The Proper Processing of Procedure Trays

March 1, 2003

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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.