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By Kathy Dix
Instruments used in an operating room (OR) or procedure room lead a busy life. Follow two instruments demonstrating the latest in technology as they progress throughout a typical day.
“THE INSTRUMENT WE’LL TRACK TODAY is the arm of a robotic instrument,” says Marc Finch, manager of the central processing department at Beaumont Hospital in Royal Oak, Mich., just outside Detroit. Finch is also a surgical tech. “The arm is detached from the main instrument. We own a da Vinci robot,” he explains. “Da Vinci offers a three-arm and a four-arm system. We own the three-arm system, which means there are two instruments that could be working at one time along with the scope.”
The system is used mainly for prostatectomies and for the left internal mammary artery (LIMA) procedure in coronary artery bypass grafting (CABG). In the LIMA procedure, the surgeon takes the LIMA down from the chest and attaches it to the heart. “Whenever you do a CABG, a lot of times that is one of the arteries they take, because you don’t have to take both ends,” Finch adds.
Diary of a Robotic Arm
Day 1. Afternoon.
Big day ahead tomorrow. The weekend was quiet, but this week will be back to the regular grind, with six procedures in four days. I’ve been cleaned and sterilized and am sitting on the case cart, ready to go to the OR. There is a case scheduled for first thing tomorrow morning.
My case cart is moved to the operating room and left until the procedure begins in the morning. I’m in sterile packaging in a sterile room that is already prepped for the first patient.
Day 2. 7:30 am.
The first procedure begins. It’s a prostatectomy, which will run approximately three hours.
The case is finished and the patient has been moved to the recovery area. Along with the accessory units for the da Vinci system, I’m being placed back on the case cart, which is now considered dirty. I’m sent back to the decontamination area, where I just spent part of yesterday. The Eject System, a dumbwaiter-type elevator, takes me from the second floor directly to the basement. Fifty feet away is the decontamination area.
I am brought into the decontamination area and hand-washed. There are several ports or lumens on each instrument that need to be flushed through with water, and those are blown dry afterwards. The water used to flush me is sterile, and I’m blown dry with compressed air.
Robotic arms merit special treatment; I cannot be placed in a washer like standard instruments are. Instead, I’m moved through the “through window” into the processing area. Now the sterile processing department (SPD) staff ensures that all my joints are moving freely and that I’m functioning properly.
I am now wrapped for the sterilization process. Today, the fold used is an envelope fold; if a different staff member is working tomorrow, they might use a rectangular fold instead.
I enter the sterilization area. However, there are some other items ahead of me today — which is unusual, so I’m left to wait for a few minutes.
I am placed in the sterilizer. Sterilization is a 45-minute process, just using a regular steam sterilizer.
Out of the sterilizer, I’m left to cool for a while.
It’s been 20 minutes, so I’m put away on a shelf until I am needed for the next procedure.
For a minor set, its day would start out similarly to the robotic arm, Finch says. “Initially, it would be sitting on a shelf until called for on a case cart. Then it would be sent to the OR on a case cart the night before the procedure, or, sometimes, the day of the procedure.
“Once used, the set would then be sent back down to the decontamination area. The instruments are hand-washed and inspected initially, but most instrument sets can be put in a washer, which will go through a sonic-type wash, very similar to a dishwasher,” he explains. “It will also be ‘milked’ in there. Milk is a lubrication you put on the instruments. After being lubricated, they are dried, and then they come through on our processing side, and it’s all automatically done. It’s about a 20- minute process from when we start hand-washing until it comes out of the washer.”
Robyn Sandrick, CRCST, CHL, is the director of the surgical reprocessing and sterilization department at Children’s Memorial Hospital in Chicago. When asked to track the progress of an endoscope through its daily routine, she begins, “For any endoscope, the process begins in the OR suite, as the OR nurse or the OR tech prepares the room for the surgical case. The OR nurse or tech creates a sterile field in which the surgical instruments will be laid, and the OR tech can work off that back table and hand instruments to the surgeon.”
Like Beaumont Hospital, the procedures begin early. “The endoscopy cases — and most other cases — start between 7:15 a.m. and 8:30 a.m. The OR has a full day starting at around 7:30 every day,” she adds.
“The endoscope gets sent up that morning or the evening before, and of course it’s wrapped and ready for the surgical field. Normally, it is sent up the night before , between 11 p.m. and 1 a.m., which gives the midnight staff time to open the OR room, which is when they unwrap the items and make them acceptable for patient use, and the room becomes a sterile environment. Once you go into the room, you must be in surgical scrubs. Before you can move around the room, you must be gowned appropriately and have a surgical mask on.”
A typical endoscopy might take approximately 45 minutes to an hour and 15 minutes, depending on the severity of the patient’s medical problem. “That includes intubation time but does not include post-op time,” Sandrick adds.
The endoscope is not whisked out of the room the moment the surgeon is finished with it. She explains, “Normally, the patient is first moved to the post-operative area, and the surgeon takes off his gown with the help of the nurse or the scrub nurse, and the RN and OR tech do a final count to make sure none of the instruments is missing. The count includes all instruments brought into the room. If they started with 15, they are leaving with 15. Everything that goes into the room is accounted for.”
The endoscope and all instruments are placed back on the surgical case cart and are then sent to the decontamination area or SPD. Normally, the SPD is close by the OR, depending on the facility. This smooth the progress of instrument turnover, in the event that many procedures are scheduled and the medical staff requires a quick turnaround of sterile items for use in upcoming cases.
“Most sterile processing departments are located right underneath the OR, like ours is,” Sandrick adds. “Some are on the same floor; ours is in the basement, two floors directly underneath the OR. We have a separate clean elevator and a separate decontamination elevator, and it is not able to stop in between floors. It can’t stop at the first floor on either side. Instead, the elevator provides a direct route for the instrumentation, to prevent cross-contamination and to limit traffic, in both areas, that the instrumentation is exposed to. That helps to maintain the integrity of the sterile package and minimize cross-contamination.”
She explains, “We have a full-size elevator, rather than a dumbwaiter- type elevator, so if the processing staff needs to track instrumentation closely, such as a loaner case, which might have 15 trays, they can pick up all of them at one time. If they’re using multiple case carts, they might have two or three, in which case they can send everything down on that case in that one elevator.”
The entire elevator process takes perhaps two minutes. “Normally, the OR tech or nurse presses the basement button. Then — as we have a set of phones that links the ORs to the processing department, so that all areas can communicate to both the clean side and the decontamination side of the SPD — they will press the ‘speaker’ button and let us know that something is on its way.”
There are usually enough staff members to take the instruments right away, so the contaminated items are addressed as soon as they emerge from the elevator. “If we are backed up, at the most by maybe two or three carts, another person often goes back to that area to assist,” Sandrick says.
“Because this is a pediatric facility, our cases are not the typical cases of an adult hospital, with 20 or 15 trays per cart. As a rule, we have no more than five trays per cart. If it’s a double procedure case, even with, perhaps, an orthopedics case, there are no more than 10 to 12 trays,” she maintains.
Because the endoscopic instruments are exceptionally sensitive, they need to be hand-washed with an approved solution that is used for hand-washing heat-sensitive items. “It takes just a couple of minutes to wash it out, then to flush it, depending on how many instruments there are per tray,” Sandrick explains.
“Normally, it’s a rigid scope, but flexible scopes require the same amount of time — several moments per item. After hand-washing, the item is transitioned to the clean side via a window, taking a total of approximately five minutes.
“However, if the instrument being reprocessed is not a heat sensitive item, it will go through an automatic washer. Our automatic washer cycle is 40 minutes. When it emerges on the other side, the door opens automatically on the clean side, so there is no cross-contamination,” she says.
“Of note, 98 percent of our endoscopic instruments are STERRAD compatible, so they go into the electric dryer. The components hook up in the dryer so all the lumens are dry. The endoscope is then assembled by a technician, wrapped or placed in the appropriate container, then is placed in the STERRAD machine,” explains Sandrick. “The STERRAD machine incorporates a 54-minute cycle to sterilize the instrument. Cleaning and disinfecting has already occurred during the handwashing or through the automatic washer. Decontamination renders the item safe for the staff to handle. It then goes to the clean side, where it undergoes assembly, drying, and sterilization of that item.”
When the endoscope is removed from the STERRAD unit, it is then placed in the ‘sterile storage area,’ also known as the ‘OR holding area,’ or the ‘OR sterile core/clean room.’ The instrument does remain in that same wrapper, or container, or whatever the surgical instruments are contained in, until the next surgical case. “Our hospital observes ‘event-related sterility,’ which means it depends which events happen to deem the item sterile or non-sterile. If, for example, it falls in a puddle of water, the tray has to be re-sterilized. If one or two employees handle it a couple of times, it’s fine for use. Studies have shown that trays remain sterile for years as long as you protect the integrity of that tray,” she says.
Day 1. Midnight.
The OR nurse or tech prepares the room for the surgical case. The endoscope was sent to the room an hour ago, along with other sterile instruments required for the case.
The first case begins.
The case is over. The nurse and OR tech begin their instrument count.
The endoscope is placed in the elevator for the quick trip two floors down to the decontamination area. The tech notifies the SPD staff that the endoscope and other instruments are on their way down.
The staff members begin cleaning the instruments immediately upon their arrival down the “dirty” elevator. Endoscopes are hand-washed.
The endoscope is passed through the window to another area of the SPD. It is placed in the electric dryer, which dries all the lumens.
The scope is assembled by a technician, wrapped and placed in the STERRAD machine.
The endoscope is placed in the OR sterile storage area to await its next case.