Infection Control Today - 09/2001: Instrumental Knowledge

Surgical Instrument Organization

By R. Michael Appleby

Organizing surgical instruments can enhance productivity, simplify theprocess of replacing missing or damaged instruments, and help to maintaincomplete instrument sets in service.

The Pick List

The organization of surgical instruments begins with complete instrument setlists. "Pick lists," as they are commonly referred to, come in avariety of configurations. They may be manually typed, be part of a schedulingprogram, or be prepared from an instrument company's computerized instrumentinventory software. Regardless of the set's form, anyone who handles theinstrument set benefits if some basic information is included in the pick list.

The pick list can be organized by the manner in which the set is built in theprocessing department. A complete description should include a manufacturer'scatalog number for easy replacement ordering, as well as quantity and unit ofmeasure. The description also should provide the length in inches and inform asto whether the instrument is straight, curved, sharp, or blunt. An example of acomplete description would be: 8 ea SU2702 forceps, Mosquito, curved, 5."

Tray Organization

Instrument sets should be organized to minimize damage to the instruments andto assist surgical personnel as they place sets into service in the operatingsuite. Place double-ringed instruments, such as hemostatic forceps, scissors,and needle holders, on stringers or instrument racks; this will keep the jaws ofthe instruments open for sterilization and allow for easier handling by thesurgical staff. Hooks, thumb forceps, knife handles, dilators, chisels, gouges,and osteotomes can be stored in peel pouches or multiple inner-pouch products toprotect delicate items or sharp edges and to aid in their overall handling.

Take care when designing your instrument sets by segregating delicateinstruments from larger, heavier patterns. Using an adequately sized tray forthe handling of instruments allows healthcare workers (HCWs) to place heavieritems at the bottom and leave delicate items toward the top. Many rigidcontainer companies offer dividers, pins, clamps, cradles, and silicone matsthat can be utilized to organize the instrument tray into instrument handlingsystems. By dividing the tray into compartments and using pins for double-ringinstruments or cradles and clamps for telescopes or other delicate endoscopic orgynecologic instruments, HCWs can preplan instrument trays to avoid damagecaused by the random placement of instruments into these trays.

Instrument companies also offer a variety of racks, cassettes, and cradlesthat are designed specifically for chisels, osteotomes, gouges, ENT picks,endoscopic instruments, and other delicate items. These products not onlyprotect the instruments during processing, but also while in storage and duringtransport within the tray. In addition, these products can be transferreddirectly to the back table or Mayo stand for use during the surgical procedure.They make it easier to tell when an instrument is missing.

Containers

Most healthcare institutions currently utilize hard sterilization containersfor their instrument sets. Containers lend themselves to the process oforganization through the use of identification tags both outside the containerand on the inner basket.

Containers' labels should identify their institution and department of originso that loaned instrument sets can be returned to the appropriate departmentafter use. In addition, each container's label should correspond to theinstrument contained within as well as to the consecutive set number. A labelmight read: "City General Hospital--Operating Room" and "MinorTray 1." Labeling the specific instrument set by name and consecutivenumber allows for the proper identification of the instrument set in use andestablishes an efficient method to track any instrument set for routinemaintenance and repair. In addition to exterior container labeling, eachinstrument basket should also list the same instrument set name and consecutivenumber on a permanent basket tag.

Many healthcare institutions utilize "on-site" surgical instrumentrepair services to perform routine refurbishing maintenance on their instrumentsets. By labeling instrument sets with their names and consecutive numbers, yourrepair service can easily set up a maintenance schedule to refurbish each set ona routine basis. The numbering of instrument sets prevents delays in routinemaintenance and eliminates the chance of overlooking some sets or inspecting thesame set repeatedly.

Instrument Pegboard

Another important part of surgical instrument organization in the processingdepartment involves the "instrument pegboard." This consists of apegboard where commonly replaced instruments are hung under labels reflectingthe catalog number and name of the instrument. Instruments that cannot be hungon the board's hooks could be placed in labeled plastic bins and stored in acabinet near the board. Par levels should be established and replacementsordered in the event that an instrument falls below the required level.Implementation of an instrument pegboard facilitates the preparation of acomplete instrument set during processing, in contrast to such methods as theinclusion of a note concerning missing instruments, or the removal of aninstrument set from service until replacements can be ordered.

Surgical Suite Organization

Instrument organization in the surgical suite is critical to the smooth flowof instruments to and from the operating field during the procedure. Incorporateback tables and/or Mayo stands to organize the instruments needed for theprocedure, depending on the quantity of instruments required.

Position a rolled Huck towel on the back table or Mayo stand to stabilizedouble-ringed hemostats and scissors. If racks, cassettes, or cradles areutilized, transfer them from the instrument tray directly to the back table.Instruments should be organized in similar patterns and in their order of useduring the procedure. As instruments are no longer required on the field,transfer them to a basin of sterile water. This will keep the bioburden wet andfacilitate cleaning during the decontamination process. An enzymatic solutionmay also be utilized in this step to help remove the bioburden prior to cleaningin SPD. Avoid placing heavy items on smaller, more delicate patterns to preventpotential damage to these instruments.

As instruments are passed on and off the field, use a moist 4"x4"towel to wipe off gross bioburden during the procedure. This will insure theproper functioning of the surgical instruments when they are returned to thefield as well as prevent pitting of the instruments from drying blood or tissue.

Damaged Instrument Organization

Everyone, from the processing and nursing staffs to the physicians who handlesurgical instruments, should watch for nonfunctioning items. When a tip isbroken or a box lock is cracked, tag the instrument so that it can be removedfrom service and placed in the "repair box." Likewise, when a surgeonmentions that a scissors or rongeur is not cutting or a hemostat or clamp is notfunctioning correctly, that instrument, too, should be tagged. Many instrumentrepair services will provide plastic locking tags for placement on instrumentsin need of repair.

The processing department should promptly remove all tagged instruments fromeach set as the set is processed and assembled. The damaged instrument should beplaced in the repair box and a replacement instrument taken from the instrumentpegboard and placed in the set. Processing personnel should be responsible forinspecting each instrument in the set and for replacing all instruments needingservice. In addition, they can identify an instrument set in need ofrefurbishing prior to its routine scheduled service by set name and number sothat it can be refurbished at its next scheduled repair service.

Missing Instruments

Instrument counts represent an important part of total instrumentorganization. The processing department should take and record a count on thepick list to assure that the instrument set has been assembled with all therequired surgical instruments. Surgical suite personnel are responsible fortaking a count both prior to the procedure to verify the pick list count'saccuracy as well as after the patient has been closed to confirm that allinstruments have been returned to the tray. The processing department alsoshould count the instruments after decontamination to ensure that allinstruments have been returned from the surgical suite. This represents the onlyway to keep track of surgical instruments and prevents instruments from beingthrown away with the trash, or left in the patient. Report and locate missinginstruments immediately; this will reduce replacement costs as well as preventpatient injury.

R. Michael Appleby is an instrument asset management consultant forAllegiance Healthcare Corporation.