Preventive Maintenance Extends Life of Surgical Instruments
By Kelly M. Pyrek
Considering that surgical instrument trays for major surgeries can bear price tags of $20,000 or more and that individual instruments can cost several hundred dollars each, sterile processing (SP) technicians must be well versed in the care and handling of surgical instruments and must engage in preventive maintenance. A properly cleaned and reprocessed instrument is to a surgeon what a chisel and hammer is to a sculptor: a set of tools worthy of respect and critical to the outcome of the professional's surgical or creative endeavor. Surgical instruments, especially those manufactured in Germany, are hand-crafted by highly skilled artisans. In fact, a mosquito hemostat requires 27 steps in the manufacturing process, proving that even the deceptively simple instrument can be complex in its creation and demand detailed care.
Proper care of instruments starts with appropriate cleaning protocol, which includes a maintenance schedule followed per facility policy. Frequency of use should dictate this schedule; busy ORs and SP departments normally schedule instrument maintenance every six months. According to Spectrum Surgical Instruments Corp., instruments that may require more frequent adjusting, sharpening or repair include knives, punches, scissors, needleholders, bone cutters, hemostats and osteotomes.
RFQ, the Tuttlingen, Germany-based instrument maker and a world leader in instrument manufacturing, emphasizes that all instruments should be examined carefully for breaks, cracks or malfunctions before use. Special attention should be paid to critical places such as blades, stops, locks, points and all movable parts. Damaged instruments should not be used, and SP techs should not attempt to repair them. Rather, faulty instruments should be separated from sets and sent out for repair.
The enemies of surgical instruments include blood, tissue and other surgical residue that cause staining, pitting and corrosion of instruments. "Instruments start out gorgeous when they're new but soon the blood and guts will attack and stain instruments," says Alex Vrancich, operations manager for Spectrum Surgical Instruments. "The chlorine ions in blood act like salt, which can corrode, pit and stain instruments. That's why it's critical for instruments to be kept moist until they can be cleaned. Moist instruments are the friends of the decontamination process."
According to Sklar Instruments' instrument troubleshooting guide, no steel is truly "stainless," and is subject to both water spotting and staining. What SP techs identify as rust may actually be something else, such as a stain caused by a surface deposit, and once the cause is found and eliminated, the problem diminishes. According to Slar, "Stainless steel is ideally suited for the surgical suite because it is rust-resistant, it can be honed to an extremely sharp edge or fine point and it can be hardened to maintain the delicate yet precise requirements of the surgeon. But it is this hardened quality -- the amount of carbon used during the manufacturing process -- coupled with harsh chemicals and improper care that renders stainless steel susceptible to corrosion."
In addition, cleaning instruments with bleach, household disinfectants and other inappropriate solutions can damage them. Vrancich emphasizes that SP techs must understand how adverse conditions develop and use approved methods of cleaning.
Vrancich says his company has seen beat-up instruments come in for repair that would horrify an instrument craftsman. "One of the worst things we have seen is a terribly worn needleholder with a cracked and missing tungsten carbide insert," Vrancich says. "The disturbing thing about this instrument was that it was able to go unnoticed through the OR, then decontam, through the clean side and eventually it re-entered the sterile field before it was identified. This is a great example of why we always have to be alert and inspect each and every processed instrument. Who knows the whereabouts of this broken insert?"
Despite being manufactured from 300 and 400 series stainless steel, surgical instruments are not indestructible and can stain, corrode, pit and crack. He explains that bodily fluids such as blood contain chloride ions that show up as orange-brown spots and can lead to corrosion if left on the instruments for an extended period of time and allowed to dry. This is why surgical instruments must be thoroughly cleaned and dried after use -- the washing process should begin within 10 minutes after surgery, even if sterilization will take place later -- and only sterilized when spotless because autoclaving an instrument with debris on it bakes the bioburden into the instrument and can make stains permanent. Corrosion, pitting and staining can be caused by acid- or alkaline-based solutions, so instruments should be washed with a neutral pH soap for optimal results. Using an instrument cleaning brush is recommended, especially for cleaning jaw serrations, teeth and hinged areas.
Some hospitals use ultrasonic cleaning, which can be up to 16 times more efficient than hand cleaning. For manual cleaning, RFQ recommends using soft brushes and standard solutions with tepid water. Manufacturer's instructions on how to use cleaners as well as directions on concentration and duration should be followed. Instruments that can be taken apart should be cleaned in a disassembled state, according to RFQ. Keep parts together and avoid mixing parts made by different manufacturers. Follow the manufacturer's instructions for reassembly.
No matter the cleaning method used, all surgical instruments must be sterilized prior to surgery to avoid infection. Ratchets should be left open to allow better steam penetration during sterilization and to prevent box locks from cracking. A perforated tray also facilitates steam penetration and aids the drying process. Heavier instruments should be placed on the bottom of the tray with lighter ones on top to prevent damage. For all instruments without other indications, steam autoclave sterilization at 270 degrees F (132 degrees C) for 15 minutes is recommended by RFQ. Other temperatures and terms should be validated by the autoclave manufacturer. Sterilization temperatures should not exceed 280 degrees F (137 degrees C). Sterilization with hot-air or flash-autoclave is not recommended by RFQ because isolations or non-metal handles may be destroyed. Cold sterilization is not recommended by Spectrum Surgical because immersing instruments in solutions for long periods of time can be damaging. Instruments with tungsten carbide inserts (gold handles) should not be immersed in solutions containing benzyl ammonium chloride, as it is known to loosen the tungsten carbide.
One of the most important steps in preventive maintenance, in addition to the proper cleaning and sterilization procedures, is lubrication of instruments after every cleaning. Proper lubrication keeps instrument parts from rubbing and scraping together, thus preventing dulling and strain to joints and hinges. Moving parts such as joints, box locks, ratchets and screw joints should be thoroughly lubricated with an appropriate surgical lubricant.
Instruments also should be tested regularly for sharpness and optimal performance.
All photos courtesy of Spectrum Surgical Instruments
"Preventive maintenance helps us to find small cracks before they become major cracks that could lead to complications in the OR," Vrancich says. "Testing scissors for sharpness will help to ensure that procedures go smoothly, but preventive maintenance will never replace the repair process, as testing will often lead us to find instruments that require repair or replacement. Our mission is to test and inspect and one of the best ways to do this is what I refer to as 'taking the instruments for a walk.' Simply put, it is the action of opening and closing the ratchets of a needle holder or hemostat, pressing and releasing a tissue forcep, or cutting with a scissor."
A rubber-like material called Theraband, available from Spectrum, can be used to test scissors' sharpness, especially at the distal tip where scissors often dull most quickly. Instruments needing the most frequent sharpening include scissors, bone cutters, osteotomes, rongeurs, chisels, knives and punches. Scissors should have complete and precise cutting actions and needleholders should have intact tread at the distal tips. Rongeurs should take a clean bite out of an index card, while bone cutters should be able to cut through a wood tongue depressor. The use of tissue paper on a biopsy punch will determine sharpness; a clean punch should occur.
According to Vrancich, proper inspection and maintenance of surgical instruments ensures the highest quality performance during surgery and protects the considerable investment a hospital has made. Instruments must be treated with care and carefully checked for potential problems.
"Technicians have to look in all the right places," Vrancich adds. "Every instrument must be inspected for missing needle holder jaw inserts, missing teeth from tissue forceps, cracked hemostats and the like. Proper training and education is key to ensuring that each instrument in each set is functioning to its highest performance level. The OR personnel, the surgeon, and most importantly, the patient require that this be the case.
If an instrument is not functioning properly when we 'take it for a walk' it's not going to get better in the OR or after we sterilize it. Testing should be followed by action. If an instrument needs to be replaced, replace it. If an instrument needs to be repaired, repair it."
Vrancich says every instrument poses unique challenges to inspection and maintenance.
With hemostats, the tips, ratchet and box lock are of greatest concern. Cracks can develop due to expansion and contraction during sterilization, as well as due to misuse. Ratchets can be tested by rapping them on a surface to see if they spring apart. When it comes to cleaning hemostats, the nooks and crannies of the serrations must be thoroughly attended to. With scissors, look for pitting along the blades and dulling at the tips, as well as cracking in the hinge areas. "Scissor tips can break off and be lost during surgery and these defective instruments can still be circulated," Vrancich says. "Be sure to look for missing pieces."
Needleholders have complicated tips that can become brittle and break off, and forceps can have missing teeth. The base of these instruments should be checked for cracks and the spring tension should be evaluated regularly. The tips and serrations should always be checked for debris. Vrancich adds that these kinds of long, slender instruments with detailed tips and jaws should be carefully inspected for tiny flaws that can soon escalate into bigger problems.
And when the instruments are completely reprocessed, according to RFQ, they must be stored in a dry and clean environment without direct solar irradiation and be stored in stainless steel or aluminum containers. Instruments should be laid out in their individual packing or in protective trays. Protect tips with cloth, gauze or tubes while keeping the instruments in drawers.
Not All Stains Are Created Equal
The Sklar Instruments Troubleshooting Guide makes the following points regarding the identification of stains on surgical instruments:
Most obvious on dull-finish instruments, brownish stains are most likely to be a deposit of chromium oxide. The brownish film occurs naturally when stainless steel is heated. Improper cleaning compounds could contain polyphosphates that cause the copper components in the sterilizer to be deposited by electrolytic action on the instruments.
BLUISH GRAY STAINS
Cold sterilization solutions may be the culprit. Techs should follow manufacturer's directions for preparing solutions. To minimize discoloration, use distilled water and add a rust inhibitor.
LIGHT AND DARK COLORED SPOTS
Spotting can be caused by slow evaporation of water drops with a high mineral content. Eliminate water droplets by adhering to autoclave manufacturer's operating instructions.