The Proper Processing of Procedure Trays
By Nancy Chobin, RN, CSPDM
Many healthcare facilities assemble and produce procedure trays for use at the bedside or in departments other than the operating room to perform minor surgical procedures. These trays may be used to perform specific procedures such as a tracheotomy tray, a cut-down tray, a paracentesis tray, etc., or they can be designed as multi-purpose (i.e., an all-purpose tray) to keep the inventory of different trays low. In many instances, these trays are designed to provide all the instruments and supplies needed for the physician to perform the procedure--often without the assistance of a nurse or aide. Other trays may need items added to them to perform a procedure such as an arteriogram tray in radiology. A procedure tray or pack should be designed in a way that reduces the time spent by the caregiver to assemble those items necessary to perform the procedure.
Procedure trays should be simple in design and contain, minimally, items for skin preparation, drapes, supplies to give a local anesthetic and items to perform a surgical closure. Once the procedure tray contents are developed and the tray is in use, there should be an annual review of the tray utilization and contents. Sometimes a review of tray lists reveals that the procedure is no longer performed, a disposable tray is currently being used in place of the reusable, or that the doctor who required the tray doesn't practice at the facility any longer.
Skin preparation items would include 2x2 or 4x4 non-sterile gauze sponges or 6-inch cotton-tipped applicators that can be used to prepare the skin with an antiseptic solution. Usually the gauze is picked up by a sponge stick and used to "paint" the antiseptic on the skin. The area where the procedure is being performed needs to be draped; usually surgical towels (the towels are clamped together with towel clips), or specialty drapes are used to define or frame the surgical site and can be included in the tray.
Drapes can be reusable (must be laundered between use, be lint-free and without holes or defects) or single use. Single-use drapes must be non-sterile and autoclavable since the majority of procedure trays are processed in pre-vacuum steam sterilization cycles. The single-use drape manufacturer should provide sterilization instructions to the facility. If autoclavable drapes are not available, then a sterile disposable drape may be included with a package of additional needed supplies that accompanies the tray.
The patient is given a local anesthetic before the procedure begins to lessen the discomfort. In order to administer the local anesthetic, the doctor will usually need a 5cc syringe and various size and gauge needles. Many facilities still use glass syringes for procedure trays. Glass syringes require manual cleaning and careful handling to prevent chips and cracks. When inspecting glass syringes, make sure the plunger fits snugly into the barrel of the syringe. One way to determine if the plunger fits correctly is to carefully invert the syringe with the plunger in place. If the plunger slides out, the syringe barrel and plunger are not matched correctly. Any glass syringe that is damaged or does not fit correctly should be replaced. If disposable syringes are used, these are provided to the facility single wrapped and sterile. The facility must check with the syringe manufacturer regarding placement of the syringes on a tray that will be steam sterilized. Remember, the manufacturer has already sterilized the syringes and in most cases the manufacturer will not recommend re-sterilization. The use of sterile, single-use needles is common practice today (with the exception of specialty needles such as Menghini needles, COPE needles). The needle manufacturer must also be contacted to provide information regarding placement of the sterile needles on a tray to be steam sterilized. Medications should not be included on special procedure trays unless the drug manufacturer has provided written instructions for sterilization and re-sterilization, and any adverse effects to the medication from the sterilization process. Again, any items that are needed for a procedure that cannot be placed on the tray prior to sterilization may be placed in a package that will accompany the tray when it is sent out for use.
Items for skin closure usually include sutures. The suture is placed on the outside of the tray and usually is contained inside a dust cover. If multiple sutures are required, they are sometimes placed in a small plastic bag for containment and then placed inside the dust cover. It is important to review the suture needs routinely to prevent unused suture material from accumulating on nursing units.
Tray consistency is critical. Every tray that is produced in the Sterile Processing Department (SPD) should be accurately and consistently prepared. We expect this from a tray prepared by an outside vendor; our customers (doctors and patients) deserve the same from an in-house prepared tray. To help ensure that all trays are prepared the same way, reference materials should be available for the SPD staff. The reference materials can be file cards, count sheets and/or photos with the tray set-up. Reference materials should be specific (i.e. three each curved mosquitoes); list items in the order in which they should appear on the tray; and contain general information such as the tray name, number of trays, etc. In addition, the reference material should answer these questions: How are the items cleaned? How are they sterilized? What items get added to the tray after sterilization? What material is used to wrap the tray? Where does the tray go after sterilization?
Whatever reference system is used, it is important to make sure that the tray contents and set-up of the tray are reviewed periodically for accuracy. When the procedure trays' contents are being reviewed, nursing personnel and the physicians performing the specific procedures should be included in the review process.
It is preferable to use a flat tray lined with a surgical towel. Tray set-up should follow the order of use of the items and are usually assembled left to right. This way, the items to prepare the skin should appear on the left side of the tray followed by the local anesthetic items (needles/syringes), drapes and towel clips, items to perform the procedure (including knife handle and blade), clamps, scissors and needle holders. If reusable knife handles are used, the blade in the foil package is placed on the tray near the knife handle. The foil packet should not be opened. Steam cannot penetrate the foil packet but will sterilize the outside of the packet for handling by the doctor. If a disposable knife blade/handle is used, check with the manufacturer to see if the handle/blade can be placed on the tray for sterilization. Some manufacturers of disposable knife handles/blades do permit steam sterilization of pre-sterilized handles/blades. Sometimes a "paint cup" is required to hold the betadine or skin antiseptic. Any medicine glasses or paint cups should be facing upright. Any items that are nested (smaller bowl inside a larger bowl) need to be wicked (separated by an absorbent material). Instruments should be placed on a stringer; they can be strung on the sponge stick, or the surgical towel used to line the tray can be folded at the bottom to create a pocket. The instruments can be held open by placing one handle inside the fold and one outside the fold. In any event, all instruments should be held open for sterilization. Any reusable needles or items with lumens (i.e. red rubber catheters) should be flushed with distilled water immediately before steam sterilization. If multi-part needles (i.e. Menghini needles), the needles should be inspected under a magnifying light for nicks and burrs; if present, the needle should not be used. Make sure all parts are present. Sometimes an autoclaveable, large glass tube can be used to contain all the parts. Place a cotton ball in the bottom of the test tube, a chemical indicator inside the tube, and place a cotton ball in the top to keep the contents inside.
All SPD employees should be trained in the processing of procedure trays. The training should include inspection of all instruments and needles, deterioration of reusable items, what the tray is used for, how it is ordered and charged, etc.
Additionally, it is recommended to number procedure trays and identify the par levels within the SPD. This will help reduce instances of non-availability. For example, tracheotomy trays are usually required post-operatively for thyroidectomy patients in the event of neck swelling. The SPD should never be without tracheotomy trays. SPD personnel should be trained to scan the procedure tray shelves daily to ensure par levels are maintained.
Nancy Chobin, RN, CSPDM, is the CS/SPD educator at Saint Barnabas Healthcare System in Livingston, N.J.