trash, or left in the patient. Report and locate missing instruments immediately; this will reduce replacement costs as well as prevent patient injury.

R. Michael Appleby is an instrument asset management consultant for Allegiance Healthcare Corporation.