By Nancy Chobin, RN, CSPDM
Many healthcare facilities assemble and produce procedure trays for use atthe bedside or in departments other than the operating room to perform minorsurgical procedures. These trays may be used to perform specific procedures suchas a tracheotomy tray, a cut-down tray, a paracentesis tray, etc., or they canbe designed as multi-purpose (i.e., an all-purpose tray) to keep the inventoryof different trays low. In many instances, these trays are designed to provideall the instruments and supplies needed for the physician to perform theprocedure--often without the assistance of a nurse or aide. Other trays may needitems added to them to perform a procedure such as an arteriogram tray inradiology. A procedure tray or pack should be designed in a way that reduces thetime spent by the caregiver to assemble those items necessary to perform theprocedure.
Procedure trays should be simple in design and contain, minimally, items forskin preparation, drapes, supplies to give a local anesthetic and items toperform a surgical closure. Once the procedure tray contents are developed andthe tray is in use, there should be an annual review of the tray utilization andcontents. Sometimes a review of tray lists reveals that the procedure is nolonger performed, a disposable tray is currently being used in place of thereusable, or that the doctor who required the tray doesn't practice at thefacility any longer.
Skin preparation items would include 2x2 or 4x4 non-sterile gauze sponges or6-inch cotton-tipped applicators that can be used to prepare the skin with anantiseptic solution. Usually the gauze is picked up by a sponge stick and usedto "paint" the antiseptic on the skin. The area where the procedure isbeing performed needs to be draped; usually surgical towels (the towels areclamped together with towel clips), or specialty drapes are used to define orframe the surgical site and can be included in the tray.
Drapes can be reusable (must be laundered between use, be lint-free andwithout holes or defects) or single use. Single-use drapes must be non-sterileand autoclavable since the majority of procedure trays are processed inpre-vacuum steam sterilization cycles. The single-use drape manufacturer shouldprovide sterilization instructions to the facility. If autoclavable drapes arenot available, then a sterile disposable drape may be included with a package ofadditional needed supplies that accompanies the tray.
The patient is given a local anesthetic before the procedure begins to lessenthe discomfort. In order to administer the local anesthetic, the doctor willusually need a 5cc syringe and various size and gauge needles. Many facilitiesstill use glass syringes for procedure trays. Glass syringes require manualcleaning and careful handling to prevent chips and cracks. When inspecting glasssyringes, make sure the plunger fits snugly into the barrel of the syringe. Oneway to determine if the plunger fits correctly is to carefully invert thesyringe with the plunger in place. If the plunger slides out, the syringe barreland plunger are not matched correctly. Any glass syringe that is damaged or doesnot fit correctly should be replaced. If disposable syringes are used, these areprovided to the facility single wrapped and sterile. The facility must checkwith the syringe manufacturer regarding placement of the syringes on a tray thatwill be steam sterilized. Remember, the manufacturer has already sterilized thesyringes and in most cases the manufacturer will not recommend re-sterilization.The use of sterile, single-use needles is common practice today (with theexception of specialty needles such as Menghini needles, COPE needles). Theneedle manufacturer must also be contacted to provide information regardingplacement of the sterile needles on a tray to be steam sterilized. Medicationsshould not be included on special procedure trays unless the drug manufacturerhas provided written instructions for sterilization and re-sterilization, andany adverse effects to the medication from the sterilization process. Again, anyitems that are needed for a procedure that cannot be placed on the tray prior tosterilization may be placed in a package that will accompany the tray when it issent out for use.
Items for skin closure usually include sutures. The suture is placed on theoutside of the tray and usually is contained inside a dust cover. If multiplesutures are required, they are sometimes placed in a small plastic bag forcontainment and then placed inside the dust cover. It is important to review thesuture needs routinely to prevent unused suture material from accumulating onnursing units.
Tray consistency is critical. Every tray that is produced in the SterileProcessing Department (SPD) should be accurately and consistently prepared. Weexpect this from a tray prepared by an outside vendor; our customers (doctorsand patients) deserve the same from an in-house prepared tray. To help ensurethat all trays are prepared the same way, reference materials should beavailable for the SPD staff. The reference materials can be file cards, countsheets and/or photos with the tray set-up. Reference materials should bespecific (i.e. three each curved mosquitoes); list items in the order in whichthey should appear on the tray; and contain general information such as the trayname, number of trays, etc. In addition, the reference material should answerthese questions: How are the items cleaned? How are they sterilized? What itemsget added to the tray after sterilization? What material is used to wrap thetray? Where does the tray go after sterilization?
Whatever reference system is used, it is important to make sure that the traycontents and set-up of the tray are reviewed periodically for accuracy. When theprocedure trays' contents are being reviewed, nursing personnel and thephysicians performing the specific procedures should be included in the reviewprocess.
It is preferable to use a flat tray lined with a surgical towel. Tray set-upshould follow the order of use of the items and are usually assembled left toright. This way, the items to prepare the skin should appear on the left side ofthe tray followed by the local anesthetic items (needles/syringes), drapes andtowel clips, items to perform the procedure (including knife handle and blade),clamps, scissors and needle holders. If reusable knife handles are used, theblade in the foil package is placed on the tray near the knife handle. The foilpacket should not be opened. Steam cannot penetrate the foil packet but willsterilize the outside of the packet for handling by the doctor. If a disposableknife blade/handle is used, check with the manufacturer to see if thehandle/blade can be placed on the tray for sterilization. Some manufacturers ofdisposable knife handles/blades do permit steam sterilization of pre-sterilizedhandles/blades. Sometimes a "paint cup" is required to hold thebetadine or skin antiseptic. Any medicine glasses or paint cups should be facingupright. Any items that are nested (smaller bowl inside a larger bowl) need tobe wicked (separated by an absorbent material). Instruments should be placed ona stringer; they can be strung on the sponge stick, or the surgical towel usedto line the tray can be folded at the bottom to create a pocket. The instrumentscan 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. Anyreusable needles or items with lumens (i.e. red rubber catheters) should beflushed with distilled water immediately before steam sterilization. Ifmulti-part needles (i.e. Menghini needles), the needles should be inspectedunder a magnifying light for nicks and burrs; if present, the needle should notbe used. Make sure all parts are present. Sometimes an autoclaveable, largeglass tube can be used to contain all the parts. Place a cotton ball in thebottom of the test tube, a chemical indicator inside the tube, and place acotton ball in the top to keep the contents inside.
All SPD employees should be trained in the processing of procedure trays. Thetraining should include inspection of all instruments and needles, deteriorationof 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 thepar levels within the SPD. This will help reduce instances of non-availability.For example, tracheotomy trays are usually required post-operatively forthyroidectomy patients in the event of neck swelling. The SPD should never bewithout tracheotomy trays. SPD personnel should be trained to scan the proceduretray shelves daily to ensure par levels are maintained.
Nancy Chobin, RN, CSPDM, is the CS/SPD educator at Saint BarnabasHealthcare System in Livingston, N.J.