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CIS Lesson Plans

CIS Lesson Plans provide members with ongoing education in the complex and ever-changing area of surgical instrument care and handling. These lessons are designed for CIS technicians, but can be of value to any CRCST technician who works with surgical instrumentation.

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Each lesson plan graded online with a passing score of 70% or higher is worth two points (contact hour). You can use these points toward either your re-certification of CRCST (12 points) or CIS (6 points).

Mailed submissions to IAHCSMM will not be graded and will not be granted a point value (paper/pencil grading of the CIS Lesson Plans is not available through IAHCSMM or Purdue University; IAHCSMM accepts only online subscriptions of the CIS Lesson Plans

Lesson Plan CIS 204
Endoscopes
[Reprinted from Communiqué: November/December 2007]

The world of medicine has joined forces with the world of engineering. The mantra of “If you can dream it, we can build it.” has taken us to places where hands will not fit. Dr. Peter Blumencranz, a women’s cancer specialist in Clearwater, Fl. (www.mortonplant.com/13695.cfm), utilizes a scope that is small enough to thread into the milk duct of a woman’s breast and see cancerous tumors long before they could be found with a mammogram or felt by manual exam. Endoscopes permit earlier detection, less invasive treatment, and better chance of cure for thousands of patients every year. Certified Instrument Specialists (CIS) are challenged to process these delicate masterpieces. Their goal is to assure the endoscope is clean, sterile, functional, complete and available when needed for patient care. Professional dedication and acquired skills contribute to the team effort to accomplish positive patient outcomes. Endoscopes are the focus of this self study lesson.

Endoscopes can be divided into three broad categories: direct vision endoscopes, rigid fiberoptic endoscopes, and flexible fiberoptic endoscopes. Recalling the lessons in medical terminology will help you determine the medical field utilizing particular endoscopes. The ophthalmoscope is a direct vision scope used to examine the interior of the eye. An otoscope is a direct vision scope used to examine the ear canal and nasal passages. These examples are typically found in doctor’s offices and the hospital’s Emergency Department. They are relatively simple scopes that are cleaned at the point of use. Seldom (if ever) would the CIS be asked to process this instrument. Laryngoscopes are direct vision scopes utilized by Respiratory Therapists and doctors to visualize the larynx and epiglottis when placing an endotracheal breathing tube into a patient’s airway. They are utilized in every area where an emergency cardiac arrest (CODE) cart is placed. Depending on facility policy, these may or may not be processed by the CIS. Manufacturers cleaning instructions are needed to assure proper cleaning techniques are utilized. Several styles are available, only one of which has a submergible handle. Laryngoscopes used for this purpose are battery operated. Testing of the battery and light source should be part of cleaning and validating proper functioning of the instrument. Laryngoscopes are a critical piece of life saving equipment in an airway emergency. The CIS who processes them (cleans, inspects and tests) performs a vital function for the patient.

Rigid fiberoptic endoscopes are utilized in surgical suites. Three surgical services that routinely use this style scope are Orthopedic, Urology, and Ear, Nose & Throat (ENT). Rigid fiberoptic endoscopes share a common design with similar components. The system instrumentation is NOT interchangeable. However, the light cable (fiberoptic bundle) may be interchangeable with the use of end adaptors. For this reason, some departments package the light cable separately to increase flexibility and improve utilization of the cables. For example, a lighted breast retractor may be used once a month or less. Packaging that light cable with the retractor ties up financial resources (cost of the light cable) by having it sit on the shelf. Similarly, the ENT panendoscopy procedure requires three different scopes, all of which can use the same light cable. This technique would maximize utilization of resources and prevent unnecessary processing when light cables are opened with a scope, even when not needed.

Cleaning of rigid scopes and accessories requires a sink or container that allows submersion of the instrument. As with other surgical instruments, they must be completely disassembled for thorough cleaning. Cleaning brushes must be long enough to pass completely through the scope, and bristles must touch all sides of the channel being cleaned. A brush too large can damage the instrument, and a brush too small will not provide adequate cleaning. Manufacturer’s written instruction for cleaning may list appropriate size cleaning brush. Channel dimensions will be listed so appropriate size brushes can be selected as necessary.

One very important task in processing rigid endoscopes is the inspection. The light transmitting capability must be assessed. Light cables and light carriers are delicate and can be easily damaged. Discovering at the point of use an instrument is not functional is not only frustrating, but can potentially be life threatening.

Inspection of the instrument includes a physical examination of the instrument. Points to inspect include the connection post for the light source, either cable or carrier; and the distal surfaces that enter the body. Surfaces must be free of nicks, burs, flaking chrome or peeling laser non-reflective coating. Any sign of abuse, mishandling or other damage requires the instrument be taken out of service until repaired.

Final inspection prior to storage or packaging for sterilization includes determining that all components and accessories are present and in working order. When computerized catalogs for endoscopes and/or sets are not available, photograph catalogs work well and both provide greater accuracy. For instance, a mediastinoscope set will likely include a specialized suction tip and biopsy forceps with a variety of bite size and angulations that would not be useful with any other scope. Taking care that these specialty instruments are not misplaced or mis-packaged requires skill and professional dedication.

Flexible fiberoptic endoscopes are unique. They are also incredibly expensive to purchase and to repair. Processing these intricate instruments requires thorough instruction, time to practice and time to learn. Details and critical points of information can not be memorized during a one hour in-service. The CIS is instrumental in preventing spread of infection proven to have occurred with these instruments. They also help maintain a balanced budget by identifying small problems with scope integrity and having it repaired before catastrophic damage can happen. A prime example is performing a leak test on the video colonoscope prior to submerging it in disinfecting solution. Recognizing the need for a five hundred dollar repair prevents the need for a four thousand dollar internal component replacement.

The range in size and configuration of flexible scopes is as varied as the clinical practice setting where they are used. Surgical and Anesthesia Services is second only to the Endoscopy Suite for overall number of scopes in use. It is beyond the scope (no pun intended!) of this lesson to describe all of them in detail, just as a one hour in-service is not sufficient to teach critical care and handling techniques. Even scopes that are approved for processing in Automatic Endoscope Reprocessors must be inspected and leak tested by qualified personnel.

Flexible scopes have the same basic components:

• The ‘head’ where the eye piece or video connection is located; the steering mechanism that permits flexion of the insertion tip; control buttons to activate air/fluid/suction channels; and ports for placement of accessory instruments.
• The power cable attachment is just below the ‘head’ portion. This cable provides connection to the light and/or video source.
• The ‘body’ is the length of the scope to the insertion tip.
• The ‘insertion tip’ is the part introduced into the patient. Flexion of this section is controlled by the steering mechanism and the most frequent site of internal damage to the scope.

Some flexible scopes may be considered ‘blind’. There are no channels inside the scope and they are used for visualization only, such as the scope used to see cancerous lesions inside breast milk ducts. Another example is the intubation scope used by the anesthesiologist. Its purpose is to guide placement of an endotracheal tube into the patient’s air way. The next level of scope includes one or two internal channels that provide a method of suctioning body fluids and flushing with water to clear the optical lense and/or thin the body fluids for suctioning. These channels include a port which permits connection to the suction or fluid source. Additional channels and ports are incorporated into the scope that permit introduction of a variety of accessory instruments. These include: biopsy forceps, cytology sample brushes, snares, injection needles and electrocautery probes; which represent the tools that permit earlier detection, less invasive treatment, and better chance of cure for thousands of patients. Channels require the correct length and width cleaning brush to provide appropriate cleaning. Historically, ports are the most difficult area to clean.

Processing these intricate instruments is the challenge accepted by the Certified Instrument Specialists, who work diligently to assure the patient is safe from transmission of disease. Assuring the instruments used in the patient’s care are clean, sterile, functional, complete and available when needed contributes to quality patient care. The CIS, truly Instrumental to Patient Care®.

Bibliography:

International Association of Healthcare Central Service Materiel Management. Central Service Technical Manual. Sixth Edition. 2005.

International Association of Healthcare Central Service Materiel Management. Inspecting Surgical Instruments, An Illustrated Guide. 2006.

International Association of Healthcare Central Service Materiel Management. Instrumentation Resource Course: Identification Handling and Processing of Surgical Instruments. 2006.

Society of Gastroenterology Nurses and Associates; 2006. SGNA Practice Guidelines and Position Statements; Chicago, IL.

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